Jansen Hospice and Palliative Care

“Based on clinical record review and staff interview, the hospice failed to conduct and document a patient specific comprehensive assessment that reflects the severity of symptoms when notified by the on-call service of the urgent care needs of all patients. This was evident in one (1) of six (6) clinical records reviewed (Patient #1) Failure to conduct comprehensive assessments to include the severity of symptoms has the potential for negative patient outcomes. Findings: Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for the certification Period of 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4 times per month and 2 visits as needed (PRN); home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication” Registered Nurse (RN) documents, “4/4/25 telephone call from patient’s daughter reporting patient refusing medications or anything by mouth reports patient sleeping and appears comfortable. Disease progression and signs and symptoms of end of life reviewed. Emotional support provided”. There is no documented evidence of a hospice nurse assessment that documents the severity of the patient’s symptoms following the patient’s daughter call on the morning of 4/4/2025 at 6:54 AM when it was reported that the patient is experiencing labored breathing. On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on clinical record review, policy and procedure review, and staff interviews, the Hospice failed to ensure updated comprehensive assessments, that includes information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care is available to the interdisciplinary team (IDT). This was evident for one (1) of six (6) patient care records reviewed (Patient #1). Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient and is available to the IDT has the potential for negative patient outcomes. Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Skilled Nursing 5 visits per week times 1 week, 2 visit per week times 12 weeks; Medical Social Worker 1 visit per month x 1 month, 3 visit per month times 1 month, 1 visit per month times 2 month; Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4 times per month and 2 visits as needed (PRN); home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. The Comprehensive Assessment Policy No. 2-030.4 documents, “the comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires; if no changes are needed, then that must be document” The following Interdisciplinary group (IDG) meeting minutes documents: 3/5/25 MD- “patient complaint of gastro-esophageal reflux disease, will manage with proton pump inhibiter (PPI). Recently discharge from hospital after treatment for Urinary Tract Infection, Stage II Sacral Wound and chronic hypoxic respiratory failure requiring Oxygen 2 liters” 3/19/25 RN Note- “Back onto Jansen Hospice Services after recent hospitalization this past week from the daughter’s report. Breathing with pursed lips on 4 liters of Oxygen through nasal cannula” 3/19/25-MD notes- “Stage II Sacral Wound and chronic hypoxic respiratory failure requiring Oxygen 2 liters” 4/2/25 RN note- “daughter express interest in Intravenous (IV) Hydration” There is no documented evidence of wound care order in the IDG meeting minutes and/or updated assessment for 3/5/25 and 3/19/25. There is no documented evidence the IDG address the family interest in IV hydration. There is no documented evidence the interdisciplinary group documents in the meeting minutes if there has been changes and/or if no changes are needed to the plan of care. On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on patient record reviews and staff interviews, the Hospice failed to ensure that the Interdisciplinary Group (IDG) developed, implemented, and maintained a Triage Policy and a complete On-Call Policy and Procedure for all healthcare personnel to follow. This was evident in review of the agency’s policies and in one (1) of (6) patient records reviewed (Patient #1). Failure to ensure that the IDG develops, implements, and maintains a Triage Policy and a complete On-Call Policy and Procedure, has the potential for negative patient outcomes. Findings: Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification period of 2/28/25 to 5/28/25. Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication”. On 5/28/25 the On-Call Policy was requested. The hospice provided a policy titled, “On-Call/Weekend Staffing Policy No. 2.032.1 revised 2024. The policy lacks documented evidence on triage procedure and when to escalate a call to the administrator on duty or physician. There is no documented evidence the Hospice nurse promptly notified or communicated with a either Supervisor and/or Administrator or the Patient’s physician on the morning of 4/4/2025 at 6:54 AM when patient’s daughter called and reported that the patient is experiencing labored breathing. There is no documented evidence the IDG develop a complete On-Call policy to include triage procedure/process. On 5/29/2025 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on patient record reviews and staff interviews, the hospice failed to ensure the patients Plan of Care include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. This was evident for one (1) of six (6) clinical records reviewed. (Patients #1)Failure to ensure the patients Plans of Care includes a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs has the potential for negative patient outcomes Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period of 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification period 2/28/25 to 5/28/25 documents, “Routine home care Skilled Nursing 1 to 4 times per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4 times per month and 2 visits as needed (PRN); home health aide (HHA) 1 to 5 times per week and 2 visits as needed(PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. The Hospice Plan of Care lacks documented evidence of: the number of PRN Volunteer services and the number PRN spiritual visits. There is no documented evidence of a detailed statement of the task/s the hospice aide is to perform to meet the patient care needs. On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on record reviews and staff interview, the agency failed to ensure all services are provided in accordance with the Plan of Care for each patient. This was evident in two (2) of six (6) clinical records reviewed (Patients #2 and #4).Failure to ensure services are provided in accordance with the Plan of Care has the potential for negative patient outcomes. The findings are:1) Patient #2 has a start of care date of 02/25/25 with diagnoses including cerebrovascular disease, chronic kidney disease (stage 4), and moderate protein-calorie malnutrition as documented on “Hospice