Rio Grande Hospice LLC

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that all disciplines involved in the patient’s care identified problems and planned interventions to guide their care. AGENCY POLICY: The agency’s policy “Plan of Care (4.40)” was approved and adopted on 11/20/2024 and included in part that “...A plan of care must... include an assessment of the needs of the patient and identify the services required by the patient...The plan of care must reflect patient and family goals and interventions based on the problems identified...” CLINICAL RECORD 1: The patient elected the hospice benefit on 01/07/2025 with the diagnosis of Parkinson’s disease. The plan of care for the benefit period 01/07/2025 to 04/06/2025 was reviewed, and it included orders for the social worker to visit the patient at home once a month. The social worker visited on 01/08/2025, 01/16/2025, 02/25/2025, and 03/06/2025. There was no documented evidence in the plan of care for identified problems and planned interventions s provided by the social worker. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024, having been diagnosed with Parkinson’s disease. The plan of care for the benefit period 12/19/2024 to 03/18/2025 was reviewed, and it included orders for the medical social worker to visit the patient at the assisted living facility one to two times a month. The social worker made visits on 12/23/2024, 12/27/2024, 01/06/2025, 01/22/2025, 02/03/2025, and 02/17/2025. There was no documented evidence in the plan of care for identified problems and planned interventions s provided by the social worker. CLINICAL RECORD 4: The patient elected the hospice benefit on 12/02/2024 with the diagnosis of cerebral infarction secondary to an embolism. The plans of care for the benefit periods 12/02/2024 to 03/01/2025 and 03/02/2025 to 05/30/2025 were reviewed, and they included orders for the social worker to visit the patient at home two to three times a month. The social worker performed visits on 12/06/2024, 01/24/2025, and 02/14/2025. There was no documented evidence in the plan of care for identified problems and planned interventions provided by the social worker. On 03/11/2025, the social worker plan of care was updated to include planned interventions for Children and Grief and Caregiver Role Strain. During a joint clinical record review and interview with the Clinical Director (Personnel Record 2) on 03/13/2025, she confirmed the missing social worker care plans.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that the plans of care included measurable outcomes for all disciplines involved in the patient’s care. AGENCY POLICY: The agency’s policy “Plan of Care (4.40)” was approved and adopted on 11/20/2024 and read in part that “...The hospice written interdisciplinary plan of care is developed and individualized... reflect patient/family goals...Measurable outcomes are anticipated from implementing and coordinating the plan of care...” CLINICAL RECORD 1: The patient elected the hospice benefit on 01/07/2025 with the diagnosis of Parkinson’s disease. The plan of care for the benefit period 01/07/2025 to 04/06/2025 included orders for the Chaplain and social worker to visit the patient once a month. The Chaplain performed visits on 01/08/2025, 01/29/2025, and 02/24/2025. The Chaplain identified two problems on 01/08/2025. The Chaplain documented; “Problem: Hospice Care 01/08/2025; I: assess how family/caregiver are dealing with loss, No Goal. Problem: Grief Process and Bereavement Risk 01/08/2025; I: assess grieving, No Goal.” There was no documented evidence of goals/measurable outcomes for the identified problems. There was no documented evidence in the clinical record for a social worker plan of care developed that included measurable outcomes, however, the social worker performed visits on 01/08/2025, 01/16/2025, 02/25/2025, and 03/06/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with the diagnosis of Parkinson’s disease. The plan of care for the benefit period 12/19/2024 to 03/18/2025 included orders for the social worker to visit the patient one to two times a month. The social worker made visits on 12/23/2024, 12/27/2024, 01/06/2025, 01/22/2025, 02/03/2025, and 02/17/2025. There was no documented evidence of a plan of care developed for the social worker that included goals of care/measurable outcomes. CLINICAL RECORD 4: The patient elected the hospice benefit on 12/02/2024 with a diagnosis of cerebral infarction secondary to an embolism. The plans of care for the benefit periods 12/02/2024 to 03/01/2025 and 03/02/2025 to 05/30/2025 included orders for the social worker to visit the patient two to three times a month. The social worker performed visits on 12/06/2024, 01/24/2025, and 02/14/2025. There was no documented evidence of a social worker plan of care developed that included goals of care/measurable outcomes from the initial visit on 12/06/2024 until 03/11/2025. During a joint clinical record review and interview with the Clinical Director (Personnel Record 2) on 03/13/2025, she confirmed the missing goals and measurable outcomes for the social worker and Chaplain.”

