Hospice Atlanta

“Based on review of policies titled, “Bill of Rights,” and “Care/Service Coordination,” record review, and staff and family interviews, it was determined the agency failed to protect and promote patient rights for one patient (P) (P2) of three sampled patients. The agency failed to ensure P2 received effective symptom management and failed to investigate and respond to a complaint. Findings include: Review of policy titled, “Bill of Rights,” (revised April 2020) revealed the following: “PROCEDURE2. The Patient Bill of Rights statement defines the right of the patient to:C. Receive an investigation by the organization of complaints made by the patient or the patients’ family or guardian regarding treatment or care that is (or fails to be) furnished, or regarding lack of respect for the patient’s property by anyone furnishing services on behalf of the organization and must document both the existence of the complaint and the resolution of the complaint.W. The right to voice a complaint or concern regarding care or service. The availability of other sources to receive questions and complaints and assist in resolution” Review of policy titled, “Care/Service Coordination,” (revised June 2026) revealed the following:POLICYTimely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. 4. Care coordination will include, but not be limited to:C. Regularly occurring telephone or email communication among team membersF. Appropriate involvement of the patient and caregiversH. Proper communication upon “hand-off’ of patient, including the opportunity for questions between the giver and receiver of patient informationI. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.J. Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities6. Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication9. All organization personnel involved in patient care/service, including those providing contracted services, will have access to the plan of care/service and all other relevant patient information to ensure coordination and continuity. All personnel will be knowledgeable regarding patient needs, goals of care, and services.” Record review revealed patient P2 received hospice services beginning 05/22/2026, until date of death, 06/26/2026. Review of P2’s clinical record and agency on call log revealed family member of P2 called on Sunday, 05/31/2026, at 10:57 AM to report, “Foley issues,” stating urine was cloudy, like “thick coffee with creamer,” with a strong odor. The triage nurse who received the call then contacted Registered Nurse (RN) AA at 11:06 AM “for visit to assess.” Review of Coordination Note dated 05/31/2026, by RN AA, acknowledged receiving the call and revealed P2’s Registered Nurse Case Manager (RNCM) “will address this on Tuesday” (06/02/2026). No visit was made. Review of Coordination Note by RNCM for P2 revealed a nursing visit on 06/02/2026. The physician was called and an antibiotic ordered received to treat a urinary tract infection (UTI). Review of Coordination Note by P2’s RNCM, dated 06/04/2026, at 03:06 PM, revealed the antibiotic was not delivered yet, but “should arrive tonight or in AM.” Review of pharmacy records for P2 revealed the antibiotic was not ordered from the pharmacy until 06/04/2026. Review of Coordination Note by Licensed Practical Nurse (LPN) BB, dated 06/25/2026, revealed P2’s family member “expressed concerns regarding her experience” and that those concerns were communicated to the Administrator. On 08/19/2026, at 11:06 AM, an office interview was conducted with LPN BB, who confirmed receiving a complaint from P2’s family member and reporting those concerns to the Administrator. On 08/20/2026, at 09:30 AM, an office interview was conducted with the Administrator, who revealed multiple patients with same/similar last names and the wrong family was called when the complaint was received. The Administrator agreed that the family member of P2 did not receive a follow-up and the complaint was not investigated. On 08/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who revealed requesting a nurse visit on 05/31/2026, but no visit made until two days after the request. Cross reference to L0509 relating to complaint investigationCross reference to L0512 relating to patients’ right to receive effective pain and symptom management”

“Based on review of policies titled, Governing Body,” “Bill of Rights,” and “Complaint/Grievance Process, record review, and complainant and staff interviews, it was determined the agency’s governing body failed to organize, manage, and administer its services to ensure the health and safety of hospice patients. Specifically, the agency failed to investigate a complaint from the family of patient (P) (P2), provide on-call staff 24 hours a day, seven days a week to meet the needs of the patient, and maintain the patients’ rights by failing to provide effective pain and symptom management in a timely manner. Findings include: Review of policy titled, “Governing Body,” No. 8-002, revised June 2026, revealed the following:POLICYThe Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services, fiscal operations, review of the organization’s budget and its operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body of Visiting Nurse will serve as the governing authority for the home care program, which will function according to Visiting Nurse’s bylaws. PROCEDUREA. The governing body will ensure the following:5. That clear expectations for patient safety are established, implemented, and maintained.B. Other