Soleil Hospice, LLC

“Based on interview and record review, the hospice agency (HA) failed to ensure, the patient’s status and care rendered to one of three patients, (Patient 1) were properly coordinated, when the licensed vocational A (LVN A) did not call and update the family member of Patient 1 health condition after her visit. This failure could affect in the provision of prompt and quality care to patients. Findings:Review of Patient 1’s face sheet (document which provides a complete and comprehensive list of the patient’s medical history) indicated, her start of care with the hospice agency (HA) was 9/13/23 with the principal diagnosis of cerebral atherosclerosis (also known as intracranial atherosclerotic disease, happens when fatty plaque builds up inside the arteries inside the brain). Patient 1 was living at a residential care facility (RCF, provides 24-hour non-medical care for adults who need support doing everyday activities).Review of Patient 1’s hospice plan of care (customized, written roadmap detailing the medical, physical, emotional, and spiritual services a terminally ill patient and their family will receive) for the certification period, from 12/12/23 to 3/10/24 indicated that the clinicians ordered include skilled nursing, once per week for fourteen weeks and twelve as needed visits, beginning during week of 12/14/23 to 3/10/24.During the concurrent review of Patient 1’s clinical records and interview with administrator/director of patient care services (ADM/DPCS) on 7/31/26 at 3:30 p.m., ADM/DPCS confirmed that LVN A visited Patient 1 on 12/8/23. He further confirmed that LVN A did not mention that she contacted the family of Patient 1 to provide updates of the patient’s care and current condition after the visit. ADM/DPCS then stated that clinicians should have update the family about their visit and patient evaluation after they saw them. He also added that he would educate the clinicians to call the family after every patient visit.During the interview with LVN A on 7/31/26 at 3:55 p.m., LVN A verified that she was not able to notify Patient 1’s family after her visit and evaluation on 12/8/23. She further confirmed that she should have called the family of Patient 1 after the visit and evaluation regarding Patient 1 health condition.Review of the hospice agency’s policy titled “Nursing Care,” revised April 2021 indicated, “Nursing services will be provided in accordance with accepted standards of practice……….The hospice nurse will:……….Coordinate all patient and family/caregiver services and prioritization of needs with the interdisciplinary group……….Provide an ongoing evaluation of the patient and family/caregiver response to patient care……….””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) home visit observations and clinical records reviewed, it was revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 12/28/2023 for a diagnosis of cerebral atherosclerosis. The patient resided in an assisted living facility. During the home visit with the Registered Nurse (Personnel Record 4) on 04/02/2025, the hospice medication profile (printed on 04/01/2025) was compared to the Assisted Living medication profile (printed on 04/01/2025). The hospice medication profile contained the following medications not listed on the assisted living medication list: Atropine 1% eye drops, administer 1 drop under tongue every 6 hours as needed for excessive secretions (ordered 12/28/2023); and Permethrin 5% topical cream, apply from the neck to soles of feet and wash off after 8-14 hours, repeat the treatment after 14 days if unresolved (ordered 01/07/2025). The assisted living facility had the following medications not listed on the hospice medication profile: Pseudoephedrine HCL 90 mg, give 1 mg by mouth every 6 hours as needed for nasal congestion (ordered 09/10/2024); and Zinc oxide apply to the groin topically two times a day for incontinence (ordered 02/02/2024). Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 03/21/2025 for a diagnosis of degenerative disease of nervous system. The patient resided in a skilled nursing facility. During the home visit with the Hospice Aide (Personnel Record 7) on 04/02/2025, the hospice medication profile (printed on 04/01/2025) was compared to the skilled nursing facility medication profile (printed on 04/02/2025). The hospice medication profile listed the following medications not on the skilled nursing profile: Metoprolol tartrate 25 mg, take 1 tablet twice daily (ordered 3/28/2025). There was also a Lorazepam order for every 6 hours as needed on the hospice medication list and every 1 hour as needed on the skilled nursing medication list. A joint clinical record review and interview with the Executive Director/Director Patient Care Services was conducted on 04/03/2025, in which she said the “medications should be reconciled at least weekly during the nursing visits.””

