Foundations Hospice

“Based on observations, interviews and record reviews, the Hospice agency failed to meet the Condition of Participation for Organization and Administration of Services as evidenced by failure to have a system in place to ensure each patient’s medications were administered in a safe and effective manner. The Hospice agency failed to have a system in place to ensure the inpatient unit (IPU) the Hospice agency contracted with:1. Ensured routine and as needed (PRN) medications were administered by a licensed nurse as evidenced by the administration of medications, including narcotics and non-narcotics, by an unlicensed, non-medical contracted caregiver, without the supervision of an onsite licensed nurse for 3 of 3 (#1 through #3) patients in the sample; 2. Ensured proper patient assessments were performed by a licensed nurse prior to the administration of PRN Morphine, Valium, Ativan, and/or Tramadol based on an assessment of needs performed by an unlicensed contracted caregiver without the supervision of an onsite licensed nurse for 3 of 3 (#1 through #3) patients in the sample; and3. Ensured secure storage of patient medications, including Morphine, Valium, Ativan, Fentanyl and/or Tramadol, was provided as evidenced by the unlicensed contracted caregiver maintaining sole possession of the key to the locked medication closet where all patient medications were stored.This deficient practice had the potential to cause harm to any of the Hospice agency’s 3 patients who resided at the contracted IPU during the past 12 months, a current census of 82 patients and any future admissions to the Hospice agency.See Findings in L660. See Findings in L660.”

“Based on observations, interviews and record reviews, the Hospice agency failed to have a system in place to ensure each patient’s medications were administered in a safe and effective manner. The Hospice agency failed to have a system in place to ensure the inpatient unit (IPU) the Hospice agency contracted with: 1. Ensured routine and as needed (PRN) medications were administered by a licensed nurse as evidenced by the administration of medications, including narcotics and non-narcotics, by an unlicensed, non-medical contracted caregiver, without the supervision of an onsite licensed nurse for 3 of 3 (#1 through #3) patients in the sample; 2. Ensured proper patient assessments were performed by a licensed nurse prior to the administration of PRN Morphine, Valium, Ativan, and/or Tramadol based on an assessment of needs performed by an unlicensed contracted caregiver without the supervision of an onsite licensed nurse for 3 of 3 (#1 through #3) patients in the sample; and3. Ensured secure storage of patient medications, including Morphine, Valium, Ativan, Fentanyl and/or Tramadol, was provided as evidenced by the unlicensed contracted caregiver maintaining sole possession of the key to the locked medication closet where all patient medications were stored.This deficient practice had the potential to cause harm to any of the Hospice agency’s 3 patients who resided at the contracted IPU during the past 12 months, a current census of 82 patients and any future admissions to the Hospice agency.Cross Reference: L648. Review of the Hospice agency’s signed contract with the IPU revealed the contract was signed on 11/12/2024 by S1ADM. Further review revealed, in part, the following: This agreement provides the terms required of Hospice agency (provider) who desire to have patients placed into the IPU. This agreement provides the terms required of providers who desire to have patients placed into the IPU. Inconsideration of the mutual covenants hereinafter, set forth, it is hereby agreed that this Agreement shall cover a collaboration between the IPU and provider, beginning upon due execution by both parties, to provide Hospice care and residential care for terminally ill persons mutually accepted by both parties pursuant to the following terms and conditions: Provider understands the costs of operating the House are substantial to the IPU and provider agrees to work with the IPU in conjunction with its fundraising efforts. Criteria for admission to the house includes: The patient’s provider has executed the contract with the IPU; and Provider’s agreement to follow the IPU’s House Rules.The IPU shall provide residential services to IPU residents. Provider shall provide Hospice services to IPU residents. Residential services shall