Doctor’s Choice Palliative and Hospice Care, Inc.

“Upon patient record review, 10 of 12 (Patient #1,2,3,4,5,7,8,10,11,12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1,2,3,4,5,7,8: The medical record does not contain evidence that the patient chose a health care provider, including an attending physician. This area of the NOE was left blank. Patient 5,10,11: The medical record did not contain election of benefit statement/forms. Patient 12: The NOE contains a name for the attending though does not indicate that the patient chose the attending. The box that attests the patient chose the attending was left blank.”

“Upon patient record review 2 of 12 (Patient #2,11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: The medical record does not contain evidence of a spiritual care or psychosocial assessment being completed within 5 days of admission. The RN did not complete in the initial comprehensive assessment. Patient 11: The initial SC assessment was not completed until 10/24/22 not within 5 days of admission. The RN did not complete in the initial comprehensive assessment.”

“Upon patient record review, 4 of 12 (Patient #2,3,6,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The SN documented on 1/14/25 “Patient on Diltiazem”. This medication was not included on the medication profile. Patient 3: Per the attending’s CTI notes for the 4th benefit period patient is Oxygen dependent. There are no orders for oxygen on the medication profile. Patient 6: The medication profile contains an order for Polyethylene Glycol with no diluent. The SN documented on 6/21/24 and 6/24/24 patient has oxygen. There are not orders for oxygen on the medication profile. Patient 8: The medication profile contains Miralax with no diluent. The medication profile contains “Testosterone 1% Transdermal Gel 1 ml, IM once a week”, this is unclear. The SN documented on the initial comprehensive assessment patient using oxygen. There is no order for oxygen on the medication profile. The SN documented on 6/1/24 received new order from MD for Augmentin and Promethazine. These were not added to the medication profile.”

“Upon patient record review, 5 of 12 (Patient #2,5,6,9,10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 2,5,6,9,10: The medical record does not contain evidence of a Bereavement assessment completed within 5 days of admission. The RN did not completed the assessment at time of initial comprehensive assessment.”

“Upon patient record review, 3 of 12 (Patient #2,4,5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: The recertification was due by the RN on 12/13/24, there was no documentation by the nurse in the medical record at time the record was reviewed. The SN did add the note late but this is not the same certification period so cannot be corrected on site. In addition, the medical record contains an order for SN 1 time per week and RN every 14 days for supervisory. At time of medical record review, there were no SN visits documented since 2/4/25. Patient 4: The POC 2/27/24 contains an order for RN every 14 days and at recertification. The last RN visit was 7/16/24 the patient did not discharge until 8/4/24. There was no missed visit documentation or evidence of refusal of visit. Patient 5: The POC orders from 6/13/24 are for RN every 14 days. There were no visits completed by the RN after 6/17/24, patient discharged 7/11/24. There was no missed visit documentation or evidence of refusal of a visit.”

“Upon patient record review, 4 of 12 (Patient #4,6,8,10) 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 4: Per initial comprehensive assessment 2/14/24 patient is a maximum assist and on a mechanical soft diet. There were no fall risk or risk for aspiration care plans with goals and interventions added. Patient 6: The SN documented on the initial comprehensive assessment 6/9/24 patient has mechanical soft diet. There was no risk for aspiration care plan added with goals and interventions. Patient 8: The SN documented on the initial comprehensive assessment 5/19/23 patient has weakness, unexplained syncope, risk of skin breakdown. There were no care plans added with goals and interventions for fall risk, or risk for skin breakdown added to the POC. Patient 10: The SN documented on the initial comprehensive assessment 11/3/22 that the caregiver was monitoring blood sugars. There is no care plan with goals and interventions for endocrine on the POC.”

“Upon patient record review, 6 of 12 (Patient #2,3,6,8,10,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The SN documented on 1/14/25 “Patient on Diltiazem”. This medication was not included on the POC orders. Patient 3: Per the attending’s CTI notes for the 4th benefit period patient is Oxygen dependent. There are no orders for oxygen on the POC. Patient 6: The POC 6/9/24 contains an order for Polyethylene Glycol with no diluent. The SN documented on 6/21/24 and 6/24/24 patient has oxygen. There are not orders for oxygen on the POC. Patient 8: The POC 6/9/23 contains Miralax with no diluent. The POC 6/9/23 contains “Testosterone 1% Transdermal Gel, 1 ml IM once a week”, not a clear order. The SN documented on the initial comprehensive assessment patient using oxygen. There is no order for oxygen on the POC. Patient 10: The SN documented on the initial comprehensive assessment that blood sugar levels were monitored by the caregiver. There are no orders for fingerstick blood sugars on the POC. Patient 12: The medical record contains an order for wound care on 3/24/24 though does not state who is to perform the wound care. The SN documented on 6/1/24 received new order from MD for Augmentin and Promethazine. These were not added to the POC orders.”