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included an initial bereavement assessment of 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. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/05/2025 for malignant neoplasm of the ovaries. The initial nursing comprehensive assessment dated 02/05/2025 documented, “Chaplain to complete” for the bereavement assessment. On 03/13/2025 a Chaplain note documented, “declined spiritual care services.” As of the date of the record review, 04/02/2025, the record lacked documentation that an initial bereavement assessment had been completed. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/14/2025 for chronic obstructive pulmonary disease. The initial nursing comprehensive assessment, dated 03/14/2025, the registered nurse marked “No” to the risk assessment being completed. The initial spiritual care assessment did not include a bereavement assessment. The social worker’s initial visit was refused. As of the date of the record review, 04/02/2025, the record lacked documentation that an initial bereavement assessment had been completed. A joint clinical record review and interview with the Executive Director/Director Patient Care Services was conducted on 04/02/2025, in which she agreed the initial bereavement risk assessment had not been documented for these clinical records.”

“It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 2: The hospice aide care plan dated 12/29/2023 contained the following relevant tasks: “recognize and report any changes in skin condition, shower, skin care, assist patient with dressing, foot care, assist with transfers, and incontinent care.” All tasks were ordered to be completed every visit with an aide visit frequency of twice weekly. The initial nursing assessment dated 12/28/2023 noted the “patient was on continuous oxygen at 2 liters per minute.” The aide care plan did not provide specific instructions that the aide could or could not remove the oxygen during tasks. The nursing assessment dated 03/04/2025 noted “wound to right lower leg with Medihoney and silicone dressing.” The hospice aide care plan was not updated to notify the aide of the wounds or to provide the aide with specific instructions to notify the nurse if the dressings became soiled, dislodged, or wet. CLINICAL RECORD 3: The hospice aide care plan dated 03/21/2025 contained the following relevant tasks: “bed bath, bath via shower chair, peri care, skin care, and shampoo.” All tasks were to be completed every visit with an aide visit frequency of twice weekly. The initial nursing assessment dated 03/21/2025 noted the “patient was on continuous oxygen at 2 liters per minute.” The aide care plan did not provide specific instructions that the aide could or could not remove the oxygen during tasks. The nursing assessment dated 03/25/2025 noted, “surgical incision right chest covered with gauze.” The hospice aide care plan was not updated to notify the aide of the wounds or to provide the aide with specific instructions to notify the nurse if the dressings became soiled, dislodged, or wet, nor did it provide the aide with specific instructions regarding the ‘bed bath’ and ‘bath via shower chair’ and when to give each type. CLINICAL RECORD 6: The hospice aide care plan dated 11/28/2024 contained the following relevant tasks: “peri care, bath, skin care, incontinent care, and turn patient every 2 hours.” All tasks were to be completed every visit with an aide visit frequency of twice weekly. The initial nursing assessment dated 11/27/2024 noted the patient to have the following wounds and wound care: “Wound to coccyx packed with gauze, pressure ulcer to right hip covered with dry dressing, and pressure ulcer to left hip covered with dry dressing.” The hospice aide care plan was not updated to notify the aide of the wounds or to provide the aide with specific instructions to notify the nurse if the dressings became soiled, dislodged, or wet. CLINICAL RECORD 13: The hospice aide care plan dated 01/10/2024 contained three bath types: “Bath- complete, shower chair, and bed bath.” It did not provide the aide with specific instructions regarding each bath or when to give each type. A joint clinical record review and interview with the Executive Director/Director Patient Care Services was conducted on 04/02/2025, in which it was agreed the care plans needed to be “more specific, not contain three bath types and should be updated more frequently during the patient’s stay on hospice.