include the following: assistance with the administration of medication. Hospice services shall provide: pharmacy, oxygen, medical supplies related to the care of the terminal illness. Hospice services must follow State and Federal regulations regarding Hospice care. Each party to this Agreement shall be responsible for the direct employment and supervision of its employees performing services pursuant to this Agreement. Notwithstanding any other provision in this Agreement, the Hospice agency remains solely responsible for: Ensuring any Hospice services provided comply with all pertinent provisions of any federal, state and local statutes, rules and regulations; Planning and coordinating and ensuring the quality of all Hospice services provided; and Ensuring adherence to the Plan of Care (POC) established for patients. Review of the IPU’s “House Rules” referenced in the aforementioned Contract revealed, in part, the following: 3. Family members are not allowed to administer any type of medications. All medicines must be ordered by the Hospice nurse and given by IPU Caregivers. Review of the IPU’s “Admission Criteria” provided by the Hospice agency on 05/20/2025 at 11:00 a.m., revealed, in part, the following: 4. Hospice House provides one Caregiver per shift. 5. Family members are not allowed to administer any medications for any reason. Caregivers are non-medical. 6. The Hospice agency is responsible for providing all aspects of Hospice care. Hospice volunteers and/or Hospice approved Caregivers will be available 24 hours a day to serve as primary Caregivers under the direction of the Hospice agency. 15. If only medications are being adjusted, the change/order can be texted to the Caregiver’s phone. Review of the Hospice agency’s Nurse In-service regarding the contracted IPU’s Policies and Procedures performed on 02/06/2025 revealed, in part, 11 nurses were in attendance; including S2DON and S3ADON. Further review revealed staff from the contracted IPU reviewed their process for providing patient care for the agency’s Hospice patients while they resided in their facility; including the process for mediation administration.Review of the Hospice agency’s list of patients who resided at the IPU during the past 12 month period, as of 05/11/2025, revealed, in part, a total of 3 patients; Patient #1. #2 and #3. Patient #1Review of Patient #1’s Clinical Record revealed he was admitted to the Hospice agency on 03/20/2024 for a Certification Period of 01/14/2025 through 03/14/2025 with a terminal diagnosis of Alzheimer’s Disease. Further review revealed he moved into the contracted IPU 02/04/2025 until he expired on 02/08/2025.Review of Patient #1’s Skilled Nurse (SN) Visits, dated 02/04/2025 through 02/08/2025, revealed, in part, the following: Visit Date: 02/04/2025 Narrative: Patient moved to contracted IPU today. Pre-filled Morphine and Valium syringes for the contracted IPU staff. Teaching and Learning Taught by SN to the contracted IPU Staff: Symptom Management. Visit Date: 02/04/2025 Physical Assessment Findings revealed, in part, Sleep Disturbances: Yes; Agitation: Yes; and Visual Hallucinations: Yes. Visit Date: 02/05/2025 Narrative: Patient #1 remains at contracted IPU. Valium scheduled nightly. Plan of Care (POC) updated and education reinforced to contracted IPU staff.Teaching and Learning Taught by SN to Facility Staff: Symptom Management. Visit Date: 02/07/2025 Narrative: Fentanyl patch in place. Phone Call Visit Date: 02/06/2025 Narrative: Phone call with contracted IPU staff to assess patient status.Review of Patient #1’s Physician’s Orders for the Certification Period at the time of his death, revealed, in part, the following: 02/04/2025 - Ativan Concentrate 2mg/2mL – 1mL by mouth every 6 hours as needed for anxiety, agitation and restlessness;02/04/2025 - Morphine Sulfate Concentrate 20mg/mL – 0.25 mL by mouth every 2 hours as needed for pain and shortness of breath;02/04/2025 - Fentanyl Patch 25mcg/hr – Apply one patch transdermal every 3 days; and 02/04/2025 - Valium Concentrate 5mg/mL – 1mL by mouth every 6 hours as needed for anxiety, agitation and restlessness.An interview was conducted on 05/20/2025 at 12:30 p.m. with S2DON. S2DON confirmed Patient #1 resided at the contracted IPU from 02/04/2025 through 02/08/2025 and was ordered to receive narcotic medications scheduled and PRN. Patient #2Review of Patient #2’s Clinical Record revealed she was admitted to the Hospice