Acg Hospice

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) provided care in its entirety to meet the needs of the patient, in two of three records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care/Service Coordination,” showed in part:- Timely and ongoing Communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided;- The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel;- Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits; - Documentation of communications will be included in the medical record on a communication note, case conference summary, or clinical note; and- Written evidence of care coordination may be found in the plan of care service, discipline specific notes in the patient’s medical record or interdisciplinary group meeting notes. Review of the provider’s undated policy titled, “Nursing Care,” showed in part:- Nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a Registered Nurse (RN);- The hospice nurse will participate in developing and implementing the plan of care and will report the condition of the patient and family/caregiver to the attending physician, medical director and IDG on a regular basis, as well as changes in the plan of care;- The hospice nurse will: * Manage discomfort and provide symptom relief * Incorporate specialized nursing skills related to palliative and end-of-life care into all clinical care provided * Initiate appropriate preventative and rehabilitative nursing procedures * Coordinate all patient and family/caregiver services and prioritization of needs with the IDG * Provide specialized hospice training to other staff, family/caregivers to insure adequate care * Assure communication between the hospice and other health care providers involved in the patient’s care- Direct provision of nursing care will be based on hospice nursing standards and clearly defined treatment protocols; and- A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of patients and families/caregivers admitted to the hospice program. Review of the provider’s undated policy titled, “Monitoring Patient’s Response/Reporting To Physician,” showed in part:- Clinicians will monitor, document, and report patient’s response to care and treatment provided on each hospice visit;- Clinicians will establish and maintain ongoing communication with the patient’s physician and the hospice medical director to ensure safe and appropriate care for the patient; - Conferences or attempts to communicate with the attending physician and/or hospice medical director will be documented in the medical record; - When unable to contact the patient’s physician for medical consultation warranted by change in the patient’s condition, the registered nurse or designee will notify the hospice medical director of the change in condition and the inability to contact the patient’s physician to request medical consultation; and- Based on the communication with the physician, a verbal order will be obtained for any change in the plan of care and communicated to all IDG members to ensure that care is provided according to the revised plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/12/2025 with a terminal diagnosis of severe protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body’s needs) and resided at home his/her spouse. Review of the medical record coordination notes report showed that the patient’s spouse (caregiver) contacted the after hours triage nurse on 07/20/2025 and reported that the percutaneous endoscopic gastrostomy (PEG) tube (a thin, flexible tube inserted through the skin of the abdomen and into the stomach) was clogged. Review of the skilled nurse (SN) visit note, dated 07/20/2021 showed:- The SN attempted to flush the peg tube and the tube was clogged;- An order was received to instill coca-cola into the clogged peg tube; and - The SN visit note failed to show documentation that the coca-cola was attempted but unsuccessful; and- The SN visit note failed to show documentation that the physician was notified regarding the failed attempt to unclog the peg tube and there was no documentation that no new orders were received for the peg tube to remain clogged. During an interview on 10/08/2025, at 2:10 PM, RN-A stated that:- The peg tube became clogged on a Sunday (07/20/2025) and the on-call nurse made a visit;- Orders were received to attempt to unclog the peg tube with coca-cola but it was unsuccessful;- The peg tube remained clogged; and - He/she made a visit that Monday (07/21/2025) and new orders were received to start sublingual (under the tongue) comfort mediations. During an interview on 10/09/2025, at 12:44 PM, the administrator designee stated that:- The visit note failed to show that the peg tube was specifically flushed with coca-cola and unsuccessful at unclogging the peg tube;- There was no documentation of a follow-up with the physician on-call regarding the peg tube remaining clogged; and- No additional orders were received for the peg tube to remain clogged after the coca-cola was unsuccessful on 07/20/2025. Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of hydrocephalus (a buildup of excess cerebrospinal fluid in the brain’s ventricles, putting harmful pressure on brain tissue). Other pertinent diagnosis included chronic pain and gastrostomy status. The patient resided at a long-term care facility (LTCF). Review of the medical coordination note dated 08/01/2025, showed the following:- The LTCF staff reported the patient’s tube (feeding tube, a medical procedure where a tube is inserted into the digestive system to provide nutrients) had been clogging, a declogger was ordered and was delivered yesterday (07/31/2025); and- Care was coordinated with the LTCF staff. (The documentation failed to show coordination with the patient’s attending physician). Review of the nurse visit note dated 08/05/2025 at 8:04 AM, showed that the patient was NPO (nothing by mouth) and required bolus feedings which the patient does not tolerate well. (The documentation failed to show monitoring and reporting of the patient’s response to care with the declogging of the feeding tube and if the feeding tube was patent.) Review of the hospice interdisciplinary group (IDG) assessment and plan of care update report dated 08/06/2025, showed the following:- The LTCF staff reported the patient’s tube clogged frequently and required an unclogging device to declog;- The family had requested to not replace the tube again if it becomes clogged where it would require having the tube changed and does not want it replaced and to stop the tube feedings;Review of the nurse visit note dated 08/19/2025 (five days later) at 8:58 AM, showed the following:- The patient was NPO (nothing by mouth) and must be tube fed six (6) bolus (a method of administering liquid nutrition through a tube directly into the stomach or small intestine) feedings a day;- The patient had been missing at least one feeding a day due to stomach pain and receiving morphine (used for the treatment of pain) daily for pain;- The staff were encouraged to go slow with the feeding and flush (the process of using a syringe to gently push water through a feeding tube to keep it (feeding tube) from clogging and to prevent dehydration; - It was noted in the LTCF charting the patient’s tube was getting clogged again and encouraged to flush at the end of the feeding; and- Care was coordinated with the charge nurse (LTCF) and the family was updated.Review of the nurse visit note dated 08/25/2025 at 12:03 PM, showed the following; and- The LTCF nurse reported the patient often had one feeding a day held due to stomach pains. (The documentation failed to show the patient’s attending physician was notified of the patient’s missed tube feeding at least once daily due to stomach pain, the patient’s response with the declogging, patency of the feeding tube.) Review of a medical record coordination note dated 08/21/2025, showed an order for G Tube replacement to be changed (there was no discussion with the family who stated they did not want the tube replaced on 08/06/2025).Review of the nurse visit note dated 09/02/2025 at 8:25 AM, showed the following:- The patient’s PPS (palliative performance scale, a reliable tool that assesses a patient’s functional abilities and helps determine their progression towards the end of life, scores range from zero to 100%, zero (0) indicating death and 100 % representing full health and ambulation) was 30 with weight up and down due to stomachaches and missing feedings at times;- The patient was crying this “AM MAD” and not feeling well without any specific complaints and denied need for any medications;- The patient required bolus feedings six (6) times a day through peg tube (feeding tube);- The patient had frequent stomach aches requiring to hold bolus feedings at times;- The patient has chronic pain with routine medications and was starting Roxanol (used to treat severe, chronic pain) about one (1) time a day for breakthrough pain; and- Coordinated care with the charge nurse (LTCF). (The documentation failed to show coordination of care with the patient’s attending physician regarding the patient’s stomachaches and missed feedings, there was no documentation to show if the feeding tube was changed and if the feeding tube was patent.)Review of the nurse visit note dated 09/08/2025 at 8:16 AM, showed the following:- The patient required tube feeding and was NPO, he/she had been missing tube feeding due to abdominal pain; and- Coordinated care with the (LTCF) charge nurse. (The documentation failed to show coordination with the patient’s attending physician regarding missed tube feedings and abdominal pain.)Review of the nurse visit note dated 09/22/2025 at 8:38 AM, showed the following:- The LTCF nurse arrived in the patient’s room to administer a tube feeding; and- The LTCF nurse stated that the patient was tolerating feedings well with only one feeding being held last week. Review of the nurse visit note dated 09/29/2025 at 12:18 PM, showed the following:- The patient had a low-grade temperature of 99.4 and verbalized via groans