information relevant to the quality of patient care (i.e., unusual occurrences in care delivered) is also consistently provided through a defined process. Review of policy titled, “Bill of Rights,” No. 9-005, revised April 2020, revealed the following:PROCEDURE2. The Patient Bill of Rights statement defines the right of the patient to:C. Receive an investigation by the organization of complaints made by the patient or the patients’ family or guardian regarding treatment or care that is (or fails to be) furnished, or regarding lack of respect for the patient’s property by anyone furnishing services on behalf of the organization and must document both the existence of the complaint and the resolution of the complaint.W. The right to voice a complaint or concern regarding care or service. The availability of other sources to receive questions and complaints and assist in resolution. Review of policy titled, “Complaint/Grievance Process,” No. 9-003, revised April 2020, revealed the following: POLICYAny difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Visiting Nurse/Hospice Atlanta concerning any aspect of services or the application of policies or procedures will be considered a grievance.The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization. The organization shall be responsible for asking the necessary questions to determine cause of injuries.PROCEDURE4. Complaints and any action taken will be documented on a complaint form.5. Corrective action will be specific and related to the complaint.6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. Review of the clinical record for P2 revealed a client coordination note dated 06/26/2026, completed by the Licensed Practical Nurse (LPN) BB, documented that the family of P2 had expressed concerns regarding their experience and that the concerns had been communicated to the Administrator. Review of agency’s complaint log for dates of May 2026, June 2026, and July of 2026, failed to reveal complaints relating to P2. On 08/19/2026, at 11:06 AM, an office interview was conducted with LPN BB, who revealed family member of P2 was unhappy in general with the care received from the agency and confirmed reporting those concerns to the Administrator. On 08/19/2026, at 1:00 PM, an office interview was conducted with the Administrator who revealed that she did not recall the conversation with the LPN BB advising her of the family of P2’s concerns. The Administrator further revealed LPN BB had reminded her this morning, 08/19/2026, of the conversation in which the family’s concerns had been communicated to her. The Administrator acknowledged LPN BB’s documentation and stated, “I’ll have to own that.” On 08/20/2026, at 09:30 AM, an office interview was conducted with the Administrator, who revealed multiple patients with same/similar last names and that the wrong family was called when complaint was received. The Administrator confirmed that P2’s family member did not receive a follow-up investigation of the complaints. On 08/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who restated the complaints submitted and revealed that the hospice was generally slow to respond to any questions or concerns. Review of coordination notes revealed P2 received a regularly scheduled Registered Nurse Case Manager (RNCM) visit on 06/02/2026. The physician was called and an antibiotic was ordered. A physician’s order for an antibiotic is dated 06/02/2026, at 02:49 PM. Review of RNCM note on 06/04/2026, at 03:06 PM, revealed the antibiotic was not delivered yet but “should arrive tonight or in AM.” Review of pharmacy records revealed the antibiotic was ordered for same day delivery on 06/04/2026, but failed to include a time of delivery. Cross refer to L0509 and L0512 related to patient rightsCross refer to L0653 related to availability of staff on a 24-hour basis seven days a week”

“Based on review of agency policy titled, “On-Call/Weekend Services,” record review, and staff and family interviews, it was determined the agency failed to comply with the State Regulation of the nursing services’ one-hour response time when there is notification by a patient or family member of a patient experiencing a crisis or change in condition. Findings included: Review of policy titled, “ON-CALL/WEEKEND SERVICES,” No. 1-012, dated January 2023, revealed the following: POLICY Patient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends. There will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends. GUIDELINES The following list is meant to guide the on-call nurse. It is not an exhaustive list but includes many problems that may require a visit from the hospice nurse. • Patient/family/caregiver perceives a problem and requests a visit PROCEDURE 8. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page). Review of an on-call note dated 05/31/2026, revealed that on 05/31/2026, at 10:57 EDT, the family member of patient (P) P2 contacted the hospice regarding concerns with P2’s foley catheter. The documentation revealed that P2’s family member reported that she observed sediment in the P2’s foley catheter tubing and that the urine was very cloudy. Further review of the on-call note dated 05/31/2026, revealed that the triage nurse documented contacting the on-call registered nurse (RN) AA on 05/31/2026, at 11:06 EST, regarding the family’s reports of P2’s foley catheter concerns. Review of the client coordination note dated 05/31/2026, completed by the RN AA revealed a return call to family informing that the registered nurse case manager (RNCM), “will address this on Tuesday,” 06/02/2026. Review of clinical record revealed a routine scheduled RNCM visit to P2 on Tuesday, 06/02/2026. P2 was observed to have amber urine with sediment and reported to have agitation over weekend. On 08/19/2026 at 10:30 AM, a telephone interview was conducted with RN AA, who revealed full-time position as RNCM but sometimes works on call when needed. RN AA did not remember the on-call events or P2. On 08/20/2026 at 11:40 AM, a telephone interview was conducted with the family member of P2, who restated complaints and revealed she requested a nurse visit on 05/31/2026 but a visit was not made until two days later. Findings included: Review of policy titled, “On-Call/Weekend Services,” No. 1-012, dated January 2023, revealed the following: POLICYPatient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends.There will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends. GUIDELINESThe following list is meant to guide the on-call nurse. It is not an exhaustive list but includes many problems that may require a visit from the hospice nurse.Patient/family/caregiver perceives a problem and requests a visit.PROCEDURE8. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page). Review of an on-call note dated 05/31/2026, revealed that on 05/31/2026, at 10:57 AM, the family member of P2 contacted the hospice regarding concerns with P2’s foley catheter. The documentation revealed that P2’s family member reported that she observed sediment in the P2’s foley catheter tubing and that the urine was very cloudy. Further review of the on-call note dated 05/31/2026, revealed that the triage nurse documented contacting the on-call Registered Nurse (RN) AA on 05/31/2026, at 11:06 AM, regarding the family’s reports of P2’s foley catheter concerns. Review of the client coordination note dated 05/31/2026, completed by the RN AA, revealed a return call to family informing that the Registered Nurse Case Manager (RNCM), “will address this on Tuesday,” 06/02/2026. Review of the clinical record revealed a routine scheduled RNCM visit to P2 on Tuesday, 06/02/2026. P2 was observed to have amber urine with sediment and reported to have agitation over weekend. On 08/19/2026, at 10:30 AM, a telephone interview was conducted with RN AA, who revealed full-time position as RNCM but sometimes worked on call when needed. RN AA did not remember the on-call events or P2. On 08/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who restated complaints and revealed she requested a nurse visit on 05/31/2026, but a visit was not made until two days later.”

“Based on review of policies titled, “Bill of Rights” and “Complaint/Grievance Process,” record review, and staff and family interviews, it was determined the agency failed to investigate a complaint for one patient (P) (P2) of three sampled patients. Findings include:Review of policy titled, “Bill of Rights,” (revised April 2020) revealed the following: “PROCEDURE2. The Patient Bill of Rights statement defines the right of the patient to:C. Receive an investigation by the organization of complaints made by the patient or the patients’ family or guardian regarding treatment or care that is (or fails to be) furnished, or regarding lack of respect for the patient’s property by anyone furnishing services on behalf of the organization and must document both the existence of the complaint and the resolution of the complaint.W. The right to voice a complaint or concern regarding care or service. The availability of other sources to receive questions and complaints and assist in resolution.” Review of policy titled, “Complaint/Grievance Process,” (revised April 2020) revealed the following:“POLICYAny difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Visiting Nurse/Hospice Atlanta concerning any aspect of services or the application of policies or procedures will be considered a grievance.The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization. The organization shall be responsible for asking the necessary questions to determine cause of injuries.”PROCEDURE4. Complaints and any action taken will be documented on a complaint form.5. Corrective action will be specific and related to the complaint.6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. Review of agency’s complaint log for dates of May 2026, June 2026 and July of 2026, failed to reveal complaints relating to P2.” Review of the clinical record revealed P2 received hospice services from 05/22/2026, until date of death on 06/26/2026. Review of a document titled, “Visit Note Report,” revealed that on 06/25/2026, P2’s family member “expressed concerns regarding her experience” during a visit with Licensed Practical Nurse (LPN) BB and that those concerns were communicated to the Administrator. On 08/19/2026, at 11:06 AM, an office interview was conducted with LPN BB, who revealed family member of P2 was unhappy in general with the care received from the agency and confirmed reporting concerns to the Administrator. On 08/20/2026, at 09:30 AM, an office interview was conducted with the Administrator, who revealed multiple patients with same/similar last names and that the wrong family was called when complaint was received. The Administrator agreed that P2’s family member did not receive a follow-up investigation of the complaints. On 08/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who restated the complaints submitted and revealed that the hospice was generally slow to respond to any questions or concerns.”