agency on 08/12/2024 for a Certification Period of 08/12/2024 through 11/09/2024 with a terminal diagnosis of Malignant Neoplasm of the Colon. Further review revealed she moved into the contracted IPU on 09/21/2024 until she expired on 09/22/2024.Review of Patient #2’s Patient Information Sheet revealed her physical address at her time of death was the contracted IPU. Review of Patient #2’s SN Visits, dated 09/21/2024 through 09/22/2024 revealed, in part, the following: Visit Date: 09/21/2024Narrative: Patient #2 arrived to the contracted IPU. Medications delivered to the contracted IPU’s staff. Reinforced Patient #2’s POC. Death Visit Date: 09/22/2024Narrative: Patient #2’s location at time of death was the contracted IPU. Review of Patient #2’s POC for the Certification Period at the time of her death, revealed, in part, the following: Goal: Patient admitted to contracted IPU. Review of Patient #2’s Physician’s Orders for the Certification Period at the time of her death, revealed, in part, the following: 08/12/2024 – Valium 5mg Tablet – One tablet by mouth daily for anxiety, restlessness and sleep; 08/12/0224 - Morphine Sulfate Concentrate 20mg/mL – 0.25 mL by mouth every 2 hours as needed for pain and shortness of breath; 08/12/2024 - Valium 5mg/mL – 1mL by mouth every 6 hours as needed for anxiety/agitation;08/12/2024 – Tramadol HCl 50 mg – 1 tablet by mouth every 5 hours as needed for pain; and08/12/2024 – Tramadol HCl 50 mg – 2 tablets by mouth every 6 hours as needed for pain.An interview was conducted on 05/20/2025 at 12:30 p.m. with S2DON. S2DON confirmed Patient #2 resided at the contracted IPU from 09/21/2024 through 09/22/2024 and was ordered to receive narcotic medications scheduled and PRN. Patient #3Review of Patient #3’s Clinical Record revealed she was admitted to the Hospice agency on 02/18/2025 for a Certification Period of 02/18/2025 through 05/18/2025 with a terminal diagnosis of Sepsis. Further review revealed she moved into the contracted IPU on 02/18/2025 until she expired on 02/19/2025.Review of Patient #3’s Patient Information Sheet revealed her physical address at her time of death was the contracted IPU. Review of Patient #3’s SN Visits, dated 02/18/2025 through 02/19/2025, revealed, in part, the following: Visit Date: 02/18/2025Narrative: Patient transported from local hospital to the contracted IPU upon admission to Hospice agency. Medication drawn up in syringes and left with the contracted IPU staff along with Medication Orders.Death Visit Date: 02/19/2025Narrative: Upon arrival, the contracted IPU’s contracted Caregiver just administered 0.25mL Morphine and 1mL Valium due to patient exhibiting discomfort. Review of Patient #3’s POC and Physician’s Orders at the time of her death revealed, in part, the following: 02/17/2025 - Diazepam Concentrate 5mg/mL – 1mL by mouth every 6 hours as needed for anxiety/agitation;02/17/2025 - Lorazepam Concentrate 2mg/2mL – 1mL by mouth every 4 hours as needed for anxiety, agitation and restlessness;02/17/2025 – Morphine Sulfate Concentrate 20mg/mL – 0.25 mL by mouth every 2 hours as needed for pain and shortness of breath; and02/18/2025 – Fentanyl Patch 25mcg/hr – Apply one patch transdermal every 3 days. An interview was conducted on 05/20/2025 at 12:30 p.m. with S2DON. S2DON confirmed Patient #3 resided at the contracted IPU from 02/18/2025 through 02/19/2025 and was ordered to receive narcotic medications scheduled and PRN. Observation, interview and record review attempts of the contracted IPU on 05/14/2025 were unsuccessful with the contracted IPU not answering the door and not answering or returning telephone calls. An interview was conducted on 05/14/2025 at 11:25 a.m. with S5RN. S5RN confirmed she had seen Hospice patients at the contracted IPU. S5RN confirmed she received an In-service in February 2025 at the Hospice agency office from staff at the contracted IPU regarding their policies and procedures; including the process for preparation of medications by the Hospice nurse to be administered by the contracted caregiver. S5RN confirmed the Hospice nurse was responsible for pre-filling at least 10 syringes of liquid medications (Morphine, Ativan, Valium, etc) to be placed in a ziploc bag labeled with the patients name and medication name which went into the patient’s medication bin inside the locked medication closet. S5RN confirmed she obtained access to the medication closet from the contracted caregiver. S5RN