Inspired Hospice Care, Inc.

“Upon patient record review, 2 of 5 (Patient #3, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3:Plan of care dated 7/19/24 orders LVN 2x2w, RN q 14 days: There is no evidence that the LVN performed any visits at all since the patient was admitted. There is no change order. Patient #5: Plan of care dated 7/20/24 orders MSW x 1 within 5 days. There is no evidence of an MSW visit nor a missed visit. There is no evidence of an order to correct frequency.”

“Upon patient record review 1 of 5 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: Plan of care dated 7/12/24 ordered aide 3x week. There are no aide visits documented after 7/26/24 to present. There are no missed visits, there are no orders to change frequency.”

“Upon patient record review, 7 of 14 (Patient #3,4,5,6,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: There is no evidence of a respiratory or oxygen care plan in patient’s medical record. There is PRN oxygen ordered for patient on admission. Admission date 03/16/24. Patient 4: There is no evidence of an oxygen care plan in patient’s medical record. There is oxygen ordered for patient on admission. There is no evidence of an integumentary care plan in patient’s medical record. Patient’s Braden score was 6 on admission. Admission date 07/17/23. Patient 5: There is no evidence of an oxygen care plan in patient’s medical record. There is PRN oxygen ordered for patient on admission. Admission date 07/12/23. Patient 6: There is no evidence of bleeding precautions in patient’s medical record. There is an order for daily aspirin written on 06/08/24. There is no evidence of seizure precautions in patient’s medical records. Patient has the following order in chart: Keppra 500mg-1 tab by mouth twice daily for seizures. This medication was ordered on admission, 6/8/24. There is no evidence of aspiration precautions in patient’s medical record. Patient’s nutrition orders were changed on 06/10/24 to include thickener as follows: Thick-It Food Thickener 36oz. Mix with food/drink every feeding. Note: Mix with food or drink every feeding. One ounce per 14oz water. Indications – difficulty swallowing. Also noted on 06/10/24, order for diet change from mechanical soft diet to “pureed food only.” The last 06/10/24 order written regarding patient’s diet is: Change thin liquids to nectar thick liquids to prevent aspiration. On 06/12/24, new order written: crush all medications as able and mix with applesauce or pudding. Patient 8: There is no evidence of bleeding precautions in patient’s medical record. Patient has an order for Eliquis and Prasugrel. Both orders were renewed on 06/10/2024. Patient has no evidence of an integumentary care plan in the medical record. Patient’s Braden score is 14. Patient 9, Patient 10: There is no evidence of aspiration precautions in patient’s plan of care despite aspiration precautions indicated in HHA care plan.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,6,7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The volunteer is ordered “PRN or upon request,” on 05/03/24. The physician’s order states RN to visit every 14 days and PRN for supervisory visits. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 2: The physician’s order written 3.11.24 states RN to visit every 14 days and PRN for supervisory visits. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 3: The physician’s order written 3.11.24 states RN to visit every 14 days and PRN for supervisory visits. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 4: The physician’s SN orders written 3.11.24: RN every 14 days for supervision and PRN. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 5: MSW is ordered “once monthly PRN.” RN visits every 14 days and PRN for supervision or recertification. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 6: The volunteer is ordered “PRN or upon request,” on 06/08/24. The physician’s order states RN to visit every 14 days and PRN for supervisory visits. This is not a detailed scope and frequency of services necessary to meet patient/family needs. Patient 7: SN visits ordered on 6.4.24 as follows: RN visits for supervision and recertification after initial visit. PRN visits for change in condition. This is not a detailed scope and frequency of services necessary to meet patient/family needs.”

