Bay Nursing, Inc.

“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 and document review. In 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure that the MSW Initial psychosocial assessment was completed or attempted to be completed within 5 calendar days after the election of hospice benefit. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/07/2025. The review period was 10/07/2025 to 01/08/2026. There was no documented evidence of an initial psychosocial assessment documented within 5 days of the patient’s election of the hospice benefit. There was no documented explanation in the clinical notes for the reason for the delay. The Clinical Director was interviewed on 01/15/2026 and she agreed that the initial psychosocial assessment was not completed within 5 days of the patient’s election of the Hospice benefit. She had no additional information to provide.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: 1. A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; 2. The patient’s current plan of care; 3. The patient’s latest physician orders; 4. Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient that transferred to a hospital, it was revealed that the hospice did not ensure that a discharge summary was completed to include a summary of the patient’s hospice stay that documented treatments, symptom management, pain management, the plan of care, latest physician orders, and any other documentation that would assist in the post-discharge continuity of care. CLINICAL RECORD 3: The patient transferred to a hospital on 11/08/2025 to seek aggressive treatment. Documentation that the patient’s medication list, history and physical and discharge summary had not been forwarded to the receiving facility. There was no discharge summary completed. During an interview and joint review of clinical records on 01/15/2026 with the Director of Clinical Services, it was confirmed that the discharge summary was not documented with the required elements.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that services were provided as ordered on the Plan of Care. CLINICAL RECORD 1: The patient was recertified for hospice services on 11/19/2024. The Plan of Care (POC) dated 11/24/2024-01/22/2025 included orders for Skilled Nursing (SN) with a frequency of 2w8, 1w1(2 visits per week for 8 weeks and one visit for one week) with 4 as needed visits for symptom management. An interim order was documented by the Registered Nurse on 11/24/2024 for a revised SN visit frequency of 1w3 (one visit per week for 3 weeks) from 11/24/2024 through 12/01/2024. SN visits were documented weekly from 11/26/2024 through 01/07/2025, in other words, after 12/01/2024 the visit frequency did not return to two visits weekly as ordered. The clinical record lacked documentation of missed visits or documentation of communication to the physician of missed SN visits. CLINICAL RECORD 2: The patient was recertified for hospice services on 12/10/2024. The Plan of Care (POC) dated 12/12/2024-03/11/2025 included orders for Spiritual Counselor (SC) 1m4 (one visit per month for 4 months) with 2 as-needed visits. Additionally, there was an order documented by the Registered Nurse (RN) on 01/08/2025, which stated, “Per request, additional weekly chaplain visits requested by patient for anxiety. New frequency effective week of 01/06/2025 through 03/01/2025. Monthly frequency to resume on 02/07/2025 through 03/11/2025 based on patient status”. This visit frequency orders were reviewed with the Clinical Manager who said the SC visits should have been weekly starting on 01/06/2025, to continue until February when the team would re-evaluate. There were no documented SC visits in the record from 12/12/2024 through 01/15/2025. There was no documentation of missed visits or documentation of communication to the physician of missed SC visits in the clinical record. CLINICAL RECORD 4: The patient was recertified for hospice services on 12/12/2024. The Plan of Care (POC) dated 12/16/2024- 02/13/2025 included orders for a Spiritual Counselor (SC) 1m3 (one visit per month for 3 months) with 2 as-needed visits. There were no documented visits from 12/16/2024 to 12/31/2024. There was no documentation of missed visits or communication to the physician of missed SC visits. CLINICAL RECORD 7: The patient elected hospice benefit and was admitted to hospice service on 10/21/2024. The Plan of Care (POC) dated 10/21/2024-01/18/2025 included orders for Skilled Nursing (SN) with a visit frequency of 2w13 (two visits per week for 13 weeks) with 4 as needed visits for symptom management. An interim order was documented by the SN on 12/03/2024 which stated, “Verbal Order received to decrease skilled nursing visit frequency related to slow progression of patient decline. New visit frequency 1wk3 (one per week for 3 weeks), effective date 11/24/2024 thru 12/1/2024. Visit frequency will be adjusted as patient status warrants.” There were no documented SN visits were present in the record for 12/03/2024 through 01/07/2025. CLINICAL RECORD 8: The patient was recertified for hospice care on 11/20/2024. The Plan of Care (POC) dated 11/24/2024-02/21/2025 included orders for Skilled Nursing (SN) with a visit frequency of 2w13 (two visits per week for 13 weeks) with four as-needed visits for symptom management. Weekly SN visits were documented in the clinical record from 11/27/2024 through 01/09/2025. There were no subsequent orders documented in the record to decrease the SN visit frequency, nor was there documentation that the physician was notified of missed visits. The Administrator and Clinical Supervisor (Personnel Record 2) were interviewed on 01/14/2025. The Administrator stated, “Visit frequencies in these patients were not followed. The current computer system does not ensure that visits are plotted and made following the visit frequency orders. We are changing to a new medical record in February, which will help clinicians stay within ordered frequencies.””

