Axiom Hospice, LLC

Patient outcome measures (42 CFR 418.54(e)(2))

“Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not maintained accurate records. In the chart for RRNHV#6, in the current benefit period, the RN documented supervision of the aide on 3 occasions. The patient was not receiving aide services. This was discussed with the Administrator.”

Rule L0535. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(2))

“Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services. In the chart for RRNHV#7, the POC did not include a visit frequency for nursing services. This was discussed with the Administrator.”

Rule L0547. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

Rule L0549. Standard-level.

Coordination of services (42 CFR 418.56(e)(2))

“Observed in Record Review. In 1 of 12 patient records reviewed, the organization had not provided care according to the patient’s individualized plan of care (POC). In the chart for RRHV#1, the POC included SN visits 3 times weekly with care to be provided to the patient’s urinary stoma 3 times weekly by the hospice nurse. There was no care documented in the most recent 3 SN visits at the time of the survey. This was discussed with the Administrator.”

Rule L0555. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Observed in Record Review. In 2 of 11 patient records reviewed, for whom aide services were ordered, the RN had not prepared complete instructions for the aide. In the charts for RRNHV#8 and RRNHV#9 the aide assignment did not include any oxygen precautions/instructions for use for the aide. This was discussed with the Administrator.”

Rule L0625. Standard-level.

Level of activity (42 CFR 418.78(e))

“Observed in Document Review. Volunteer staff had not provided day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. Volunteers had provided a care amount that equaled more than 4% but less than 5% of the total patient hours for calendar years 2024 and 2025 as confirmed with the Administrator.”

Rule L0647. Standard-level.

Content (42 CFR 418.104(a)(3))

“Observed in Record Review. In 1 of 14 patient records reviewed, the patient record did not contain complete documentation of care provided. In the chart for RRNHV#7, In a SN visit made within a month prior to the survey, the documentation was incomplete and read Her pleural drainage dressing was starting to come off, so I performed a dressing change while maintaining sterile procedure. This was discussed with the Administrator.”

Rule L0674. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(1)(i))

“Observed in Record Review. In 1 of 1 patient records reviewed, when the patient was transferred to another Medicare/Medicaid-certified facility, the hospice did not provide the receiving facility with a copy of the hospice discharge summary. In the chart for RRDC#2, the patient revoked due to hospitalization. There was no documentation that any information was provided to the admitting hospital. This was discussed with the Administrator.”

Rule L0682. Standard-level.

Discharge or transfer of care (42 CFR 418.104(e)(3)(i))

“Observed in Record Review. In 1 of 2 patient records reviewed, for a live discharge, the hospice discharge summary did not include the following: A summary of the patient’s stay, including treatments, symptoms, and pain management. In the chart for RRDC#2, the discharge summary did not include a summary of the patient’s stay. This was discussed with the Administrator.”

Rule L0684. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

“Observed in Regulatory Review. In 1 of 8 records reviewed consisting of every record for this organization., There was no bereavement risk or assessment recorded and available in one patient record. This was confirmed by organization’s leadership accompanying the surveyor.”

Rule L0531. Standard-level.