“Upon patient record review, 8 of 12 (Patient #1,3,5,7,8,9,10,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: Upon home visit finding, patient has a hospital bed that was not ordered on the POC. Patient 3: Pt has a walker per comprehensive assessment. This was not included on the POC. Patient 5: The SN documented in the comprehensive assessment patient has a wheelchair. This was not included on the POC. Patient 7: The SN documented on the comprehensive assessment patient has a walker and cane. These were not included on the POC. Patient 8: The SN documented on 1/4/24 patient uses a walker, cane and wheelchair. These were not added to the POC. Patient 9: The SN documented on the initial comprehensive assessment patient uses a wheelchair. This was not added to the POC. Patient 10: The SN documented on the initial comprehensive assessment patient uses a walker. This was not added to the POC. Patient 12: The SN documented on the aide POC the patient is up with a walker and has a wheelchair. These were not included on the POC.”

“Upon patient record review, 3 of 12 (Patient #3,5,6) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 3: The CTI attending for the patients 5th certification period indicated patient has difficulty swallowing, is a high aspiration risk and on a mechanical soft diet. There was no Aspiration risk care plan developed with goals and interventions. Patient 5: The SN documented on 6/14/24 patient has dysphagia. There was no risk for aspiration care plan initiated. Patient 6: The SN documented on 6/29/24 “patient with dry throat, choking and having difficulty breathing. There was no risk for aspiration care plan added with goals and interventions.”

“Upon patient record review, 8 of 12 (Patient #2,3,4,5,7,8,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The SC visited on 9/14/24 with no evidence of an order. The MSW saw the patient 9/16/24, 12/15/24, 2/13/25 with no evidence of an order. The recertification was due by the RN on 12/13/24, there was no documentation by the nurse in the medical record at time the record was reviewed. The SN did add the note late but this is not the same certification period so cannot be corrected on site. In addition, the medical record contains an order for SN 1 time per week and RN every 14 days for supervisory. At time of medical record review, there were no SN visits documented since 2/4/25. The SN updated and added their documentation but the first missed visit updated by the nurse was performed 2/11/25 this is not in the current certification period. Patient 3: The MSW visits patient 12/25/23, 3/23/24, 5/22/24, 7/22/24, 9/20/24 with no evidence of an order on the POC for these visits. Patient 4: The SC provider visited the patient on 5/11/24 with no evidence of an order. The MSW saw the patient 5/13/24 with no evidence of an order. The POC 2/27/24 contains an order for RN every 14 days and at recertification. The last RN visit was 7/16/24 the patient did not discharge until 8/4/24. There was no missed visit documentation or evidence of refusal of visit. Patient 5: The POC orders from 6/13/24 are for RN every 14 days. There were no visits completed by the RN after 6/17/24, patient discharged 7/11/24. There was no missed visit documentation or evidence of refusal of a visit. Patient 7: The SC visited the patient on 2/22/24 with no evidence of an order. The MSW visited the patient on 2/23/24 with no order. Patient 8: The SC visited patient on 12/12/23 with no evidence of an order. The MSW visited the patient on 8/16/23, 10/15/23, 12/16/23 with no orders. Patient 10: The POC contains an order for SC with every recertification. There is no evidence that the SC made a visit at recertification and no evidence of missed visit documentation or refusal. Patient 11: The SC performed visits on 4/22/23, 3/24/23, 2/22/23 with no evidence of an order. The MSW performed visits on 5/2/23, 3/1/23, 2/2/23 with no evidence of an order.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: The SN placed the nursing bag on a cloth chair with no barrier, entered the clean nursing bag with gloved hands. Per nursing bag policy N120 the nursing bag must be placed on a clean surface with a barrier. SN must cleanse hands prior to entering nursing bag. Patient 2: The Aide placed the nursing bag on a cloth sofa with no barrier. Per nursing bag policy N120 the nursing bag must be placed on a clean surface with a barrier.”

“Upon patient record review, 1 of 12 (Patient #12) did not have evidence the hospice offers bereavement counseling that includes: Patient 12: The medical record contains no evidence of the hospice 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, ensuring that bereavement services reflect the needs of the bereaved, or the development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery.”

“Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 5: The initial aide competency upon hire in the employee file was performed verbally, not on a patient or pseudo-patient. The aide did not have evidence of a competency in 2023. The 2024 aide competency did not include sponge bath, shampoo, sink, tub and bed.”

“Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel 5: The medical record did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. The aide had no annual educations completed. The aide had educations on infection control and emergency management at hire.”

“Upon patient record review, 4 of 12 (Patient #1,2,5,12) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The aide POC 2/19/25 contains orders to record BM, dress in both street clothes and pajamas, encourage fluids, change bed linens all with no frequency. Patient 2: The aide POC contains tasks to change gown and change patient linens with no frequency. Patient 5: The aide POC contains tasks of change pajamas/gown and change patient linens with no frequency. Patient 12: The aide POC contains tasks of record BM, change street cloths and dentures with no frequency.”

