Residential Hospice

“Upon patient record review, 2 of 27 (Patient #8, 20) 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 8, 20 - No evidence of an initial bereavement assessment completed.”

“Upon patient record review, 2 of 27 (Patient #23, 27) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #23 - SN documented cellulitis of g-tube site 05/27/25 - there was no assessment of g-tube site following visits 06/02/25 or 06/05/25. Patient #27 - No assessment of patients wound 05/22/25 - 6/11/25”

“Upon patient record review, 4 of 27 (Patient #9, 19, 21, 25) 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 #9 - SN visit made visit on 05/20/25 and 05/29/25 “applied antifungal powder to wound bed” but no order on chart for antifungal powder. Patient #19 - Patient using condom catheter at night and when leaving home but no order on POC for condom catheter. Patient #21 - Patient on oxygen 2L/min per nasal cannula but visit 05/15/25 SN documented in the record that patient was on 2.5 L/min. Patient #25 - New wound care ordered on 05/09/25 with no frequency.”

“Upon patient record review, 1 of 27 (Patient #23) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #23 - Aide assignment -to shave patient every visit. Patient is on Eliquis - aide care plan does not identify type of razor aide should use.”

“Upon patient record review 5 of 27 (Patient #10, 15, 18, 22, 26) did not have evidence documentation in the patient record that a Registered Nurse made 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 and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #10 - Aide supervisory visit made 03/26/25 not again until 04/10/25 - 15 days between supervisory visits. Patient #15 - Aide supervisory visit made 05/20/25 not again until 06/06/25 - 17 days between supervisory visits. Patient #18 - Aide supervisory visit made 05/20/25 not again until 06/05/25 - 16 days between supervisory visits. Patient #22 - RN completed aide supervisory visit 05/12/25 then again on 06/02/25 - 21 days between supervisory visits. Patient #26 - Aide services started on 05/16/25 - No supervisory visit until 06/02/25.”

“Upon patient record review, 2 of 27 (Patient #10, 12) 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 #10 - SN documented completion of LPN supervisory visit on 03/11/25 and 04/10/25 but LPN has never made a visit. Patient #12 - SN documented completion of LPN supervisory visit on 04/11/25, 04/24/25 and 05/05/25 but LPN has never made a visit.”

“Upon patient record review, 1 of 27 (Patient #13) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour oncall system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient. Patient #13 - During home visit there was no evidence that the hospice provided the following information - the most recent hospice plan of care, physician certification of the terminal illness or the names and contact information for hospice personnel involved in hospice care.”