Ideal Hospice Services, Inc.

“It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure that the patient’s advanced directives were documented per the agency’s policy. Agency Policy No. H:2-070.1, Do Not Resuscitate/Do Not Intubate Orders (undated), stated in part, “A written Do Not Resuscitate (DNR) order, signed by the patient’s physician (or other authorized independent practitioner) must be on file in the patient’s clinical record and admission folder in the patient’s home.” CLINICAL RECORD 2/ Home Visit 2: The patient elected the hospice benefit on 02/06/2025. A home visit observation with the Registered Nurse (RN) (Personnel Record 3) was performed on 02/25/2025. The patient’s home information packet was reviewed. The agency’s “Do Not Resuscitate” form in the packet was not completed. The patient’s wife was interviewed during the visit and asked about the patient’s advanced directives. The patient’s wife produced an executed document of the patient’s advance directives (dated 07/07/2022), which stated in part that the patient did not want any life-saving measures. This document was notarized but not signed by a physician and did not explicitly state that the patient did not want cardiopulmonary resuscitation. A review of the clinical record revealed that the copy of the patient’s Advance Directive was present. Still, no signed “Do Not Resuscitate” order was in the record as required by the agency’s policy. The RN/Clinical Manager (Personnel Record 3) was interviewed during the home visit (on 02/25/2025) and stated, “I thought the signed Advance Directive was enough documentation for the DNR.””

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, it was revealed that the agency did not ensure that the comprehensive assessment was completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/04/2025. The initial Plan of Care (POC) included orders for Social Work (SW) visits “PRN” (as needed). The initial comprehensive nursing assessment was documented on 01/04/2025 and documented that the patient required SW intervention. The initial SW assessment was documented on 01/18/2025 (14 calendar days after election of benefit). There was no documentation in the record of a reason for a delay in the SW initial evaluation. The Administrator was interviewed on 02/25/2025 and stated, “There should have been documentation indicating why the SW was delayed.””

“It is required that each patient’s individualized written plan of care that includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 6 (17%) clinical records reviewed, the agency did not ensure that the written plan of care included all treatments necessary to meet the needs of the patient. CLINICAL RECORD 2: A home observation visit was made on 02/25/2025 with the Registered Nurse (RN) (Personnel Record 3). The patient was observed wearing an oxygen cannula, and oxygen was flowing at 2 liters per minute as indicated on the oxygen concentrator. A clinical record review revealed no order on the plan of care (POC) dated 02/06/2025 for oxygen. The patient’s wife was interviewed during the visit and stated she was unsure of the actual dose setting for the oxygen. The RN was interviewed during the home visit and stated that the oxygen order was 2-6 liters per minute via nasal cannula as needed for shortness of breath, this was not included on the plan of care. Additionally, the wife provided medication bottles for the following medications: Lantus Solostar Injectable 8 units at bedtime; MiraLAX daily in the morning; PreserVision 1 tablet twice daily; Glucosamine 1 tablet twice daily; Levothyroxine 175 micrograms daily; and Metformin 500mg tabs, two tabs twice daily. The wife also stated that “[the patient] has been taking these medications before the hospice care started.” The current plan of care (POC) dated 02/06/2025 did not include these medications. The RN was interviewed during the home visit and stated, “I added the medications based on the hospital discharge instructions, and I don’t think they were on there.” During this same home visit the RN performed a blood glucose check using the patient’s glucometer. The POC (dated 02/06/2025) did not include orders for blood glucose testing or orders for the RN to perform blood glucose testing. The RN performed an intervention without physician orders. The RN (Personnel Record 3) was interviewed on 02/25/2025 and stated, “I thought we could do glucometer testing without specific orders, like vital signs.” CLINICAL RECORD 6: The patient elected the hospice benefit on 01/15/2025. The initial nursing comprehensive assessment included documentation that the patient had a PEG (Percutaneous Endoscopic Gastrostomy) tube and that medications could be administered via the PEG tube, if necessary. There were medications documented on the initial plan of care (POC) dated 01/15/2025, that listed the route of administration was via the PEG tube. The POC did not include orders for care of the PEG tube or to flush the PEG tube, nor was there documentation that the patient or family was independent in PEG tube care. The Administrator was interviewed on 02/25/2025 and stated, “The nurse would get an order to give medications through the PEG tube when it became necessary. There should have been orders for care to the tube.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, in which hospice aide services were accepted, the agency did not ensure that the aide plan of care (POC) included patient-specific interventions. CLINICAL RECORD 1: A review of the hospice aide plan of care dated 01/13/2025 included the following assigned Personal Care tasks: Clothing Assist - PRN (as needed), Complete Bed Bath – PRN, Foot Care – PRN, Nail Care – PRN, Partial Bed Bath - PRN, Perineal Care - PRN, Shampoo - PRN, Shave - PRN, Shower - PRN, Skin Care - PRN. The aide POC created by the Registered Nurse omitted specific frequencies or descriptors for when the aide was to perform the personal care tasks. The aide POC also included three types of bathing tasks (Complete Bed Bath, Shower, and Partial Bed Bath), which did not provide specific instructions for the aide. CLINICAL RECORD 3: A review of the hospice aide plan of care dated 01/16/2025 included the following assigned Personal Care tasks: Clothing Assist – PRN, Complete Bed Bath - PRN, Foot Care - PRN, Oral Care - PRN, Partial Bed Bath - PRN, Perineal Care - As needed, Shampoo - PRN, Shower - PRN, Skin Care - PRN. The aide POC created by the Registered Nurse omitted specific frequencies or descriptors for when the aide was to perform the personal care tasks. The aide POC also included three types of bathing tasks (Complete Bed Bath, Shower, and Partial Bed Bath), which did not provide specific instructions for the aide. CLINICAL RECORD 6: A review of the hospice aide plan of care dated 01/19/2025 included the following assigned Personal Care tasks: Clothing Assist, Complete Bed Bath, Denture Care, Foot Care, Nail Care, Oral Care, Partial Bed Bath. Perineal Care, Shampoo, Shave, Shower, Skin Care. The aide POC also included three types of bathing tasks (Complete Bed Bath, Shower, and Partial Bed Bath), which did not provide specific instructions for the aide. The Clinical Manager was interviewed on 02/26/2025 and stated, “We are still learning how to use [the electronic medical record] to create the aide care plan. I think we have a better understanding now.””