“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 and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) bereavement patient records reviewed, the agency did not ensure that the bereavement services, for the bereaved survivors, was provided in accordance with the agency policy. Agency Policy #2-010.1, Bereavement Services, stated in part, “8. Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved. 9. After three weeks, a bereavement letter or phone call offering support and outlining the hospice bereavement services. 10. Within three to five weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor following the family and caregiver. This assessment will identify grief issues. [Name/Title] will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction. 11. If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for ongoing assessment and support at 3, 6, and nine months after the patient’s death and at the anniversary of the patient’s death. 12. In addition to the services outlined above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered at intervals defined in the plan of care.” CLINICAL RECORD 13: The patient elected the hospice benefit on 11/29/2024. On 12/01/2024, there was a documented Bereavement Risk Assessment identified as “Low Risk” completed by the Medical Social Worker (MSW). The documented patient’s death was on 12/10/2024. The MSW documented three communication notes after the patient’s death. On 12/13/2024 and 12/20/2024, the MSW documented attempts to reach the bereaved by phone. On 01/08/2025, the MSW documented, “No return call.” The clinical record lacked documentation of a re-assessment of the bereaved risk and there was no additional documentation on offered, declined, or completed bereavement services. CLINICAL RECORD 14: The patient elected the hospice benefit and was admitted to hospice care on 10/21/2024. On 10/24/2024, there was a documented Bereavement Risk Assessment identified as “Low Risk” completed by the Medical Social Worker (MSW). The documented patient’s death was on 10/25/2024. There was a note entered on 10/30/2024 by the MSW that stated, “Sympathy Card sent to the patient’s family”. There was no bereavement risk re-assessment documented in the record following the patient’s death, and no further documentation of bereavement services was present in the record after the Sympathy Card was mailed. The Bereavement Coordinator (Personnel Record 6) was interviewed on 01/15/2025, and the selected Bereavement records were reviewed. The Bereavement Coordinator stated, “(she) was unaware of the interventions and care planning outlined in the policy for low, moderate, and high-risk bereaved.” She said, “I tried calling the bereaved after death to get consent for bereavement services, but I have had a hard time contacting them by phone.””

“A hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the hospice aide provided the visit frequency services as ordered by the Interdisciplinary Group. CLINICAL RECORD 3: The patient elected hospice benefit on 01/03/2025. The Plan of Care (POC) dated 01/03/2025 to 04/02/2025 included Hospice Aide orders with a frequency of 2w12 (two times a week for 12 weeks). Only one HA visit was documented in the record for the week of 01/03/2025. There was no documentation of missed visits or documentation of communication with the physician regarding missed aide visits. CLINICAL RECORD 11: The patient elected hospice benefit on 11/29/2024. The Plan of Care (POC) dated 11/29/2024 to 02/26/2025 included visit frequency orders for Hospice Aide of 2w12 (two times a week for 12 weeks). There were no documented aide visits during the first week of care (11/29/2024 to 11/30/2024). The record did not include documentation of missed visits for the aide services, nor was there documented communication to the physician regarding missed visits. The Administrator and Clinical Supervisor (Personnel Record 2) were interviewed on 01/14/2025. The Administrator stated, “Visit frequencies in these patients were not followed. The current computer system does not ensure that visits are plotted and made following the visit frequency orders. We are changing to a new medical record in February, which will help clinicians stay within ordered frequencies.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The organization’s documentation of volunteer cost savings was reviewed with the Administrator/Volunteer Coordinator (Personnel Record 1). The agency’s utilization of volunteer services was 2.1% for the calendar year 2024, below the minimum of 5%. The Administrator/Volunteer Coordinator was interviewed on 01/15/2025, and stated, “The agency has not utilized volunteer services enough and will increase the pool of volunteers and the number of volunteer hours.” The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed where the patient revoked or was discharged from hospice services, the agency did not ensure that a discharge summary was provided to the patient’s attending physician. CLINICAL RECORD 11: The patient elected hospice benefit on 11/29/2024. On 12/19/2024, the record documented that the patient was transferred to and admitted to the hospital. The patient/caregiver signed the hospice revocation document (present in the record) on 12/19/2024. There was no documentation in the record that a discharge summary was provided to the patient’s attending physician. The Administrator was interviewed on 01/14/2025 and confirmed that a discharge summary was not sent to the attending physicians for this patient.”