“Based on review of policies titled, “Care/Service Coordination” and “On-Call/Weekend Services,” record review, and staff and family interviews, it was determined the agency failed to ensure patients receive effective symptom management for one patient (P) (P2) of three sampled patients. Findings include: Review of policy titled, “Care/Service Coordination” (revised June 2026) revealed the following:“POLICYTimely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel.4. Care coordination will include, but not be limited to:C. Regularly occurring telephone or email communication among team membersF. Appropriate involvement of the patient and caregiversH. Proper communication upon “hand-off’ of patient, including the opportunity for questions between the giver and receiver of patient informationI. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.J. Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities6. Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication9. All organization personnel involved in patient care/service, including those providing contracted services, will have access to the plan of care/service and all other relevant patient information to ensure coordination and continuity. All personnel will be knowledgeable regarding patient needs, goals of care, and services.” Review of a policy titled, “On-Call/Weekend Services,” (dated January 2023) revealed the following:“POLICYPatient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends.GUIDELINESThe following list is meant to guide the on-call nurse. It is not an exhaustive list, but includes many problems that may require a visit from the hospice nurse.Patient/family/caregiver perceives a problem and requests a visit” Clinical records review revealed family member of P2 called the agency on Sunday, 05/31/2026, to report “Foley issues,” stating urine cloudy, like “thick coffee with creamer,” with a strong odor and patient not able to report symptoms. Registered Nurse (RN) AA was contacted at 11:06 AM “for visit to assess.” A Coordination Note by RN AA, dated 05/31/2026, revealed a conversation with the family member and that P2’s Registered Nurse Case Manager (RNCM) “will address this on Tuesday” (06/02/2026). Review of Coordination notes further revealed P2 received a regularly scheduled RNCM visit on 06/02/2026. The physician was called and an antibiotic was ordered. A physician’s order for an antibiotic is dated 06/02/2026 at 02:49 PM. Review of RNCM note on 06/04/2026, at 03:06 PM, revealed the antibiotic was not delivered yet but “should arrive tonight or in AM.” Review of pharmacy records revealed the antibiotic was ordered for same day delivery on 06/04/2026, but failed to include a time of delivery. On 08/19/2026, at 10:30 AM, a telephone interview was conducted with RN AA, who revealed she normally worked as a RNCM, but acknowledged being on call 05/31/2026. RN AA did not recall P2 or events 05/31/2026. On 8/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who revealed she requested a nurse visit on 05/31/2026, and confirmed a visit was not made until two days later.”