“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 5 of 5 (100%) bereavement records reviewed revealed the agency did not ensure that there was a documented post-death bereavement risk assessment or a bereavement plan of care. AGENCY POLICY: The hospice’s policy “Bereavement Services (4.14)” was approved and adopted on 11/20/2024 and read in part that “A bereavement care plan is developed for identified family members and other involved individual’s after the patient’s death. The hospice bereavement plan of care is developed based on an assessment of the patient/family needs at the time of admission... and when the patient dies and includes... services to be provided and the frequency of service delivery...The Bereavement Coordinator is notified of all deaths and initiates the bereavement discussion and care planning at the first IDG meeting following the patient’s death...” CLINICAL RECORD 10: The patient elected the hospice benefit on 12/04/2024 and died at home as a result of the admitting diagnosis of malignant neoplasm of the left breast on 12/16/2024. The post-death Interdisciplinary Group Meeting (IDG) on 12/23/2024 did not include a bereavement risk level. There was no bereavement risk assessment update documented at the time of the patient’s death, and no bereavement plan of care was documented. CLINICAL RECORD 11: The patient elected the hospice benefit on 11/01/2024 and died on 12/23/2024. The post-death Interdisciplinary Group Meeting (IDG) on 01/11/2025 did not include a bereavement risk level. There was no bereavement risk assessment update documented at the time of the patient’s death, and no bereavement plan of care was documented. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/01/2025 and died on 02/26/2025. The post-death Interdisciplinary Group Meeting (IDG) on 03/03/2025 did not include a bereavement risk level. There was no bereavement risk assessment update documented at the time of the patient’s death, and no bereavement plan of care was documented. CLINICAL RECORD 13: The patient elected the hospice benefit on 01/21/2025 on 01/27/2025. The post-death Interdisciplinary Group Meeting (IDG) on 02/03/2025 did not include a bereavement risk level. There was no bereavement risk assessment update documented at the time of the patient’s death, and no bereavement plan of care was documented. CLINICAL RECORD 14: The patient elected the hospice benefit on 11/19/2024 and died on 01/03/2025. The post-death Interdisciplinary Group Meeting (IDG) on 01/06/2025 did not include a bereavement risk level. There was no bereavement risk assessment update documented at the time of the patient’s death, and no bereavement plan of care was documented. On 03/12/2025 it was confirmed during a joint clinical record review and interview with the Executive Director (RN) (Personnel Record 1) and the Clinical Director (Personnel Record 2) that the current practice did not include documentation of an assessed bereavement risk level or a bereavement plan of care for a patient after death. They believed that the Electronic Medical Record’s generation of mailings were sufficient to meet the requirements. The Bereavement Coordinator/Chaplain (Personnel Record 6) was interviewed on 03/13/2025, and a discussion of the post-death bereavement risk assessment and bereavement care plans occurred. While he has over ten years of experience in hospice, he only recently assumed the role of a Bereavement Coordinator with this agency. During the conversation, he relayed he was not aware of the requirement of the post-death bereavement risk assessment or for a bereavement plan of care. His documentation has been a spreadsheet where he documented when sympathy cards, letters, or phone contact has been made, but no future planned interventions or risk levels appeared on the spreadsheet. The patient’s clinical record only includes bereavement documentation when phone contact or attempts at contact have been made.”

