Achs Hospice & Palliative Care

“It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the patient was informed about the scope of services the hospice provides and any specific limitations on those services. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/16/2025 for a diagnosis of Alzheimer’s disease. The notification of non-covered items was requested upon admission. The clinical record did not contain documentation that it was given to the patient/representative within the required five days of the admission. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated, “she couldn’t ensure that it was given as it wasn’t scanned into the record.””

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/28/2024. A review of the clinical record indicated the initial social worker and spiritual counselor visits had not been completed. The initial nursing assessment dated 10/28/2024 left the psychosocial assessment blank. Under the spiritual assessment it was blank except to notate “chaplain to visit within 5 days.” A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/14/2025 during which she stated, “if the social worker and chaplain are declined, the nurse should complete the initial assessment.””

“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 1 of 18 (6%) 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 1: The hospice aide care plan dated 08/05/2025 and updated 09/03/2025 included the following relevant tasks: “shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, external catheter care, empty drainage bag, moisture skin, walker, wheelchair, change bed linens (if soiled), make bed (if not made), straighten room, safety precautions, assist with transfers, fall risk, soak feet.” All tasks were to be completed every visit. The Aide visit frequency was twice weekly. A physician’s order dated 06/09/2025 noted the following: “ALF (assisted living facility) staff to apply size F Tubi grip in the morning, remove at night before bedtime. Wash and hang dry..” The hospice aide care plan did not notify the aide of the Tubi grips nor provide specific instructions for the care of the Tubi grips during tasks. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated “I’m not sure why soaking the feet would be added to the aide care plan but if it got on there, they should be given instructions regarding the Tubi grips. Even with just cleaning the feet.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 18 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure hospice aide provided services included in the plan of care. CLINCIAL RECORD 2/HOME VISIT 2: The hospice aide care plan dated 10/07/2025 included the following relevant tasks: “shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, moisture skin, walker, wheelchair, make bed, straighten room, safety precautions, assist with transfers, fall risk.” All tasks were to be completed every visit. Aide visit frequency of twice weekly. The home visit was conducted on 11/12/2025 with the Hospice Aide (Personnel Record 7). The aide did not complete the tasks of filing the nails or making the bed. CLINICAL RECORD 11: The hospice aide care plan dated 05/16/2025 included the following relevant tasks: “shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, external catheter care, empty drainage bag, moisture skin, walker, wheelchair, change bed linens (if soiled), make bed (if not made), straighten bed, safety precautions, assist with transfers, fall risk.” All tasks were to be completed every visit. Aide visit frequency of twice weekly. A hospice aide visit dated 05/22/2025 noted the following: “Bed bath given due to fall.” This same aide note had noted the patient did not have a catheter. A hospice aide note dated 07/10/2025 noted “no” to the tasks of catheter care and empty drainage bag as “patient did not have a catheter.” A review of the clinical record indicated the patient never had a catheter and these tasks were placed on the aide care plan dated 05/16/2025. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated that the “names in Clinical Record 9 the aide reported to appeared to be staff at the facility and not hospice staff.” The DON also confirmed the patient in Clinical Record 11 did not have a catheter and was “not sure how the catheter care and empty drainage bag made it onto the aide care plan.” She confirmed the aides should not “switch the bath types without an updated care plan.””

“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 was conducted with the Volunteer Coordinator and Administrator on 11/14/2025, during which time the volunteer percentage for the last twelve (12) months (November 2024 to October 2025) averaged to 4.3%. The Volunteer Coordinator stated she was recently placed in the role (July 2025) and has been actively recruiting and onboarding volunteers since being hired. She has started using flyers with QR codes to help recruitment. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 11/14/2025, during which time the volunteer percentage for the last twelve (12) months (November 2024 to October 2025) averaged to 4.3%. The Volunteer Coordinator advised she was recently placed in the role (July 2025) and has been actively recruiting and onboarding volunteers since being hired. She has started using flyers with QR codes to help recruitment.”