“Based on review of policy titled, “On-Call/Weekend Services,” records review, and staff and family interviews, the hospice agency failed to ensure nursing services were made available on a 24-hour basis 7 days a week and failed to provide a timely nursing assessment and intervention to meet the needs of the patient for one patient (P) (P2) of three patients reviewed. Findings include: Review of policy titled, “On-Call/Weekend Services,” No. 1-012, dated January 2023, revealed the following:PURPOSETo establish the process by which patients have access to hospice services 24 hours per day.POLICYPatient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends.There will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends. PROCEDURE1. On admission, the patient will be made aware of the organization’s 24-hour availability.8. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page). Review of an on-call note dated 05/31/2026, revealed that on 05/31/2026, at 10:57 AM, the family member of P2 contacted the agency to report that she observed sediment in P2’s foley catheter tubing and that the urine was very cloudy. Review of a client coordination note dated 05/31/2026, completed by the on-call Registered Nurse (RN) AA, revealed that she returned a phone call to family and informed P2’s family member that the Registered Nurse Case Manager (RNCM), “will address this on Tuesday,” 06/02/2026. Further review of clinical record revealed no documented evidence that a nurse made a visit to see P2 on 05/31/2026, or 06/01/2026, to assess P2’s Foley catheter concerns reported by the family member on 05/31/2026. Review of clinical record revealed a routine scheduled RNCM visit to P2 on 06/02/2026. P2 was observed to have amber urine with sediment and reported to have agitation over weekend. On 08/19/2026, at 10:30 AM, a telephone interview was conducted with RN AA, who revealed full-time position as RNCM but sometimes works on call when needed. RN AA did not remember the on-call events or P2. On 08/20/2026, at 11:40 AM, a telephone interview was conducted with the complainant, who restated complaints and revealed she requested a nurse visit on 05/31/2026, but a visit was not made until two days later.”

“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. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medications. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the drug profile was updated. Home Visit 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility [SNF]. During the home visit observation with the Hospice Aide (staff 2), a medication review was completed by comparing the hospice medication profile with the medication administration record [MAR] from the SNF. The SNF MAR included Bisacodyl 10MG suppository every 72 hours as needed for constipation and Acetaminophen suppository 650MG every 24 hours as needed for pain or fever greater than 100.5 degrees Fahrenheit. The hospice plan of care dated 05/03/2024 and medication profile did not include Bisacodyl and Acetaminophen suppository. Home Visit 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The patient resided in a SNF. During the home visit observation with the Medical Social Worker (staff 3), a medication review was completed by comparing the hospice medication profile with the MAR from the SNF. The SNF MAR included Metoprolol succinate Extended-Release 50MG tablet. The hospice plan of care dated 04/18/2024 and medication profile did not include Metoprolol. Home Visit 4: The patient elected the hospice benefit on 03/17/2024 with a terminal diagnosis of Parkinson’s disease. The patient resided in a SNF. During the home visit observation with the Chaplain (staff 4), a medication review was completed by comparing the hospice medication profile with the MAR from the SNF. The SNF MAR included Acetaminophen 325MG tablet, Dilaudid oral liquid 1MG/1ML, Ipratropium-albuterol inhaled solution 0.5-2.5 (3) MG/3ML every 12 hours as needed for shortness of breath/cough/difficulty breathing/abnormal breath sounds, and Sinemet 25MG-100MG tablet. The hospice plan of care dated 04/18/2024 and medication profile did not include Acetaminophen, Dilaudid, Ipratropium-albuterol, and Sinemet. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the plans of care and medication profiles had not been updated to include medications given by the skilled nursing facility staff.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the IDG. Clinical Record 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The initial plan of care dated 10/21/2023 and updated on 11/21/2023, 12/05/2023, and 12/20/2023 included the order for “Hospice nurse to perform wound care to laceration on right lateral ankle… change every day and PRN (as needed).” The updated plan of care dated 01/03/2024 did not include the daily wound care order. The clinical record contained no documented evidence that the hospice nurse completed daily visits and performed wound care to the right lateral ankle as ordered from 10/22/2023 through 01/03/2024. Clinical Record 17: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The bereavement plan of care dated 11/15/2023 included an intervention for the Bereavement Coordinator to make monthly phone calls. The clinical record contained no documented evidence that the Bereavement Coordinator completed the telephone call with the bereaved in December 2023 or documentation of why the call was not made. Clinical Record 18: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The bereavement plan of care included an intervention for the bereavement coordinator to make monthly phone calls. The clinical record contained no documented evidence that the Bereavement Coordinator completed the telephone call with the bereaved in December 2023 or documentation of why the call was not made. Clinical Record 19: The patient elected the hospice benefit on 03/09/2023. The patient died at home on 06/12/2023. The bereavement plan of care dated 06/14/2023 included an intervention for grief-related mailings at two (2) weeks, three (3) months, and nine (9) months after death and telephone calls from the Bereavement Coordinator one (1) and six (6) months after the patient’s death. Although the Bereavement Care Lead provided a spreadsheet tracking bereavement services and a personal notebook documenting the services were provided, the clinical record contained no documented evidence that the mailings and telephone calls identified in the bereavement plan of care had been completed. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the hospice nurse had not completed daily visits and provided wound care as ordered on the initial and updated plans of care. The leaders also confirmed that the clinical records did not include documentation to indicate the bereavement plan of care was followed.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The initial nursing comprehensive assessment dated 05/03/2022 included documentation that the patient was a fall risk with a fall risk score of nine out of ten. The assessment also described the patient as bedbound, non-ambulatory, incontinent of bowel and bladder, and cachectic with a comorbid condition of severe protein-calorie malnutrition. The initial plan of care dated 05/03/2022 did not include patient and family goals and planned interventions associated with the fall and skin integrity risks identified in the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 02/10/2024 with a terminal diagnosis of Parkinson’s disease. The initial nursing comprehensive assessment dated 02/10/2024 included documentation that the patient’s blood sugar was checked daily. The initial plan of care dated 02/10/2024 included the goal, “Blood glucose levels… managed according to MD (Doctor of Medicine) parameters.” The plan of care dated 02/10/2024 through 05/09/2024, did not contain measurable outcomes and planned interventions associated with diabetes and the need for daily glucose monitoring. Clinical Record 6: The patient elected the hospice benefit on 03/30/2024 with a terminal diagnosis of end stage heart failure. The initial nursing comprehensive assessment dated 03/30/2024 included documentation that the patient had an internal cardiac defibrillator and pacemaker in place and was receiving hyperbaric treatment for a pressure ulcer on the left inner ankle. The initial plan of care dated 03/30/2024 did not include patient and family goals and planned interventions associated with the internal cardiac defibrillator and wound identified in the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 09/15/2023 with a terminal diagnosis of Alzheimer’s disease. The initial nursing comprehensive assessment dated 09/15/2023 included documentation that the patient had a history of recurrent aspiration pneumonia and received four (4) cans of 1.5CAL (calorie) Jevity, a nutritional supplement, and prescribed medications each day through a gastrostomy tube. The initial plan of care dated 09/15/2023 did not include patient and family goals and planned interventions associated with the patient’s risk for aspiration, care of the gastrostomy site, and maintaining gastrostomy tube patency. Clinical Record 13: The patient elected the hospice benefit on 11/04/2023 with a terminal diagnosis of malignant neoplasm of the colon. The initial nursing comprehensive assessment dated 11/04/2023 included documentation that the patient had a terminal diagnosis of malignant neoplasm of the colon, a history of constipation, and a one (1) year history of seizures requiring scheduled Keppra [medication for seizures] 1000MG daily. The initial plan of care dated 11/04/2023 did not include patient and family goals and planned interventions associated with constipation and seizure risks identified in the comprehensive assessment. Clinical Record 14: The patient elected the hospice benefit on 08/26/2023 with a terminal diagnosis of cerebral infarction. The initial nursing comprehensive assessment dated 08/26/2023 included documented that the patient had a history of aspiration pneumonia, received Osmolite 1.5CAL (calorie), a nutritional supplement, and prescribed medications through a gastrostomy tube, and had a tracheostomy tube (size 6.0) in place to aid breathing. The plan of care dated 08/26/2023 did not include patient and family goals and planned interventions associated with the patient’s risk for aspiration, gastrostomy site care and management, and tracheostomy site care and management. Clinical Record 15: The patient elected the hospice benefit on 05/12/2023 with a terminal diagnosis of cerebral infarct. The initial nursing comprehensive assessment dated 05/12/2023 included documentation that the caregiver performed blood sugar checks before meals and bedtime (AC and HS) and administered insulin as ordered. The initial plan of care dated 05/12/2023 included the goal, “Blood glucose levels… managed according to MD parameters.” The plans of care, effective 05/12/2023 and reviewed and updated no less frequently than every 15 days through the discharge date of 03/06/2024, did not contain measurable outcomes and planned interventions associated with diabetes management and the need for AC and HS glucose monitoring. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the written plans of care did not include patient and family goals and planned interventions for problems identified during the initial comprehensive assessments including the risks associated with falls, skin integrity, seizures, and aspiration, the care and management of gastrostomy and tracheostomy sites, and glucose monitoring.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 9 (11%) clinical records reviewed with Licensed Practical Nurse (LPN) services provided, the agency did not ensure the Registered Nurse (RN) supervised the LPN services as required by agency policy. Agency policy No. 1-031 RESPONSIBILITIES/SUPERVISION OF CLINICAL SERVICES, no date, stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.” Clinical Record 6: The plan of care dated 03/30/2024 included an order for the Skilled Nurse (SN) to provide nursing visits at a frequency of two visits per week. Clinical record review revealed the LPN completed one skilled nurse visit per week since 03/30/2024. The clinical record contained no documented evidence that the RN completed monthly LPN supervisory visit for April 2024, as of the date of record review on 05/10/2024. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that an LPN supervisory visit was not completed monthly, per the agency’s policy, for the clinical record identified. Leaders also confirmed that “monthly,” referred to in the “Responsibilities/Supervision of Clinical Services” policy, was recognized by the agency as a calendar month.”