“It is required that a hospice aide provides services ordered by the Ordered by the Interdisciplinary Group (IDG) and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) clinical records reviewed where hospice aide services were accepted the agency did not ensure that the hospice aide followed the aide plan of care ordered by the Interdisciplinary Group. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with the diagnosis of Parkinson’s. The plan of care for the benefit period 12/19/2024 to 03/18/2025 included orders for the hospice aide to visit the patient once a week, then twice a week, beginning 01/14/2025. On 01/03/2025, the hospice aide documented that the patient refused to shampoo her hair. On the aide visit dated 01/10/2025, both the shampoo and shower chair bath were refused. On 02/14/2025 the aide documented that the patient refused shampoo and a shower chair bath. On 02/21/2025, the aide documented that the patient refused shampoo, shower chair bath, and linens to be changed. On 02/25/2025, the patient refused a shampoo. On 03/04/2025, the patient refused a shampoo and shower chair bath. There was no documented evidence that the aide followed the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/29/2025 with the diagnosis of malignant neoplasm of the prostate. The plan of care for the benefit period 01/29/2025 to 04/28/2025 included orders for the hospice aide to visit the patient twice a week until the week of 02/23/2025 when the visits were increased to three times a week. During the hospice aide visit on 02/20/2025, the aide documented that the interventions to ambulate the patient using an assistive device and assist to the bedside commode or toilet were not completed. There was no documented evidence that the aide followed the plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/04/2024 with the diagnosis of malignant neoplasm of the left breast. The plan of care dated 12/04/2024 to 03/03/2025 included orders for the hospice aide to visit the patient twice a week the first week, and then five times a week. The hospice aide visits documented on 12/06/2024, 12/09/2024, 12/10/2024, 12/11/2024, 12/12/2024, and 12/13/2024 included no care plan interventions within the visit and only a narrative by the hospice aide was documented. The aide visit note dated 12/09/2024 stated, “Upon arrival patient was in bed asleep. I gathered supplies needed for a bed bath. She got a bath, lotion, clean clothes, and oral care.” The aide visit narrative from 12/13/2024 stated, “Upon arrival patient was in bed asleep. I gathered supplies needed for a bed bath. She got a bath, lotion, clean clothes, and oral care. I cleaned up all supplies used and my area worked in.” There was no documented evidence that the aide followed the plan of care. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/01/2025 with the diagnosis of malignant neoplasm of the colon. The plan of care dated 02/01/2025 to 05/01/2025 included orders for the hospice aide to visit twice a week. During the hospice aide visit on 12/13/2024, the aide did not complete the intervention to ambulate the patient using an assistive device and noted the linen was not changed. The aide visit dated 02/20/2025, the aide noted that the patient refused to have her linen changed. Two other interventions were not completed due to a “decline in patient condition”—ambulating the patient using an assistive device and transferring to bed/chair with assistance. There was no documented evidence that the aide followed the plan of care. During a joint clinical record review and interview with the Clinical Director (Personnel Record 2) on 03/13/2025, she confirmed the findings that the aide did not follow all interventions in the aide plan of care. During a joint personnel record review and interview with the Clinical Director (Personnel Record 2) on 03/12/2025 and reviewed with the Executive Director/COO, RN (Personnel Record 1), and both co-owner/co-CEOs on 03/13/2025, all present confirmed, after reviewing joint visit observation forms completed by the Clinical Director, that the tasks for a tub bath, shampooing hair (sink), shampoo hair (tub), toileting (bedpan/urinal), normal range of motion, and massage remained unobserved. The hospice aide completed normal and active range of motion under observation, and the clinical director marked them as performed satisfactorily.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) Clinical records reviewed for patients receiving hospice aide services revealed the agency did not ensure that the hospice aide notified the Registered Nurse (RN) when the plan of care was not completed or for a change in the patient’s condition. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with the diagnosis of Parkinson’s. The plan of care for the benefit period 12/19/2024 to 03/18/2025 included orders for the hospice aide once a week, then twice a week beginning 01/14/2025. On 01/03/2025, the hospice aide documented the patient refused to shampoo her hair; on 01/10/2025, both the shampoo and shower chair bath were refused, and the aide also noted, “...She wasn’t feeling very good, so I got her changed, dressed, transferred to wheelchair... made her bed and brushed her hair.” On 02/14/2025 the aide documented the patient refused shampoo and a shower chair bath. She indicated that the “...Patient was not feeling well and refused a shower.” On 02/21/2025, the aide documented that the patient refused shampoo, shower chair bath, and linens to be changed; on 02/25/2025, the patient refused a shampoo and on 03/04/2025, the patient refused a shampoo and shower chair bath. There was no documented evidence that the nurse was notified that the aide tasks were not completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/29/2025 with the diagnosis of malignant neoplasm of the prostate. The plan of care for the benefit period 01/29/2025 to 04/28/2025 included orders for the hospice aide to visit twice a week until the week of 02/23/2025 when the visits were increased to three times a week. The aide documented on 02/20/2025that the interventions to ambulate the patient using an assistive device and assist to the bedside commode or toilet were not completed and noted that the patient’s condition had declined. There was no documented evidence that the nurse was notified that the aide tasks were not completed. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/04/2024 with the diagnosis of malignant neoplasm of the left breast. The plan of care dated 12/04/2024 to 03/03/2025 included orders for the hospice aide to visit the patient twice a week the first week, and then five times a week. The hospice aide visits documented on 12/06/2024, 12/09/2024, 12/10/2024, 12/11/2024, 12/12/2024, and 12/13/2024 included no care plan interventions within the visit and only a narrative by the hospice aide was documented. The aide visit note dated 12/09/2024 stated, “Upon arrival patient was in bed asleep. I gathered supplies needed for a bed bath. She got a bath, lotion, clean clothes, and oral care.” The aide visit narrative from 12/13/2024 stated, “Upon arrival patient was in bed asleep. I gathered supplies needed for a bed bath. She got a bath, lotion, clean clothes, and oral care. I cleaned up all supplies used and my area worked in.” There was no documented evidence that the nurse was notified that the aide tasks were not completed. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/01/2025 with the diagnosis of malignant neoplasm of the colon. The plan of care dated 02/01/2025 to 05/01/2025 included orders for the hospice aide to visit twice a week. During the hospice aide visit on 12/13/2024, the aide did not complete the intervention to ambulate the patient using an assistive device and noted the linen was not changed. The aide visit dated 02/20/2025, the aide documented that the patient refused to have her linen changed. Two other interventions were not completed due to a “decline in patient condition”—ambulating the patient using an assistive device and transferring to bed/chair with assistance.; it was just a narrative that read, “Patient did not want to be transferred into chair. She was in bed, so I didn’t need to make it this visit and family did not want linen change.” There was no documented evidence that the nurse was notified that the aide tasks were not completed. During a joint clinical record review and interview with the Clinical Director (Personnel Record 2) on 03/13/2025, she confirmed the findings that the aide did not follow all interventions in the aide plan of care and did not notify the Registered Nurse.”

“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. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that the Hospice Election Statement Addendum was provided to the patient/representative within the required regulatory time frame. AGENCY POLICY: The agency’s policy “Election of the Medicare Hospice Benefit (4.11)”, approved and adopted 11/20/2024, included in part that “...If the hospice election statement addendum is requested on the date of the initial hospice election... the hospice must provide this information, in writing, to the individual (or representative) within 5 days from the effective date of the election...” CLINICAL RECORD 1: The patient, who resided at home, elected the hospice benefit on 01/07/2025 with the diagnosis of Parkinson’s disease. The patient’s medical record included the Election of Hospice Medicare Benefit document signed and dated 01/07/2025. The patient’s spouse checked the box “I elect to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” and this statement was initialed by the patient’s spouse and dated 01/07/2025. The Patient Notification of Hospice Non-Covered Items, Services, and Drugs documented the date of request 02/10/2025, and the patient’s spouse signed and dated the form 02/10/2025 - after the five-day required timeframe. CLINICAL RECORD 2: The patient, who resided at an assisted living facility, elected the hospice benefit on 12/19/2024 with the diagnosis of Parkinson’s disease. The patient’s medical record included the Election of Hospice Medicare Benefit document signed and dated 12/19/2024. The patient’s daughter checked the box “I elect to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” and this statement was initialed by the patient’s spouse and dated 12/19/2024. The patient’s clinical record did not contain the document “The Patient Notification of Hospice Non-Covered Items, Services, and Drugs. “ CLINICAL RECORD 14: The patient, who resided at an assisted living facility, elected the hospice benefit on 11/19/2024 with the diagnosis of unspecified severe protein-calorie malnutrition. The patient’s medical record included the Election of Hospice Medicare Benefit document signed and dated 11/19/2024. The patient’s daughter checked the box “I elect to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” and this statement was initialed by the patient’s spouse and dated 11/19/2024. The patient’s clinical record did not contain the document “The Patient Notification of Hospice Non-Covered Items, Services, and Drugs. “ During a joint clinical record review with the Clinical Director (Personnel Record 2), the Executive Director/COO/RN (Personnel Record 1) and both co-owners/co-CEO’s on 03/13/2025, they confirmed that they had no further documentation to provide and confirmed the findings of one late and two missing Hospice Election Addendum statements.”