“Upon client record review, 10 of 14 (Patient #1-10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s orders state LVN to visit twice weekly x2 weeks; LVN to visit three times weekly x2 weeks. Both orders were written 05.03.24 so unclear if visit frequency is 2 or 3 times per week. LVN visits were made on 5.7.24, 5.8.24, 5.10.24, 5.14.24 and 5.17.24. Patient 2: The physician’s order written 3.11.24 states RN to visit every 14 days and PRN for supervisory visits. There is no evidence that an RN has visited the patient since 06.06.24. SN visits ordered twice weekly on 3.11.24. There is no evidence of an order for PRN visits for SN, RN, or LVN. LVN visited the patient: 4.2.24, 4.3.24, 4.4.24, 4.9.24, 4.12.24, 5.7.24, 5.10.24, 6.4.24, 6.6.24, 6.11.24, 6.13.24, 6.14.24. The RN visited the patient on 4.11.24, 5.9.24, 6.6.24. MSW initial visit ordered on 3.11.24. On 3.13.24, MSW visits were ordered monthly. There is no evidence of further MSW visits. SC initial visit ordered on 3.11.24. On 3.13.24, SC visits ordered monthly. There is no evidence of another SC visit made in March 2024. Patient 3: The physician’s order written 3.11.24 states RN to visit every 14 days and PRN for supervisory visits. There is no evidence of an RN visit since 6.7.24. There is no evidence in the plan of care that these visit orders were changed by the physician. Patient 4: The physician’s SN orders written 3.11.24: RN every 14 days for supervision and PRN. LVN twice weekly. There is evidence the RN visited the patient twice on 5.3.23 without PRN visit. It is noted that RN opened a visit for 6.14.24 and left the visit blank so not clear if visit actually occurred. LVN saw this patient 4.8.24, 4.10.24, 4.12.24. There is no evidence of SN visits between 6.6.24 and 6.18.24. Patient 5: SN visits ordered on 7.12.23 as follows: RN visits every 14 days and PRN for supervision or recertification. SN visits 3 times weekly and one PRN. There is no evidence of RN visit between 4.23.24 and 5.7.24. It is noted that RN opened a visit for 5.21.24 and left the visit blank so not clear if visit actually occurred. There is no evidence of RN visit made since this date. LVN visited the patient on 4.1.24 4.4.24, 4.8.24, 4.10.24, 4.12.24, 4.22.24, 4.24.24, 4.26.24, 6.12.24, 6.13.24, 6.17.24, 6.19.24. RN visited the patient on 4.9.24, 4.23.24. There is no evidence in the plan of care that these visit orders were changed by the physician. Initial spiritual care assessment ordered 7.15.23 without further orders. Chaplain made a routine visit to patient on 5.27.24. There is no evidence of a physician’s order for this visit in the plan of care. MSW with 7.12.23 visit order for initial psychosocial assessment within 5 days of admission. 7.14.23: 1mo PRN visit set ordered. There is evidence of scheduled MSW visits on 10.07.23, 1.3.24, 1.8.24, 2.23.24, 5.7.24. There is no evidence of a physician’s order for these routine visits in the plan of care. Patient 6: The physician’s order states RN to visit every 14 days and PRN for supervisory visits. Physician’s orders state LVN to visit three times weekly. It is noted that RN opened a visit for 6.22.24 and left the visit blank. LVN visited patient 6.11.24 without further scheduled visits this week. LVN visited this patient 4 times during the week of 6.9.24. There is no evidence of a physician’s order for PRN visits for the LVN in the plan of care. Patient 7: MSW visited the patient on 6.10.24. There is no evidence of a physician’s order for this visit in the plan of care. SN visits ordered on 6.4.24 as follows: RN visits for supervision and recertification after initial visit. PRN visits for change in condition. LVN visits weekly. RN visited this patient on 6.14.24 and 6.18.24. Both visits made were supervisory visits. LVN last visited patient on 6.11.24 with no evidence of further visits. There is no evidence of a physician’s order change in the plan of care Patient 8: SN visits ordered on 7.12.23 as follows: SN visits twice weekly. RN every 14 days for supervision. There is evidence in the medical record that RN made a PRN visit on 4.20.24. There is no evidence of a physician’s order for this visit in the plan of care. There is no evidence of a SN visit since 6.19.24. SC initial visit ordered on 5.6.23 for spiritual care assessment within 5 days of admission. Chaplain has visited patient monthly since admission. There is no evidence of a physician’s order for these monthly visits in the plan of care. Patient 9: SN visit orders: SN weekly and 3 PRN. RN every 14 days for supervision. On 5.22.24 and 5.29.24, there is evidence that SN visits were missed by the LVN. There is no documentation in the medical record that the case manager or physician were notified. There is no evidence of SN visit between the dates of 5.30.24 and 6.14.24. There is no evidence of a SN visit since 6.19.24. Patient 10: RN visit orders: every 14 days for supervision. LVN visit orders: twice weekly. RN visits: 3.18.24, 3.29.24, 4.11.24, 6.14.24. There is no evidence in the plan of care for physician’s order to increase frequency of supervisory visits. PRN visits made by LVN on 5.4.24, 6.11.24, 6.13.24. There is no evidence in the plan of care for physician’s order for these visits. SC visits made by chaplain on 4.15.24 and 5.20.24. There is no evidence in the plan of care of physician’s order for these visits. Patient seen by MSW on 6.14.24 for recertification visit. No evidence of physician’s order for this recertification visit in the plan of care.”

“Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13: No evidence of a bereavement plan of care in patient’s medical record.”

“Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,9,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: change linen; turn and reposition; record BM; transfer; dressing. Patient 2: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: record BM; dressing; change linen. HA care plan includes catheter without evidence of catheter in plan of care. Patient 3: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: Record BM; transfer per 1 assist; change linen. Patient with order for oxygen. No oxygen precautions noted on HA care plan. Patient 4: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: turn and reposition; record BM; encourage fluids; change linens; dress in street clothes. Patient is documented as incontinent of bowel and bladder. No evidence of incontinent care on HA care plan. Patient 5: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: Record BM; transfer per 1 assist; change linen; turn and reposition; feeding assistance. Patient has no order for bath type on HA care plan. States only shower chair. Patient has an order for oxygen on plan of care. No evidence of oxygen precautions on HA care plan. Patient 6: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: Record BM; change linen; bed rails; bed bound; turn and reposition; measure urine; empty foley bag. Patient has order for Keppra on plan of care. No evidence of seizure precautions on HA care plan. Patient has order for aspirin on plan of care. No evidence of bleeding precautions on HA care plan. Patient has hoyer lift ordered on DME section of POC. On HA care plan, 1-person transfer is ordered. Per this hospice’s policy, hoyer transfers should be 2-person. Patient 9: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: bed rails raised; bed bound; turn and reposition; record BM; change linens; 2-person transfer. Patient 10: There is no evidence of frequencies for the following HA tasks noted in HA plan of care: record BM; change linens; 1-person transfer; dressing.”

“Upon patient record review 7 of 14 (Patient #2,3,4,5,6,9,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: There is documentation on 5/24/24 that patient did not receive an ordered shower this date. There is no evidence in the documentation that the case manager or the physician were notified. Patient 4: There is no evidence of HHA visit made since 6/7/24. Patient 5: There is no evidence of HHA visit made since 6/8/24. Patient 6: There is evidence of a missed HHA visit during week of 6/10/24. There is no evidence in the documentation that the case manager or the physician were notified of a missed visit this week. Patient 9: HHA orders changed to 3 times per week on 5/2/24. There were two visits made on 5/2/24 and 5/4/24. There is no evidence of a third HHA visit made this week. Patient 10: 3 times weekly HHA visit frequency order written 3/18/24. Visits were made only 2 times per week on 3/20, 3/22, 3/25, 3/27. 4 times per week visits were also made 4/29, 5/1, 5/2, 5/3. There is no evidence of a physician’s order for these frequency changes.”

“Upon patient record review 3 of 14 (Patient #2,5,6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 2: There is no evidence of a HA supervisory visit since 5/23/24. Patient 5: There is no evidence of HA supervisory visit 4/23/24-5/21/24. Patient 6: There is no evidence of HA supervisory visit since admission on 6/8/24.”

“Upon patient client record review, 6 of 14 (Patient #1,2,4,11,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patients 1,2,4,11,13,14: Notice of Medicare Election Statement has no evidence that patient elected to receive or decline notice of non-covered items, services, and drugs on admission. Area on this document for all above named patients is blank.”