when asked if he/she wasn’t feeling well and the patient “nods” when asked about nausea;- The findings were reported to the LTCF nurse who reported scheduled Tylenol was due at 1:00 PM and will be administered per order; and- Care was coordinated with the LTCF nurse and family notified of patient not feeling well. (The provider failed to notify the attending physician of the patient’s low-grade temp and “nods” when asked about nausea.) During an interview on 10/08/2025 at 2:50 PM, showed RN C stated the following:- The patient had a peg tube since the start of care and his/her POA questioned to keep the feeding tube out but decided to place it back;- The patient had what was referred to as an abscess at the feeding tube site and that was causing the issues with the bolus feeding and stomach pain, and the physician said it was possibly stomach cancer;- The patient was not tolerating feedings due to his/her stomach pain, the feeding tube came out, and the abscess drained mucous like drainage;- After the abscess drained the patient’s symptoms temporarily resolved and the physician stated that the abscess would likely come back;- They are currently monitoring the patient’s symptoms, and administering tube feedings as the patient tolerates; and- The facility physician (the patient’s primary physician) does not want the hospice staff contacting him/her, the physician only wants the facility nurses to contact him/her. During an interview on 10/09/2025 @ 12:21 PM, showed the administrator designee stated that the facility physician only likes the facility nurses to call him/her so there was likely additional physician coordination in the LTCF in their chart.”

“Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s interventions in, three of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of hydrocephalus (a buildup of excess cerebrospinal fluid in the brain’s ventricles, putting harmful pressure on brain tissue). Other pertinent diagnosis included chronic pain and gastrostomy status. The patient resided at a long-term care facility (LTCF).Review of the clinical record showed that the patient had a feeding tube (a medical procedure where a tube is inserted into the digestive system to provide nutrients). The patient’s tube had been clogging and a declogger was ordered. The patient had been missing at least one feeding a day due to stomach pain. The LTCF staff were instructed to go slow with the bolus feeding and feeding tube flush (the process of using a syringe to gently push water through a feeding tube). Review of the plan of care failed to show specific problems and interventions for the missed tube feeding at least once a day due to stomach pain, and/or instructions regarding education, safety measures and emergency procedures related to the feeding tube becoming clogged. During an interview on 10/10/2025 at 2:51 PM, the administrator stated that he/she would expect the plan of care to reflect the patients needs. Findings included: Review of the provider’s undated policy titled, “The Interdisciplinary Plan of Care,” showed in part:- The care provided to the patient must be in accordance with the plan of care;- The plan of care will meet the documentation requirements of the physician-directed orders and the care planning process;- The plan of care will be based on the initial, comprehensive and on-going comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every fifteen days; - This plan will focus on identified problems, goals, and interventions; - The plan of care will identify patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief; - Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes; and- Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service. Review of the provider’s undated policy titled, “Nursing Care,” showed in part:- Nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a Registered Nurse (RN);- The hospice nurse will participate in developing and implementing the plan of care and will report the condition of the patient and family/caregiver to the attending physician, medical director and IDG on a regular basis, as well as changes in the plan of care; and- Direct provision of nursing care will be based on hospice nursing standards and clearly defined treatment protocols. Review of the provider’s undated policy titled, “Monitoring Patient’s Response/Reporting To Physician,” showed in part:- Clinicians will monitor, document, and report patient’s response to care and treatment provided on each hospice visit;- Clinicians will establish and maintain ongoing communication with the patient’s physician and the hospice medical director to ensure safe and appropriate care for the patient; - Conferences or attempts to communicate with the attending physician and/or hospice medical director will be documented in the medical record; - When unable to contact the patient’s physician for medical consultation warranted by change in the patient’s condition, the registered nurse or designee will notify the hospice medical director of the change in condition and