confirmed the contracted caregiver was responsible for the administration of patient medications. S5RN confirmed she counted the doses of medications available for administration during each visit to ensure the patient had enough medications available for administration by the contracted caregiver and if something was running low, she filled more. S5RN confirmed she did not report to the contracted IPU to administer patient medications. S5RN confirmed the contracted IPU did not employ and/or contract a nurse, only contracted unlicensed, non-medical caregivers. An interview was conducted on 05/14/2025 at 11:35 a.m. with S4RN. S4RN confirmed she had seen Hospice patients at the contracted IPU. S4RN confirmed she received an In-service in February 2025 at the Hospice agency office from staff at the contracted IPU regarding their policies and procedures; including the process for preparation of medications by the Hospice nurse to be administered by the contracted caregiver. S4RN confirmed the Hospice nurse was responsible for pre-filling at least 10 syringes of liquid medications (Morphine, Ativan, Valium, etc) to be placed in a ziploc bag labeled with the patients name and medication name which went into the patient’s medication bin inside the locked medication closet. S4RN confirmed she obtained access to the medication closet from the contracted caregiver. S4RN confirmed the contracted caregiver was responsible for the administration of patient medications. S4RN confirmed she counted the doses of medications available for administration during each visit to ensure the patient had enough medications available for administration by the contracted caregiver and if something was running low, she filled more. S4RN confirmed she did not report to the contracted IPU to administer patient medications. An interview was conducted on 05/14/2025 at 12:10 p.m. S3ADON. S3ADON confirmed the aforementioned In-service regarding the contracted IPU’s policies and procedures was performed with all of the Hospice agency’s nurses in attendance. S3ADON confirmed she expected their staff to follow the procedure for the contracted IPU. S3ADON confirmed upon admission to the contracted IPU, the Hospice agency provided the IPU with a copy of each patient’s Medication Orders and POC. S3ADON confirmed the contracted IPU did not employ and/or contract a nurse, only contracted non-medical, unlicensed caregivers. S3ADON confirmed the only time a nurse was present in the contracted IPU was when the Hospice nurse made their visit. S3ADON confirmed the Hospice agency nurse was responsible for delivering patient medications and pre-filling syringes of liquid medications (Morphine, Ativan, Valium, etc.) to be placed in a ziploc bag labeled with the patients name and medication name then placed into the patient’s medication bin. S3ADON confirmed the Hospice agency nurse counted medications available for administration during each visit and drew up additional refills if they were needed. S3ADON confirmed the Hospice agency nurse typically pre-filled 10 doses of each medication and maintained that number to ensure enough medication was on-hand at the contracted IPU for administration. S3ADON confirmed the Hospice agency nurses did not report to the contracted IPU for the administration of patient medications. S3ADON confirmed the Hospice nurse provided education to the contracted non-medical, unlicensed caregivers as to what medications should be administered when and why based on current signs and symptoms. S3ADON confirmed patient medications were administered by the contracted non-medical, unlicensed caregivers when ordered and/or as needed; both narcotic and non-narcotic. An interview was conducted on 05/14/2025 at 12:00 p.m. S2DON. S2DON confirmed the aforementioned In-service regarding the contracted IPU’s policies and procedures was performed with all of the Hospice agency’s nurses in attendance. S2DON confirmed she expected their staff to follow the procedure for the contracted IPU. S2DON confirmed upon admission to the contracted IPU, the Hospice agency provided the IPU with a copy of each patient’s Medication Orders and POC. S2DON confirmed the contracted IPU did not employ and/or contract a nurse, only contracted non-medical, unlicensed caregivers. S2DON confirmed the only time a nurse was present in the contracted IPU was when the Hospice nurse made their visit. S2DON confirmed the Hospice agency’s nurses did