“It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure that the bereavement plan of care included the frequency of service delivery. Clinical Record 17: The patient elected the hospice benefit on 02/21/2024. The patient died at the skilled nursing facility on 02/29/2024. The identified bereaved were determined to be at low risk for complicated grief by the Interdisciplinary Group (IDG) and a “low risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 03/13/2024. The bereavement plan of care included interventions to provide supplemental materials (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, and connect bereaved with community resources. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, and community resource connections would be performed. Clinical Record 18: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The identified bereaved were assessed to be at high risk for complicated grief by the IDG and a “high risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 11/15/2023. The bereavement plan of care included interventions to provide supplemental materials as needed (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, grief education, and address complex grief issue. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, education, and complex grief would be performed. Clinical Record 19: The patient elected the hospice benefit on 03/09/2023. The patient died at home on 06/12/2023. The identified bereaved were assessed to be at moderate risk for complicated grief by the IDG. A “moderate risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 06/14/2023. The bereavement plan of care included interventions to provide supplemental materials as needed (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, grief education, and address complex grief issue. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, education, and complex grief would be performed and addressed. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that the bereavement plans of care did not include frequencies for all services to be provided.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. 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 13 (31%) clinical records reviewed with hospice aide services provided, the agency did not ensure that the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the initial nursing assessment dated 10/21/2023 included documentation that the patient had a fall risk score of ten out of ten indicating the patient was at risk for falls, and the patient had sustained a right hip fracture from a fall before electing hospice services. The hospice aide care plan assignment dated 10/21/2023 and updated on 04/25/2024 assigned the aide the tasks: seated shower, transfer from bed/chair, transfer from chair/bed, and use of gait belt. The aide care plan did not include information to alert the aide to the patient’s high fall risk. Clinical Record 4: The patient elected the hospice benefit on 03/17/2024 with a terminal diagnosis of Parkinson’s disease. Clinical record review revealed the initial nursing assessment dated 03/17/2024 included documentation that the patient had a fall risk score of eight out of ten indicating the patient was at risk for falls. The aide care plan assignment dated 03/17/2024 and updated on 04/20/2024 assigned the aide to provide the patient with a seated shower at each visit. The aide care plan did not include information to alert the aide of the patient’s fall risk or safety measures to be taken. Clinical Record 6: The patient elected the hospice benefit on 03/30/2024 with a terminal diagnosis of end stage heart failure. Clinical record review revealed the initial nursing assessment dated 03/30/2024 included documentation that the patient had an internal cardiac defibrillator with a pacemaker as well as a fall risk score of nine out of ten indicating the patient was at risk for falls. The hospice aide care plan assignment dated 03/30/2024 and updated on 05/08/2024 included instructions for the aide to provide a seated shower and ensure the patient used a rollator walker when ambulating. The care plan did not alert the aide to the patient’s internal defibrillator and the risk of falls or safety measures to be taken. Clinical Record 13: The patient elected the hospice benefit on 11/04/2023 with a terminal diagnosis of end stage heart failure. Clinical record review revealed the nursing assessment completed on 11/04/2023 included documentation that the patient had a secondary diagnosis of metastatic cancer to the brain, a history of seizures, and a fall risk score of seven out of ten indicating the patient was at risk for falls. The initial aide care plan dated 11/04/2023 and updated aide care plan dated 01/15/2024 included instructions for the aide to provide the patient with a standing shower. The aide care plan did not alert the aide to the patient’s risk for seizures and falls or safety measures to be taken. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that the Registered Nurse did not alert the aide to possible patient and staff risks associated with falls, seizures, and the internal cardiac defibrillator.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes in the patient’s care needs to the Registered Nurse as they related to changes needed in the plan of care. Clinical Record 9: The patient elected the hospice benefit on 07/04/2023. Clinical record review revealed the hospice aide completed visits on 03/20/2024, 03/22/2024, 03/29/2024, and 05/08/2024 and documented that mouth care was not completed as instructed because the patient was “unable to tolerate.” The clinical record contained no documented evidence that the hospice aide reported a change in the patient’s medical needs to the Registered Nurse. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the clinical record did not contain documented evidence that the hospice aide reported changes in the patient’s ability to tolerate mouth care during the identified visits to the Registered Nurse.”