the inability to contact the patient’s physician to request medical consultation; and- Based on the communication with the physician, a verbal order will be obtained for any change in the plan of care and communicated to all IDG members to ensure that care is provided according to the revised plan of care. Review of the provider’s undated policy titled, “Administration of oxygen,” showed in part:- Obtain orders from the primary care physician for: * Type of oxygen therapy * Administration device and liter flow rate or concentration- Evaluate the patient’s oxygen needs: * Prescribed flow rate or concentration * Humidity requirements * Continuous or intermittent use- Select an oxygen delivery system: * High-pressure cylinder * Oxygen concentrator * Liquid oxygen system- Nasal cannula administration, you may deliver up to 6L/minute and allow a range of concentration of 22-40%; and- Humidification of low-flow oxygen through nasal cannula is not considered essential and may be contraindicated because it supports bacterial growth. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/12/2025 with a terminal diagnosis of severe protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body’s needs) and resided at home his/her spouse. Review of the clinical record showed:- The patient had a tracheostomy (a surgically created opening in the trachea, windpipe, to provide an airway and facilitate breathing); and- The patient had a percutaneous endoscopic gastrostomy (PEG) tube (a thin, flexible tube inserted through the skin of the abdomen and into the stomach). Review of the POC failed to show:- The size of the tracheostomy;- Patient-specific tracheostomy suctioning instructions; - Specific interventions and/or instructions regarding safety measures and emergency procedures related to the tracheostomy; and- Specific interventions and/or instructions regarding safety measures and emergency procedures related to the PEG tube becoming clogged. During an interview on 10/08/2025, at 2:10 PM, RN-A stated that:- The peg tube became clogged on a Sunday (07/20/2025) and the on-call nurse made a visit;- Orders were received to attempt to unclog the peg tube with coca-cola but it was unsuccessful;- The peg tube remained clogged; and - He/she made a visit that Monday (07/21/2025) and new orders were received to start sublingual (under the tongue) comfort mediations. During an interview on 10/09/2025, at 12:44 PM, the administrator designee stated that:- The hospice POC report lists specific visit interventions and goals;- There was not any specific suctioning instructions; - There was not any specific emergency interventions listed; and- The tracheostomy size was not on the POC. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 08/09/2025 with a terminal diagnosis of cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain tissue damage) and resided at home with an adult child as the primary caregiver. Review of the client medication report showed supplemental oxygen, two (2) to six (6) liters for shortness of breath, and titrate as needed for comfort. Review of the vital signs report showed:- On 08/20/2025 the patient was on 9 liters of supplemental oxygen;- On 08/21/2025 the patient was on 9 liters of supplemental oxygen;- On 08/22/2025 the patient was on 8 liters of supplemental oxygen;- On 08/24/2025 the patient was on 9 liters of supplemental oxygen;- On 08/26/2025 the patient was on 9 liters of supplemental oxygen;- On 08/27/2025 the patient was on 8 liters of supplemental oxygen; - On 08/29/2025 the patient was on 9 liters of supplemental oxygen;- On 08/30/2025 the patient was on 9 liters of supplemental oxygen;- On 08/31/2025 the patient was on 10 liters of supplemental oxygen; and- On 09/01/2025 the patient was on 10 liters of supplemental oxygen. Review of skilled nurse visit notes showed that the patient received supplemental oxygen via nasal cannula. Review of the POC failed to show specific oxygen equipment that the patient received, orders for oxygen greater than 6 liters, and the specific type of delivery method that was to be used (the patient received oxygen via nasal cannula and the policy showed a nasal cannula may be used up to 6 liters). During an interview on 10/08/2025, at 2:40 PM, RN-B stated that:- The patient received oxygen through a low-flow nasal cannula;- He/she would not use a mask or high-flow nasal cannula unless ordered by the physician;- He/she adjusted the patient’s oxygen levels for comfort; and - He/she monitored the patient’s oxygen saturations during nursing visits and increased the oxygen to maintain levels above 90%. During an interview on 10/09/2025, at 12:44 PM, the administrator designee stated that:- A high-flow nasal cannula could have been used for supplemental oxygen above 6 liters but he/she did not see anything in the clinical record about the use of a high-flow nasal cannula;- There was an order to keep oxygen levels above 90% on 08/13/2025 but the medication profile was not updated; and - There was no order for oxygen above 6 liters.”