Certificate and Plan of Care” for certification period 02/25/25 – 05/25/25. The Plan of Care documents orders for: “skilled nursing 1-4 times per week plus 3 PRN (as needed), medical social worker 1-4 times per month plus 2 PRN, home health aide 1-5 days a week plus 2 PRN, spiritual 1-4 times a month plus PRN, and volunteer services PRN.”In a “Hospice Home Health Aide Request” note dated 02/26/25, the Registered Nurse documented “Hospice home health aide request. Frequency: 5. Hours per day: 4. Wants 12-4pm.”In an “Interdisciplinary Group note” dated 02/26/25, the Social Worker documented “Services requested are registered nurse, social worker, home health aide, chaplain, and massage therapy.”There is no documentation the patient received the services of home health aide or chaplain prior to 03/02/25 when patient expired.In a “Missed Visit Notification” note dated 03/03/25, a chaplain documented “Reason for missed visit chaplain was not on the work schedule for 02/28/25.”On 5/29/25 at 10:20AM the Administrative Director was interviewed and stated “It looks like there was missed visits.” 2) Patient #4 has a start of care date of 05/16/25 with diagnoses including Parkinsonism as documented on “Hospice Certification and Plan of Care” for certification period 05/16/25 – 08/13/25. The Plan of Care has medical orders for: “skilled nursing 1-4 times per week plus 3 PRN (as needed), medical social worker 1-4 times per month plus 2 PRN, home health aide 1-5 days a week plus 2 PRN, spiritual 1-4 times a month plus PRN, and volunteer services PRN.”In an “Interdisciplinary Group note” dated 05/16/25, the Registered Nurse documents: “Family requests home health aide.”The record lacks documentation that the patient received the services of home health aide prior to 05/23/25 when patient expired.On 5/29/25 at 12:57PM the Administrative Director was interviewed and stated “We have a process for home health aides where the nurse who opens the case puts in a coordination note with home health aide requests including days, hours, if there is already an agency involved. This starts the workflow for obtaining an aide. The nurse did not make a formal request for home health aide.””

“Based on clinical records review and staff interviews, the agency failed to ensure Hospice care provided is consistent with the patient and/or family needs and goals to optimize care. This was evident for two (2) of six (6) clinical records reviewed (Patients #1 and #2). Failure to ensure Hospice care is consistent with patient and family needs and goals as priority places the patient at risk for negative outcomes. Findings: 2. Patient #2 has a start of care date of 02/25/25 with diagnoses including cerebrovascular disease, chronic kidney disease (stage 4), and moderate protein-calorie malnutrition as documented on “Hospice Certificate and Plan of Care” for certification period 02/25/25 – 05/25/25.The patient expired on 03/02/25. On 03/03/25 the Registered Nurse documented in a “Narrative” note “Daughter reports father, spouse of patient having a difficult time, crying almost all day. Daughter is requesting bereavement counseling sooner than later.”The record lacks documentation that the family received any bereavement counseling.On 5/29/25 at 10:20AM the Administrative Director was interviewed and stated the social worker “did attempt to contact spouse multiple times.” Documentation of this communication was requested. On 5/29/25 at 11:42AM the Administrative Director was interviewed and stated, “There are no notes from social worker”. Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site Female Breast as documented on the Hospice Certification and Plan of Care for certification Period of 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4 times per month and 2 visits as needed (PRN); home health aide (HHA) 1 to 5 times per week and 2 visits as needed (PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. Statlinx On-call message log documents, “4/4/2025 taken 6:54 AM from patient’s daughter, patient is experiencing labored breathing. Patient is refusing medication”. Registered Nurse (RN) documents, “4/4/25 telephone call from patient’s daughter reporting patient refusing medications or anything by mouth reports patient sleeping and appears comfortable. Disease progression and signs and symptoms of end of life reviewed. Emotional support provided”.There is no documented evidence of a nursing visit to address the daughter’s concerns. There is no documented evidence the hospice nurse provided care to the patient experiencing labored breathing that would optimizes comfort and dignity; and is consistent with patient and family needs. On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the hospice failed to ensure in one (1) out of six (6) records that professional staff maintained an accurate, current, complete and clearly documented record related to the provision of the patient’s care. (Patient #1) Failure to maintain an accurate, current, complete and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings: Patient #1 has a start of care date of 1/29/25, re-admission date of 2/28/25 and a discharge date of 4/4/25 with diagnosis of secondary Malignant Neoplasm unspecified Lung, Malignant Neoplasm unspecified site unspecified Female Breast documented on the Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25. The Hospice Certification and Plan of Care for certification Period 2/28/25 to 5/28/25 documents, “Skilled Nursing 5 visits per week times 1 week, 2 visit per week times 12 weeks; Medical Social Worker 1 visit per month x 1 month, 3 visit per month times 1 month, 1 visit per month times 2 month; Hospice Interdisciplinary Team (IDT) to provide care in the setting in the settings determined most appropriate for the patient and family. Routine home care Skilled Nursing 1 to 4 times per week, and 3 visits as needed (PRN); Medical Social Worker 1 to 4 times per month and 2 visits as needed(PRN); home health aide (HHA) 1 to 5 times per week and 2 visits as needed(PRN); Spiritual 1 to 4 times per month and as needed (PRN); Volunteer Services as needed (PRN); continuous care (continuous nursing in the home for acute medical situations); Hospice Nurse observation and assessment of signs and symptoms of declining status/imminent death; instruct patient/family on signs and symptoms of dying and plan for managing symptoms”. · The record documents 2 orders for skilled nursing and medical social worker running simultaneously. The record lacks documented evidence the caregiver was educated on the pronouncement and how to provide postmortem care. There is no documented evidence the record is complete and/or the documentation is clear. On 5/29/25 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the findings.”