Caretenders Hospice

“Based on a review of clinical records and staff interviews, it was determined that in 4 of 15 (Pts. #6, 3, 12, and 10) clinical records reviewed, the Hospice failed to provide services ordered by the Physician and/or required by the IDG. 4. Pt. #10 was admitted to Hospice on 7/1/23 with the diagnosis of Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 1/14/25. The clinical record included the POC 7/1/23, that required the Aide 2 times a week for 12 weeks. The Aide failed to provide any care during the week #9 and week# 10. 5.The above findings were confirmed with the Patient Care Manager and Executive Director, on 01/14/25 at 3:00 PM, and on 01/15/25 between 1:00 PM and 4:00 PM. 2. Pt. # 3 was admitted on 8/18/23 to hospice with diagnosis of Dysphagia following Cerebral Infarction. The clinical record was reviewed on 1/14/25. The clinical record included the document “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report” for the period of 11/10/24 to 1/8/25 requiring, “Frequency: HHA effective 12/22/24 – 1WK3; HHA effective 1/12/25 – 2WK8.” The record lacked documentation of Aide visits from 12/22/24 to 1/11/25. The above IDG report also included documentation, “;LSW will provide emotional care and support during future visit scheduled for 12/31.” The record lacked documentation of LSW visits for the entire month of December 2024. The record lacked documentation of the reason of the missed visits. 3. Pt. # 12 was admitted on 10/13/24 to Hospice with the diagnosis of Hemiplegia following Cerebral Infarct. The clinical record was reviewed on 1/15/25. The clinical record included the document “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” for the period of 10/13/24 to 11/4/24 requiring, “Frequency: SN 3WK1, 1WK2...” The record lacked documentation of a SN visit for the week of 10/12/24 to 10/18/24. The record also lacked documentation of the reason of the missed visit. Findings include: 1. Pt. #6 was admitted to Hospice on 12/20/24 with the diagnosis of Alzheimers Disease. The clinical record was reviewed on 1/14/25. The clinical record included the POC effective 12/20/24 that required “;HHA effective 12/22/24 1WK1, 2WK11, 1WK1”. The record lacked documentation the HHA provided a second visit during the week of 12/29/24 to 1/4/25.”

“Based on a review of clinical records and staff interview, it was determined in 4 of 13 records (Pts. # 2, 4, 9 and 10) with the Aide services, the Hospice failed to ensure Aide supervision by the RN every 14 days. Findings include: 1. Pt.#2 was admitted to Hospice with the diagnosis of Respiratory Failure with Hypoxia. The clinical record was reviewed on 01/14/25. The clinical record included the POC dated 9/05/24, that required the SN 2 times a week for 14 weeks and the Aide 2 times a week for 11 weeks, and 1 time a week for 1 week. The Hospice lacked the Aide supervision every 14 days. The RN visit note dated 12/03/24 includes Aide supervision. The next RN supervision was conducted 12/26/24 (more than 14 days). 2. Pt. #4 was admitted to Hospice with the diagnosis of Parkinson, Unspecified. The clinical record was reviewed on 01/14/25. The clinical record included the POC dated 11/12/24, that required the SN 2 times a week for 14 weeks and the Aide 3 times a week for 11 weeks. The Hospice lacked the Aide supervision every 14 days. The RN visit note dated 11/15/24 includes Aide supervision. The next RN supervision was conducted 12/02/24 (more than 14 days). 3. Pt.#9 was admitted to Hospice 11/15/22 with the diagnosis of Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 01/14/25. The clinical record included the POC dated 10/30/24, that required the SN 2 times a week for 13 weeks and the Aide 2 times a week for 12 weeks. The Hospice lacked the Aide supervision every 14 days. The RN visit note dated 12/16/24 includes Aide supervision. The next RN supervision was conducted 1/05/25 (more than 14 days). 4. Pt. #10 was admitted to Hospice 7/1/23 with the diagnosis of Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 01/14/25. The clinical record included the POC dated 07/01/23, that required the SN 1 time a week for 14 weeks and the Aide 2 times a week for 12 weeks. The Hospice lacked the Aide supervision every 14 days. The RN visit note dated 11/04/24 includes Aide supervision. The next RN supervision was conducted 12/23/24 (more than 14 days). 5. The above findings were confirmed with the Patient Care Manager and Executive Director, on 01/14/25 at 3:00 PM.”

“Based on the staff interview it was determined the Hospice failed to document the amount of hours the volunteer worked in relation to the amount of patient care hours provided by hospice employees and contracted staff, documenting 5 percent total or more for the years 2023 and 2024. Findings include: 1. During the interview with the Volunteer Coordinator, on 1/14/25 at 11:10 AM, it was stated that the Hospice has one volunteer. The Hospice lacked documentation of the 5% requirement, for the years 2023 and 2024. 2. The above findings were confirmed with the Executive Director on 1/14/25 at 3:00 PM.”