“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. A review of the agency’s volunteer program and services revealed that the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care service hours equal to five percent (5%) of the total of all paid patient care hours. Document 2: The agency started providing hospice care and services on 01/30/2024 and has had a total of eight (8) unduplicated admissions. The agency’s active census was seven (7). The electronic medical record report titled, “Hospice Volunteer Requirements,” documented a total of 61.65 hospice-paid patient care hours and zero (0) volunteer hours for the date range of 01/01/2024 through 04/11/2024. The agency did not provide documented evidence to support that hospice volunteers had provided day-to-day administrative or direct patient care services equal to five percent (5%) of the total of all paid patient care hours. On 04/11/2024 joint documentation review of electronic medical record reports and interviews were conducted with the Directors of Accreditation and Regulatory Compliance, Operations Integration, and Operations for the agency and the Vice President of Clinical Operations Integration who confirmed that hospice volunteers had not provided, at a minimum, five percent (5%) of the total of all paid patient care hours. The Director of Accreditation and Regulatory Compliance provided documented evidence to support a Performance Improvement Project to increase volunteer hours that was currently in place. A review of the agency’s volunteer program and services revealed that the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care service hours equal to five percent (5%) of the total of all paid patient care hours.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes at a minimum, physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 8 (50%) clinical records reviewed it was revealed that the agency did not ensure the clinical record contained physician orders for all care and services provided. Clinical Record 2: The initial nursing assessment completed on 04/06/2024 documented that the patient required and was using oxygen at two (2) liters per minute The plan of care orders, effective 04/06/2024, included an oxygen concentrator as part of the durable medical equipment ordered for the patient. The clinical record did not contain a physician’s order for the administration of oxygen, including flow rate, frequency, and route. The nursing assessment completed on 04/08/2024 documented that the patient was wearing Thrombo-Embolic Deterrent (TED) hose on both legs. The clinical record did not contain a physician’s order for TED hose. During the home visit on 04/11/2024 (Home Visit 2) to a Skilled Nursing Facility (SNF), completed with the Chaplain (Staff 4) a copy of the skilled nursing facility’s order summary report was reviewed and compared to the hospice plan of care. The hospice plan of care and medication profile did not contain physician orders for the following scheduled medications: Mucinex Oral Tablet Extended Release 12 Hour 600mg (Guaifenesin), Mylanta Maximum Strength Oral Suspension 400-400-40mg/mL, and Senna Plus Oral Tablet 8.6-50mg that were on the facility medication report. Clinical Record 3: The initial nursing assessment completed on 03/25/2024 documented that the patient was consuming a nutritional supplement, a chocolate house shake two (2) times per day. The clinical record did not contain a physician’s order for the chocolate house shakes. During the home visit to the SNF, performed on 04/11/2024 (Home Visit 3) completed with the Registered Nurse (Staff 1) a copy of the skilled nursing facility’s order summary report was reviewed, and compared to the hospice plan of care. The hospice plan of care and medication profile did not contain physician orders for the following scheduled and as needed medications: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT, Baclofen oral tablet 5MG, Docusate sodium oral capsule 100mg, Gabapentin oral capsule 100mg, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, Polyethylene Glycol 3350 oral powder 17 GM/scoop, and Potassium chloride ER tablet extended release 20MEQ that were documented on the facility medication report. Clinical Record 5: The initial comprehensive nursing assessment completed on 03/25/2024 documented that the patient had a Stage 4 (four) pressure ulcer on the left hip and that blood sugars were being checked by the caregiver four (4) times a day. The plan of care (POC), effective 03/25/2024, did not contain a physician’s order to check the patient’s blood sugar four times a day. Clinical Record 6: The nursing assessment completed on 03/21/2024 documented that the patient reported an anxiety score of eight (8) out of ten (10). Hydroxyzine as needed was added in addition to the patient’s scheduled two (2) times a day dose. There was no physician order for Hydroxyzine as needed. On 04/11/2024 joint clinical record reviews and interviews were conducted with the Directors of Accreditation and Regulatory Compliance, Operations Integration, and Operations for the agency and the Vice President of Clinical Operations Integration who confirmed that the clinical records identified did not contain physician orders for all care and services provided.”