Anew Hospice

“Upon patient record review 1 of 19 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: Patient admitted 7/8/25 and the psychosocial comprehensive assessment was not completed by MSW or SN within 5 days. The MSW did not visit within 5 days as patient refused MSW on 7/10/25 when the MSW called. The SN did not cover financial needs in the comprehensive assessment to cover the MSW assessment. Many of the psychosocial questions have documented “None noted or verbalized this visit”. ie: Ethnic and or cultural considerations affecting family/patient, community support.”

“Upon patient record review, 2 of 19 (Patient #10,11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 10: The medication profile contains an order for Nystop topical powder with no location to apply. Order updated, corrected on site. Patient 11: The medication profile contains an order for Ammonium lactate 12% topical lotion, apply 1 application topical 2 times per day; Apply small amount topically two times per day. There is no application site. Order updated, corrected on site.”

“Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: There is no Bereavement assessment completed within 5 days of SOC.”

“Upon patient record review, 4 of 19 (Patient #2,4,5,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The patient is on Eliquis twice daily per POC 7/8/25, there is no risk for bleeding care plan with goals and interventions. Care plans updated to include the cited element, corrected on site. Patient 4: Physician order stated patient is receiving dexamethasone 4mg oral tab daily for brain swelling, aspirin EC 81mg oral delayed release tab daily for platelet aggregates and Ibuprofen 400mg oral every 6 hours as needed for pain. There is no bleeding risk care plan with goals and interventions. Care plan added corrected on site. Patient 5: Pt is a high aspiration risk per CTI, per initial POC 3/28/25 there was no aspiration risk care plan with problems, goals and interventions Patient 9: The initial POC 6/10/25 contains orders for aspirin and Plavix. There is not risk for bleeding care plan with goals and interventions. Care plans updated to include the cited element, corrected on site.”

“Upon patient record review, 2 of 19 (Patient #10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 10: POC 7/12/25 contains an order for Nystop topical powder with no location to apply. Corrected on site, order updated. Admit order remains on POC for a recertification. The SN documented on 7/12/25. Agency updated order corrected onsite. Patient 11: The POC 2/22/2025 contains an order for Ammonium lactate 12% topical lotion, apply 1 application topical 2 times per day; apply small amount topically two times per day. There is no application site. Agency updated order, corrected on site.”

“Upon patient record review, 2 of 19 (Patient #2,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The SN documented 7/9/25 ordering a lift chair for the patient. There is no order for a lift chair on the POC. Pt received lift chair per SN documentation 7/11/25. Agency obtained order, corrected on site. Patient 12: The SN documented 7/14/25 ordering a seat cushion for the wheelchair, there is no order for a seat cushion. Agency added an order corrected on site.”

“Upon patient record review, 1 of 19 (Patient #12) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 12: The SN documented on 7/28/25 “patient on a dysphagia ground diet and Kennedy cup for liquids” there is no risk for aspiration care plan with goals and interventions. On 7/24/25 the patient is sleeping 18+ hours a day and is incontinent of bowel and bladder. There is no risk for skin breakdown care plan. Both care plans updated to include the cited elements, corrected on site.”

“Upon patient record review, 2 of 19 (Patient #17,19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients 17 and 19: The medical records do not contain evidence of the development of a bereavement plans of care that note the kind of bereavement services to be offered and the frequency of service delivery.”

“Upon personnel record review, 1 of 15 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: There is no evidence of a tub shampoo being performed as a competency. Agency brought in the aide and the RN and competency performed at facility with RN day 3 survey.”

“Upon patient record review 2 of 19 (Patient #10,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 10: The SN ordered for linens to be changed every visit. The aide documented on 7/28/25, 7/14/25 under linen change “unable to document: Caregiver”. There is no evidence the SN was notified. The aide is ordered to provide intervention for oxygen precautions each visit, the aide documented on 7/21/25 “unable to document: Not needed at this time. Patient 14: The aide POC has ordered a shower with chair every visit. The aide documented on 7/18/25 “Unable to document: Refused shower but she did request a bed bath this visit. Facility staff aware of this situation. Bed bath was given.” There is no evidence the SN was made aware of these changes to order a bed bath.”

“Upon patient record review, 2 of 19 (Patient #2,7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 2: The EOB under Right to choose an attending. Neither box is marked for “I do not wish to choose an attending” or “I acknowledge that my choice for attending is”. The alternate medical director’s name is written in the Physician full name box. Patient 7: Pt is documented as orientation x 3. RN in summary notes Patty (POA) present and signed EOB. There is no evidence of a DPOA for health care on file and Patty is a friend of the patient, not a family member.”

“Upon patient record review, 2 of 19 (Patient #7,14) did not have evidence that each patient record contains Advance Directives. Patient 7: Pt is documented as orientation x 3. RN in summary notes Patty (POA) present and signed consent. There is no evidence of a DPOA for health care on file and Patty is a friend of the patient, not a family member. Patient 14: MSW documented on 3/10/25 comp assessment advanced directives completed by RN on comprehensive assessment. RN documented 3/7/25 advanced directives discussed and copy of documentation provided. There was no evidence of a copy in the medical record.”

“Upon patient record review, 5 of 19 (Patient #2,5,7,10,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: SN documented “eol” in the narrative 7/8/25. The approved abbreviation in the agency policy is “EOL” capitalized. SN documented 7/17/25 “Pt’s anxiety is fair to Middling” this does not make sense. Patient 5: The POC contains the following documentation in the goals: “MSW provided education to patient/caregiver**on measures to manage stress appropriately including **”. This is unclear what the goal is for. In addition, the SN documented 0n 6/16/25, 6/19/25, 6/23/25 wound care by restating the order and then documented “completed”. There are no details of the wound care provided. Patient 7: RN Comprehensive Assessment 3/31/25 The SN documented “Advanced Directives discussed and copy provided. Then under clinical record items notes the SN documented under section: Advance care plan/advance directive reviewed and completed by admitting clinician, then the SN documented “not completed with this visit.” It is unclear whether the advance directives were discussed and there was no evidence of copies of Advance directives in the medical record. Patient 10: POC 7/12/25 contains “SN: Home health staff will wash pubic area with soap and water, dry thoroughly and apply antifungal powder to groin TID.” This is a hospice patient there is no Home Health involved. Patient 14: The SN documented Wound care dressing change “Per care plan” and in narrative the SN documents “dressing clean dry and intact on 6/20/25 and 7/18/25. It is unclear if the dressing was changed. The SN documented 6/20/25 “She does have some redness to her right lower area”. It is unclear what area the SN is describing. SN documents on SOC wound care performed by both clinician and caregiver, though the narrative the SN documents “declined to let writer asses since the FSN had already completed wound care and it causes her pain.” It is unclear who performed the wound care. Wound care completed on 6/27/25 documented by restating the order and then “completed” there are no details of the wound care provided. On 7/18/25 the SN documented “Dressings removed and wound cleaned with new dressings applied during visit.””