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 14 (14%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. CLINICAL RECORD 3/Home Visit 3: The hospice aide care plan dated 03/21/2025 included the following relevant tasks: bathing via bed bath and shower chair, foot care, nail care, oral care, perineal care, shampoo, shaving with a safety razor, and skin care. The aide frequency was twice weekly, and each of these tasks was to be performed every visit. During the home visit on 04/02/2025 with the hospice aide (Personnel Record 7), the aide was observed to perform the following tasks listed on the care plan: bathing via bed bath, perineal care, shampoo, and skin care. She did not perform the following tasks listed on the aide care plan: foot care, nail care, bathing via shower chair, oral care, shaving with a safety razor. The aide also performed the following tasks, which were not listed on the aide care plan: assisted the patient with dressing and changed the bed linens. CLINICAL RECORD 14: The hospice aide care plan dated 11/13/2024 included the following relevant tasks: “all assigned tasks to be completed every visit, catheter care, incontinent care, assist with dressing, foot care, nail care, peri care.” For the Hospice Aide visits, dated 11/26/2024 and 11/19/2024, the aide documented, “changing bedsheets.” This task was not included in the plan of care. The hospice aide care plan was updated on 02/06/2025 and included the following relevant tasks: “skin care, assist with dressing, fall precautions, ROM (range of motion) exercises, nail care, foot care, make bed, change linens, assist with transfers, incontinent care, change diapers, trim nails, report if no BM (bowel movement), shower chair, oral care, and shampoo.” An aide visit dated 02/14/2025 noted “placed patient in a sling to transfer in Hoyer lift to shower chair. Notified nurse.” An aide visit dated 03/05/2025 “placed patient in Hoyer lift for transfer. Notified nurse.” The Hoyer lift was not included in the aide care plans. A joint clinical record review and interview with the Executive Director/Director Patient Care Services was conducted on 04/02/2025, in which she agreed the aides had “not followed the tasks included in the plans of care.””

“It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed in which aide services were accepted revealed the agency did not ensure a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. CLINICAL RECORD 9: Hospice aide services were ordered for a frequency of three times weekly on 07/28/2024. This was renewed on 10/21/2024, 12/23/2024, and 01/20/2025. There was a documented registered nurse supervisory visit on 09/17/2024, and the next one was 10/18/2024 (17 days outstanding). The next documented registered nurse supervisory visit was on 11/04/2024, (3 days outstanding). Between 11/04/2024 and 01/12/2025, there was no documentation of a registered nurse supervisory visit. There was a documented registered nurse supervisory visit on 01/31/2025, and the next one was 02/18/2025 (18 days outstanding). CLINICAL RECORD 13: Hospice aide services were ordered for two times weekly on 01/09/2024. There was a documented registered nurse supervisory visit on 06/18/2024 and the next one documented was 07/07/2024 (19 days outstanding). There was a documented registered nurse supervisory visit on 09/20/2024 and the next one was on 10/16/2024, (12 days outstanding). A joint clinical record review and interview with the Executive Director/Director Patient Care Services was conducted on 04/02/2025, in which she confirmed lack of documentation of the registered nurse supervisory visits and stated they “already had a new process in place to track these.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program documents revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review were conducted with the Executive Director and Owner on 04/03/2025 and the volunteer percentage for the past year (March 2024 to March 2025) in either an administrative or patient care role, was calculated at 2%. They described difficulty with recruitment and said they had recently hired a new Volunteer Coordinator. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review was conducted with the Executive Director and Owner on 04/03/2025 and the volunteer percentage for the past year (March 2024 to March 2025) in either an administrative or patient care role, was calculated at 2%. They described difficulty with recruitment and had recently hired a new Volunteer Coordinator.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed the agency did not ensure the hospice assessed the skills and competencies of all individuals providing care, including volunteers providing services. Agency Policy #501, Staff Competency (effective October 2020), stated in relevant part, “Purpose: To ensure that employees and volunteers maintain competencies and knowledge levels. 9. Competency is addressed as part of the annual performance evaluation of the clinical staff.” Personnel Record 3: A Registered Nurse, hired on 04/12/2022, did not have documentation of annual skills competencies for 2023 or 2024, in accordance with agency policy. A joint clinical record review and interview with the Executive Director/Director Patient Care Services (DPCS) was conducted on 04/02/2025, in which she explained that since the previous DPCS had left, “they were unable to locate many parts of employees’ files. She may have done something with them.””