not report to the contracted IPU for the administration of patient medications. S2DON confirmed the Hospice nurse provided education to the contracted non-medical, unlicensed caregivers as to what medications should be administered when and why based on current signs and symptoms. S2DON confirmed the Hospice agency nurses delivered patient medications and pre-filled syringes to be given when ordered and/or as needed by the contracted non-medical, unlicensed caregivers; both narcotic and non-narcotic. An interview was conducted on 05/20/2025 at 11:57 a.m. with S1ADM. S1ADM confirmed the Hospice agency had a current contract in place with the IPU at this time. S1ADM confirmed he was the person who signed the contract with the IPU and agreed the Hospice agency would follow the terms of the contract.”

“Based on record review and interview, the Hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, following a patient’s death. This deficient practice was evidenced by failure to: 1. Establish a written policy and procedure in accordance with Louisiana Revised Statute (LA RS) 40:2191 to ensure the safe disposal of unused controlled substances by the Hospice nurse following a patient’s death; 2. Ensure the Hospice nurse, in the presence of a witness, documented the name and remaining counts of controlled drugs in the patient’s death note for 1 (#3) of 3 (#1, #2, and #3) patients in the sample; and 3. Ensure the Hospice nurse, in the presence of a witness, performed the disposal of, documented the name of the witness and disposal method of controlled drugs in the patient’s death note for 1 (#3) of 3 (#1, #2, and #3) patients in the sample. Review of the memo issued by LDH Health Standards Section, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the LDH Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.1. Review of the Hospice agency’s undated policy and procedure regarding Patient Death revealed, in part, the following: Procedure: 9. The nurse will instruct the family/caregiver to dispose of all medications, including controlled substances, per federal, state and local regulations and organization policy. This instruction and the specific medications will be documented in the clinical note. Review of the Hospice agency’s undated Addendum 2-008.B revealed, in part, no documented evidence of LA RS 40:2191’s requirements for a witnessed final count or a witness to the disposal of controlled substances upon a patient’s death. 2. and 3. Patient #3Review of Patient #3’s Clinical Record revealed a Start of Care date of 02/18/2025. Further review revealed, in part, Patient #3 expired at a local unlicensed IPU on 02/19/2025.Review of Patient #3’s Plan of Care and Physician’s Orders at the time of her death revealed, in part, the following: 02/17/2025 - Diazepam 5mg/mL – 1mL by mouth every 6 hours as needed for anxiety/agitation;02/17/2025 - Lorazepam Concentrate 2mg/2mL – 1mL by mouth every 4 hours as needed for anxiety, agitation and restlessness;02/17/2025 – Morphine Sulfate Concentrate 20mg/mL – 0.25 mL by mouth every 2 hours as needed for pain and shortness of breath; and02/18/2025 – Fentanyl Patch 25mcg/hr – Apply one patch transdermal every 3 days. Review of Patient #1’s Death Visit Note, as of 05/14/2025, revealed, in part, the following: Death Visit Performed on 02/19/2025 Narrative: Controlled substances wasted per policy. Further review revealed no documented evidence of a final narcotic count being conducted with a witness on the above medications, no documented evidence of a witness for the disposal of the above narcotic medications, and no documented evidence of the method used for disposal. An interview was conducted on 05/20/2025 at 12:10 p.m. with S2DON. S2DON reviewed the Hospice agency’s policy and procedure regarding a patient’s death and the Hospice agency’s addendum. S2DON confirmed neither reflected the requirements set forth in LA RS 40:2191 and should. S2DON reviewed the Clinical Record for Patient #3 and confirmed her Death Visit Note did not contain a final narcotic count and/or disposal with a witness and the method used for disposal. S2DON confirmed she expected all of the aforementioned information to be documented in every patient’s Death Visit Note and it was not for Patient #3. An interview was conducted on 05/20/2025 at 11:57 a.m. with S1ADM. S1ADM confirmed expected the Hospice agency’s policies and procedures to reflect all applicable regulations and laws.”

