Guardian Healthcare & Hospice, LLC

“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, document review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Document 6: Agency Policy titled Comprehensive Assessment #1-014 (Dated: 11/20) stated in part, “Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician.” Clinical Record 2: The patient elected the hospice benefit on 11/28/23. The record lacked evidence of Chaplain initial assessment or documentation that the patient/family were offered a Chaplain and refused, no later than five (5) calendar days after the election of hospice care, Clinical Record 4: The patient elected the hospice benefit on 8/11/22. The record lacked evidence of Chaplain initial assessment or documentation that the patient/family were offered a Chaplain and refused, no later than five (5) calendar days after the election of hospice care. On 10/27/23 the Social Worker documented that the patient requested a Chaplain for Prayer. There was a Chaplain visit on 11/1/23. Clinical Record 5: The patient elected the hospice benefit on 4/4/23. The record lacked evidence of Chaplain initial assessment or documentation that the patient/family were offered a Chaplain and refused, no later than five (5) calendar days after the election of hospice care, Clinical Record 9: The patient elected the hospice benefit on 3/17/23. The record lacked evidence of Chaplain initial assessment or documentation that the patient/family were offered a Chaplain and refused, no later than five (5) calendar days after the election of hospice care. The Administrator, Office Manager, and Director of Clinical Services stated in an interview on 12/14/23 that the agency did not ensure that the Chaplain completed an initial comprehensive assessment, or that the record had documentation that the Chaplain was offered and refused by the patient/family no later than five (5) calendar days after the election of hospice care,”

“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, document review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure the patient’s individual written plan of care (POC) identified goal(s) and interventions based on problems identified in the initial and updated comprehensive assessments. Document 5: Agency Policy titled The Plan of Care #9-017 (Dated: 11/20) stated in part, “Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments. This plan will focus on identified problems, goals, and interventions.” Clinical Record 1: The initial nursing assessment dated 10/27/23 stated the patient had a cholecystectomy drain. The POC dated 11/2/23 had a goal to prevent skin infection but lacked intervention(s) for the specific wound care ordered for the cholecystectomy drain site. Clinical Record 2: The initial nursing assessment dated 11/28/23 stated the patient was incontinent of bowel and bladder. The POC dated 11/29/23 lacked evidence of goal(s) and intervention(s) for bowel and bladder incontinence. Clinical Record 9: The initial nursing assessment dated 3/17/23 stated the patient was incontinent of bowel and bladder. The POC dated 3/17/23 lacked evidence of goal(s) and intervention(s) for bowel and bladder incontinence. Clinical Record 10: The initial nursing assessment dated 11/17/23 stated the patient was incontinent of bowel and bladder. The POC dated 11/17/23 lacked evidence of goal(s) and intervention(s) for bowel and bladder incontinence. Clinical Record 11: The Registered Nurse (RN) visit note dated 9/15/23 stated the patient elected volunteer services. The first volunteer visit was completed on 9/17/23. The POC dated 9/26/23 lacked evidence of goal(s) and intervention(s) for volunteer services. The Administrator, Office Manager, and Director of Clinical Services stated in an interview on 12/14/23 that the agency did not ensure the patient’s individual written plan of care (POC) identified goal(s) and interventions based on problems identified in the initial and updated comprehensive assessments.”

“Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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, document review and interview. In 3 of 3 (100%) clinical records reviewed of patients discharged due to death, it was revealed that the agency did not ensure a post-death bereavement assessment and plan of care (POC) was completed. Document 4: Agency Policy titled Bereavement Services #1-021 (Dated: 11/20) stated in part, “Procedure: 4. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment.” Clinical Record 5: The patient expired on 10/8/22. The record lacked evidence of a completed post-death bereavement assessment and POC. There was evidence of phone contact to the family post-death offering bereavement services. Clinical Record 6: The patient expired on 7/27/23. The record lacked evidence of a completed post-death bereavement assessment and POC. There was evidence of phone contact to the family post-death offering bereavement services. Clinical Record 7: The patient died on 7/27/23. The record lacked evidence of a completed post-death bereavement assessment and POC. There was evidence of phone contact to the family post-death offering bereavement services. The Administrator, Office Manager, and Director of Clinical Services stated in an interview on 12/14/23 that the agency did not ensure a post-death bereavement assessment and plan of care (POC) was completed.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure the volunteer program included documented viable and ongoing efforts to recruit and retain volunteers. Document 3: Agency Policy titled Volunteer Services #9-024 (Dated: 11/20) stated in part, “Procedure: 5. The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and backgrounds.” The Volunteer Coordinator (VC) stated in an interview on 12/14/23 that the agency has used multiple methods to recruit volunteers like volunteermatch.com but has not documented these efforts. Also, the VC reported that the agency has implemented multiple methods to retain volunteers like thank you cards, but has not documented these efforts. The Administrator, Office Manager, and Director of Clinical Services in an interview on 12/14/23 agreed the agency did not ensure that recruitment and retention efforts were being documented. The agency did not ensure the agency documented viable and ongoing efforts to recruit and retain volunteers.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure a physician order was written for services provided. Document 7: Agency Policy titled Verification of Physician Order #2-002 (Dated: 11/2020) stated in part, “Policy: Orders will be obtained from a licensed physician (or other independent practitioner) for care and services to be provided to hospice patients.” Clinical Record 1: The patient elected the hospice benefit on 10/27/23. During the home visit on 12/12/23, the registered nurse performed wound care to the cholecystectomy drain site. The record lacked evidence of a physician order for the cholecystectomy drain site wound care. The Administrator, Office Manager, and Director of Clinical Services stated in an interview on 12/14/23 that the agency did not ensure a physician order was written for the wound care provided by the RN.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by document review, interview and observation. In 2 of 2 (100%) home visit observations for patients that were receiving care in a Skilled Nursing Facility (SNF), it was revealed that the agency did not ensure the plan of care (POC) specified which provider was responsible for performing the care and services that were included in the plan of care. Document 1: Agency Policy titled Provision of Care to Residents of SNF/NF or ICF/IID #1-030 (Dated: 11/2020) stated in part, “Procedure: The organization provides hospice care to residents of a SNF/NF or ICF/IID and will abide by the following standards: 4. A written plan of car3e must be established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must be in accordance with this plan of care. The plan of care must: A. Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions.” Home Visit 1: The patient elected the hospice benefit on 10/27/23 and was receiving routine hospice care at a SNF. The record lacked evidence of which provider was responsible for performing the care and services that were included in the patient’s POC. Home Visit 2: The patient elected the hospice benefit on 11/28/23 and was receiving routine hospice care at a SNF. The record lacked evidence of which provider was responsible for performing the care and services that were included in the patient’s POC. The Administrator, Office Manager, and Director of Clinical Services stated in an interview on 12/14/23 that the agency did not ensure the POCs for the patients at the SNF specified which provider was responsible for performing the care and services that were included in the plan of care.”