Hands of Hope Hospice

“It is required that each patient’s individualized written plan of care: 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 12/06/2023. On 12/06/2023, the physician ordered oxygen. The POC dated 12/06/2023 documented a goal for shortness of breath. The POC did not document interventions specific to the administration of oxygen. On 03/14/2024, the physician ordered wound care for the coccyx, calf, and foot. The POC dated 03/27/2024 documented a goal for skin integrity and an intervention for the coccyx, calf, and foot wounds. The POC did not document an intervention with the specific wound care for each wound. Clinical Record 12: The patient elected hospice care on 02/03/2023. The narrative for the Certificate of Terminal Illness (CTI) dated 03/27/2024 for the certification period dated 03/29/2024 through 05/27/2024 documented the patient had a stage 2 coccyx wound. The POC dated 03/27/2024 documented a goal for skin Integrity and an intervention for coccyx wound care. The POC did not document an intervention with the specific wound care for the stage 2 coccyx wound. Clinical Record 15: The patient elected hospice care on 01/18/2024. The narrative for the CTI dated 01/18/2024 for the certification period dated 01/18/2024 through 04/16/2024) documented that the patient had “unhealing chronic open wounds on the face.” On 01/24/2024, the physician ordered wound care for the facial wounds. The POC dated 01/24/2024 documented a goal for skin integrity and an intervention for wound care for facial wounds. The POC did not document an intervention with the specific wound care for each facial wound. During an interview and a joint clinical record review on 04/10/2024, the Vice President (VP) of Accreditation, Regulations, and Education, the Administrator, the Director of Patient Care Services, and the Regional Vice President of Operations confirmed that the plans of care did not include the specific interventions being done based on problems identified in the initial and updated comprehensive assessments. The VP of Accreditation, Regulations, and Education launched an action plan prior to the end of the site visit.”

“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. This standard was not met as evidenced by clinical record review and interview. In 5 of 17 (29%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure the Hospice Aide reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 1: The patient elected hospice care on 12/06/2023. The aide care plan dated 01/10/2024 assigned the HA the relevant tasks: “Shampoo and Change Linens.” The HA visit notes dated 03/13/2024 and 04/08/2024 documented: “Shampoo: Completed: N... Patient refused...Change Linens: Completed: N... Patient refused bed clean.” A clinical record review revealed no evidence that the HA reported the changes in the patient’s care needs to the RN. Clinical Record 2: The patient elected hospice care on 05/26/2022. The aide care plan dated 08/17/2023 assigned the HA the relevant task: “Change Linens.” The aide visit notes dated 03/21/2024 and 04/05/2024 documented, “Change Linens: Completed: N... Patient refused; bed clean.” A clinical record review revealed no evidence that the HA reported the changes in the patient’s care needs to the RN. Clinical Record 9: The patient elected hospice care on 11/10/2023. The aide care plan dated 11/10/2023 assigned the HA the relevant tasks: “Shower, Shampoo, and Change Linens.” The aide visit note dated 11/20/2023 documented: “Shower: Completed: N... Patient refused shower...Shampoo: Completed: N...Patient refused, feeling weak in energy... Change Linens: Completed: N...Patient refused, bed clean.” A clinical record review revealed no evidence that the HA reported the changes in the patient’s care needs to the RN. Clinical Record 17: The patient elected hospice care on 03/22/2024. The aide care plan dated 03/22/2024 assigned the HA the relevant task: “Change Linens.” The aide visit notes dated 03/26/2024 and 04/11/2024 documented: “Change Linens: Completed: N... Patient refused.” A clinical record review revealed no evidence that the HA reported the changes in the patient’s care needs to the RN. Clinical Record 19: The patient elected hospice care on 08/02/2023. The aide care plan dated 08/03/2023 assigned the HA the relevant tasks: “Shower and Nail Care.” The aide visit note dated 04/11/2024 documented: “Shower: Completed: N... Patient refused...Nail Care: Completed: N... Patient refused.” A clinical record review revealed no evidence that the HA reported the changes in the patient’s care needs to the RN. During an interview and a joint record review on 04/10/2024, the Vice President (VP) of Accreditation, Regulations, and Education, the Administrator, the Director of Patient Care Services, and the Regional Vice President of Operations stated that the Hospice Aide did not report changes in the patient’s care needs to the RN as the changes related to the aide care plan. The VP of Accreditation, Regulations, and Education launched an action plan prior to the end of the site visit.”

“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 agency’s “Hospice Volunteer Requirement Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Document 2: The “Hospice Volunteer Requirement Report” for 2024 quarter one documented that the volunteer percentage of hours worked was 1.39%. During an interview on 04/12/2024, the Vice President (VP) of Accreditation, Regulations, and Education, the Administrator, the Director of Patient Care Services, and the Regional Vice President of Operations confirmed that the agency’s volunteers had not provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff since January 2024. The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visits observed of a patient residing in a Skilled Nursing Facility (SNF), the agency did not ensure that the SNF was provided with the most recent hospice plan of care (POC). Home Visit 1/Clinical Record 1: The patient elected hospice care on 12/06/2023 and resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 04/10/2024, a review of the patient’s facility records revealed no evidence of the patient’s most recent plan of care. The SNF Director of Nursing could not locate the patient’s most recent plan of care. During the visit, the Registered Nurse (RN) confirmed that the patient’s most recent hospice POC was not included in the hospice binder. During an interview on 04/10/2024, the Vice President (VP) of Accreditation, Regulations, and Education, the Administrator, the Director of Patient Care Services, and the Regional Vice President of Operations confirmed that the agency did not ensure that the SNF was provided with the most recent hospice POC.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visits observed of a patient residing in a Skilled Nursing Facility (SNF), the agency did not ensure that the SNF was provided with the physician certification and recertification of the terminal illness (CTI). Home Visit 1/Clinical Record 1: The patient elected hospice care on 12/06/2023 and resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 04/10/2024, a review of the patient’s facility record revealed no evidence of the certification and recertification of the terminal illness. The SNF Director of Nursing at could not locate the patient’s certifications of terminal illness. During the visit, the RN confirmed that the patient’s CTIs were not included in the hospice binder. During an interview on 04/10/2024, the Vice President (VP) of Accreditation, Regulations, and Education, the Administrator, the Director of Patient Care Services, and the Regional Vice President of Operations confirmed that the agency did not ensure that the SNF was provided with the physician certification of the terminal illness.”