“It is required that medical social services are provided by a qualified social worker: Based on a psychosocial assessment; According to the patient’s and family’s needs and acceptance of these services; Per the plan of care; Under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical record review revealed the agency did not ensure that the medical social services were provided per the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/03/2023 with diagnosis of Senile degeneration of brain. A Physician order dated 12/10/2024 stated,” social worker frequency increased to 2 times a month and PRN every 90 days.” There was no documented evidence for social worker visits for the month of December 2024 and only one visit was documented for January 2025 (01/10/2025) as of the site visit ending 01/31/2025. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/19/2024 with diagnosis of Senile degeneration of brain. The clinical record review for the benefit period 12/19/2024 to 03/18/2025 revealed that the clinical record lacked documented evidence that the social worker frequency was provided per the plan of care. The plan of care order for social worker frequency was two times a month. There was one visit documented on 12/23/2024 and there is no documented evidence of the second visit in December as of the site visit ending 01/31/2025. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/15/2024 with a diagnosis of Senile degeneration of brain. The clinical record review for the benefit period 09/12/2024 to 11/10/2024 revealed that the clinical record lacked documented evidence that the social worker frequency was provided per the plan of care. The social worker frequency was ordered once a month starting on 09/12/2024. There was no documented evidence for the social worker visit for the month of September after the order on 09/12/2024, and two visits were documented for October 10/30/2024, 10/31/2024 and no documented social worker visit for the month of November. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/05/2024 with a diagnosis of Occlusion and stenosis. The clinical record review for the benefit period 12/20/2024 to 02/27/2025 revealed that the clinical record lacked documented evidence that the social worker frequency was provided per the plan of care. The social worker frequency on the plan of care was ordered two times a month starting on 12/07/2024. There was only one visit documented in December on 12/20/2024 and 01/15/2025 for January as of the date of the site visit ending 01/31/2025. During an interview with the Director of Nurses on 01/30/2025 she stated that she plans on giving additional education to the social workers on how to enter their frequencies into the electronic medical record.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. 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; The frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 3 (67%) records reviewed revealed that the agency did not ensure that an organized bereavement program, including a bereavement plan of care and the type of bereavement services or the frequency of service delivery, was provided. Agency policy titled Bereavement Assessment stated in part “After death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions.” CLINICAL RECORD 15: The hospice benefit period was elected on 05/03/2024, and the date of death was 05/04/2024. There was no documented evidence in the record that post-death bereavement services were provided. CLINICAL RECORD 16: The hospice benefit period was elected on 04/19/2024, and the date of death was 06/07/2024. There was no documented evidence in the record that post-death bereavement services were provided. During a joint review of the clinical record with the Bereavement Coordinator on 01/31/2025, he stated that he had just started in September 2024 and said at that time, he went back to July of 2024, reaching out to all of the bereaved and provided bereavement services as needed. Also stated that he could not speak to the bereavement program prior to that time frame.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 18 (28%) records reviewed for patients receiving hospice aide services revealed the agency did not ensure the hospice aides were supervised by a registered nurse who makes an on-site visit no less frequently than every 14 days. Agency policy, Hospice Aide Supervisory Visits Policy No. 1-037, stated in part, “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days.” CLINICAL RECORD 1: The patient elected the hospice benefit on 11/02/2023 with a diagnosis of Senile degeneration of brain. The patient resided in a facility. A review of the record for the benefit period 10/28/2024 to 12/26/2024 lacked evidence of an RN on-site supervisory visit no less frequently than every 14 days. Aide