“Upon patient record review 4 of 12 (Patient #1,2,5,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The aide documented on 2/19/25 that they dressed the patient in both street clothes and pajamas. Patient 2: The aide POC contains an order to check vital signs every visit. There were no vital signs assessed at any of the patient aide visits performed. Patient 5: The aide POC contains orders to check vital signs every visit, vital signs were never checked on any of the aide visits. Fall precautions and transfers are ordered every visit and these were not completed on the 7/10/24 visit. On 7/8/24 the aide was to place the bed in low positions each visit with was not completed. Patient 12: The aide POC contains orders to check vital signs every visit. The aide did not check vital signs on on the following dates: 4/29/24, 5/13/24, 5/20/24, 5/27/24, 6/3/24.”

“Upon patient record review 1 of 12 (Patient #5) 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 5: The medical record contains the last aide supervisory visit being completed by the RN on 6/17/24, the next one would have been due 7/1/24 this was not completed.”

“Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel 5: There was no evidence in the aide personnel file of an RN making an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation. This lack of oversight is demonstrated by the hospice’s inability to provide documentation of annual competency training and inability to furnish evidence of physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) therapy services being available or provided to patients. Furthermore, hospice aides were found to lack appropriate competency training, as evidenced by incomplete aide plans of care and tasks that were not performed as directed the RN. Additionally, there was insufficient supervision of the hospice aide. A review of patient records revealed that hospice patients lacked documentation confirming receipt of Patient Rights and Responsibilities, Notice of Election, and other required hospice consents. These required documents were either not completed as required, incomplete, or entirely absent from the patient medical records. Additionally, three patients did not have any documented evidence of having signed an election statement for hospice care or consent forms. The plan of care did not show evidence of nursing services being provided in a manner that ensured the continuous assessment of patients as the RN was not completing visits every 15 days as required. Similarly, medical social workers and spiritual care services were found to have completed visits without orders to make visits. Moreover, discharge summaries were not completed with all required elements and submitted to the physician/s. The agency also exhibited a lack of adequate nursing supervision, as there was supervisory visits for hospice aides not consistently conducted and the Director of Nursing failed to review medical records for content verification of the medical record. Furthermore, the hospice failed to maintain patient medical records for the required time period as evidenced by the hospice did not have medical records from the initial survey approximately 3 years ago. Lastly, the hospice agency did not document a patient-specific comprehensive assessment in a timely manner. This assessment, which is required to be completed within 5 days of admission, should have identified the patient’s need for hospice services and addressed physical, emotional, and spiritual care needs. However, there was no evidence that such an assessment was completed, leaving gaps in the provision of hospice care related to palliative management of terminal illnesses and associated conditions.”

“Upon patient record review, 10 of 12 (Patient #1,2,3,4,5,6,7,8,10,11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1: The NOE does not contain evidence the patient was given a choice of attending physician. This area was left blank on the NOE. The NOE start of care date was left blank. Patient 2: The NOE does not contain evidence the patient was given a choice of attending physician. This area was left blank on the NOE. Patient 3: The NOE does not contain evidence the patient was given a choice of attending physician. There was no signature on the notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice. There was a partial signature on the patient line and that was scribbled over and no further signatures was obtained. Patient 4: The NOE did not contains evidence the patient was given a choice of attending physician. Patient 5: The medical record did not contain a signed election election of benefit statement/form. Patient 6: The NOE did not contains evidence the patient was given a choice of attending physician or the date the hospice service was elected. Patient 7,8: The NOE does not contain evidence the patient was given a choice of attending physician. This area was left blank on the NOE. The NOE start of care date was left blank. Patient 10, 11: The medical record did not contain a signed election of benefit statement/forms.”

“Upon patient record review, 3 of 12 (Patient #1,2,12) 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. Patient 1: The SN documented “PCG” in the narrative on 2/19/25. This is not an approved abbreviation. All of the visits by the nurse and aide have not been appropriately authenticated and dated. SN signed off on all visits to correct on site. The agency was not aware the DON needed to approve the visits before the EMR documentation shows the visits are signed and authenticated. Patient 2: All the visits made by the nurse and aide have not been appropriately authenticated and dated. The SN documented “PCG” on 2/13/25. This is not an approved abbreviation. SN signed off on all visits to correct on site. The agency was not aware the DON needed to approve the visits before the EMR documentation shows the visits are signed and authenticated. In addition, the SN documented on 12/31/24 “Patient educated on Atorvastatin”. Pt is not taking Atorvastatin. Patient 12: The SN documented wound care on 3/29/24 and 4/3/24 by restating the order and it is not in past tense to indicate the wound care was completed. The SN documented on 4/17/24, 5/1/24, 5/8/24 “SN performed wound care”. There is not evidence the SN followed the POC.”