“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 3 of 13 (23%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed and documented an on-site visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days. Clinical Record 3: The plan of care order dated 04/18/2024 through 06/16/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 04/18/2024. The next on-site supervisory visit by the RN was documented on 05/07/2024, a total of 19 days after the 04/18/2024 visit and 5 days outstanding. Clinical Record 4: The plan of care order dated 03/17/2024 through 06/14/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. The RN documented an on-site supervisory visit was completed on 04/15/2024. The next on-site supervisory visit by the RN was documented on 05/07/2024, a total of 22 days after the 04/15/2024 visit and 7 days outstanding. Clinical Record 6: The plan of care order dated 03/30/2024 through 06/27/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. There was no documented evidence in the clinical record that the RN had completed an on-site supervisory visit between the start of hospice aide services on 04/03/2024 and the last RN visit dated 05/04/2024, a total of 31 days. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed aide supervisory assessments were not documented by the RN as completed every 14 days.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for care and services provided. Agency policy No. 1-003 PHYSICIAN ORDERS AND PARTICIPATION IN PLAN OF CARE, (Rev 4.0 Jan 2024), stated in part, “Physician ... orders will be individualized, based on patient’s needs, and include: ...Treatments and/or procedures needed, including type, frequency, duration, and goals.” Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility [SNF]. During the home visit observation with the Hospice Aide (staff 2), a treatment review was completed by comparing the hospice plan of care with the treatment record from the SNF. The SNF treatment record included 2.0CAL (calorie) Supplement 120ML twice a day. The hospice plan of care dated 04/22/2024 did not include an order for 2.0CAL Supplement. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The patient resided in a SNF. During the home visit observation with the Medical Social Worker (staff 3), a treatment review was completed by comparing the hospice plan of care with the treatment record from the SNF. The SNF treatment record included orders for the patient to have a pureed texture/honey consistency diet, and knee-high compression stockings to the right lower extremity. The hospice plan of care dated 04/18/2024 did not include an order for pureed texture/honey consistency diet, and knee-high compression stockings to the right lower extremity. Clinical Record 12: The patient elected the hospice benefit on 08/15/2023 with a terminal diagnosis of senile degeneration of the brain. The nursing comprehensive assessment dated 08/15/2023 included documentation that the patient consumed two to three cans of the nutritional supplement, Ensure daily. The clinical record clinical record contained no documented evidence of a physician order for Ensure. Clinical Record 14: The updated plan of care order dated 04/22/2024 ordered an indwelling urinary catheter to be inserted, maintained, and irrigated with sterile normal saline. The order did not include the amount of irrigation solution to be used and the frequency of irrigation. Clinical Record 16: The patient elected the hospice benefit on 08/25/2023 with a terminal diagnosis of malignant neoplasm of the bronchus and lung. The nursing assessment dated 08/31/2023 included documentation that the patient was drinking three cans of Ensure per day and that the patient’s blood sugar was being checked weekly. The clinical record contained no documented evidence of a physician order for Ensure and weekly blood sugar checks. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the clinical records did not include complete physician orders.”