supervisory visits by the registered nurse were done on 11/11/2024, 12/09/2024, (28 days) and 12/31/2024, (22) days. There was no documented evidence that the RN provided supervisory visits every 14 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/19/2024 with a diagnosis of Senile degeneration of brain. A review of the record for the benefit period 12/19/2024 to 03/18/2025 lacked evidence of an RN on-site supervisory visit no less frequently than every 14 days. Aide supervisory visits by the registered nurse were documented on 01/07/2025 and 01/24/2025, (17 days). There was no documented evidence that the RN provided supervisory visits every 14 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/17/2023 and resided in a facility. A review of the record for the benefit period 09/12/2024 to 11/10/2024 lacked evidence of an RN on-site supervisory visit no less frequently than every 14 days. Aide supervisory visits by the registered nurse were documented on 10/21/2024, (39 days) from the beginning of the benefit period. There was no documented evidence that the RN provided supervisory visits every 14 days. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/31/2024 with a diagnosis of Neurocognitive disorder. The patient resided in a facility. A clinical record review for the benefit period 10/29/2024 to 01/26/2025 2024 lacked evidence of an RN on-site supervisory visit no less frequently than every 14 days. Aide supervisory visits by the registered nurse were documented on 10/29/2024 and 12/03/2024, (36 days) . There was no documented evidence that the RN provided supervisory visits every 14 days. CLINICAL RECORD 8: Clinical record review for the benefit period 10/14/2024 to 12/12/2024 lacked evidence of an on-site visit no less frequently than every 14 days. Patient had hospice aide visits as ordered five (5) times per week starting on 10/14/2024. Aide supervisory visits by the registered nurse were documented on 11/22/2024, 12/13/2024 (21 days). There was no documented evidence that the RN provided supervisory visits every 14 days. During an interview with the Director of Nurses on 01/30/2025, she stated that they have been educating the staff on the importance of supervision of aides and how to document that it was done in the new electronic medical record.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 3 of 11 (27%) personnel records reviewed revealed that the agency did not ensure that the skills and competencies of all individuals providing care were assessed. Agency policy titled Competency Program stated in part “The preceptor/supervisor will observe and deem proficient the indicated skills and core competencies. If necessary, additional training, or in-service education will be provided to the staff member. Organization personnel will not provide the care or service independently until satisfactory completion of required skills competency.” Personnel Record 4: A personnel record review for the social worker hired on 01/22/2024 revealed there was no documented evidence of an initial competency assessment at the time of the review ending on 01/31/2025. Personnel Record 5: A personnel record review of the Chaplain/Bereavement Coordinator hired on 03/07/2024 revealed there was no documented evidence of an initial competency assessment at the time of the review ending on 01/31/2025. Personnel Record 10: A personnel record review of the Volunteer hired on 07/24/2024 revealed a blank form of an initial volunteer competency assessment. There was no documented evidence of an initial competency assessment at the time of the review ending on 01/31/2025. During an interview with the Administrator and Director of Nurses on 01/28/2025, they stated they were unaware that the competency had not been completed.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) records reviewed revealed the agency did not ensure a discharge summary was sent to the patient’s attending physician following a revocation or discharge from hospice. Agency policy titled Discharge from Hospice Program stated in part “A copy of the discharge summary will be sent to the attending physician. If requested, the patient’s clinical record will be provided.” CLINICAL RECORD 18: The patient elected hospice services on 09/04/2024 and revocated hospice services on 09/21/2024. There was no documented evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 19: The patient elected hospice services on 07/25/2024 and was discharged from agency on 11/15/2024. There was no documented evidence that the discharge summary was sent to the attending physician. During an interview with the Director of Nurses on 01/31/2025, she stated that she could not find evidence that the discharge summary was sent to the attending physician but would be sure to educate the staff on the requirement.”