O’neill Healthcare - Hospice

“It is required that Hospice Aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the Hospice Aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The Hospice Aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed of patients with Hospice Aide services provided, the agency did not ensure that Hospice Aide supervisory visits were completed no less frequently than every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/12/2025. The plans of care dated 12/12/2025 through 03/11/2026 and 03/12/2026 through 06/09/2026 ordered “Aide 3 times weekly starting week of 12/15/2025”. The first Hospice Aide visit was dated 12/15/2025. Hospice Aide supervisory visits were dated 12/18/2025, 12/29/2025, 01/05/2026, 01/09/2026, 01/20/2026, 01/27/2026, 02/10/2026, 02/19/2026, and 02/24/2026. The next Hospice Aide supervisory visit was dated 03/12/2026, a total of 16 days from the previous supervisory visit, and 2 days outstanding. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/05/2026. The plan of care dated 02/05/2026 through 05/05/2026 ordered “Aide 1 time weekly on week of 02/05/2026 and 3 times weekly starting week of 02/09/2026”. The first Hospice Aide visit was dated 02/05/2026. Hospice Aide supervisory visits were dated 02/13/2026, 02/20/2026, 03/02/2026, 03/06/2026, 03/13/2026, and 03/18/2026. The next Hospice Aide supervisory visit was dated 04/02/2026, a total of 15 days from the previous supervisory visit, and 1 day outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/07/2024. The plans of care dated 10/07/2024 through 01/04/2025 and 01/05/2025 through 04/04/2025 ordered “Aide 2 times weekly”. The first Hospice Aide visit was dated 10/11/2024. Hospice Aide supervisory visits were dated 10/11/2024, 10/21/2024, 10/28/2024, 11/04/2024, 11/07/2024, and 11/21/2024. The next Hospice Aide supervisory visit was dated 12/17/2024, a total of 26 days from the previous supervisory visit and 12 days outstanding. Additionally, Hospice Aide supervisory visits were dated 12/27/2024, 01/06/2025, and 01/10/2025. The next Hospice Aide supervisory visit was dated 01/31/2025, a total of 21 days from the previous supervisory visit, and 7 days outstanding. The next Hospice Aide supervisory visit was dated 02/28/2025, a total of 28 days from the previous supervisory visit and 14 days outstanding. During joint record reviews and interview on 04/24/2026, the Alternate Clinical Director confirmed the above findings that Hospice Aide supervisory visits were not completed every 14 days.”

“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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024 with a terminal illness of unspecified chronic obstructive pulmonary disease. The Medical Social Worker (MSW) completed the initial psychosocial, emotional, and spiritual assessments on 04/18/2024, seven days after the hospice benefit was elected, and two days outstanding. Clinical Record 7: : The patient elected the hospice benefit on 07/03/2024 with a terminal illness of unspecified pulmonary fibrosis. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 07/16/2024, 13 days after the hospice benefit was elected, and eight days outstanding. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024 with a terminal illness of unspecified severe protein-calorie malnutrition. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 05/02/2024, six days after the hospice benefit was elected, and one day outstanding. Clinical Record 18: The patient elected the hospice benefit on 01/19/2024 with a terminal illness of unspecified chronic obstructive pulmonary disease. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 02/20/2024, 32 days after the hospice benefit was elected, and 27 days outstanding. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the comprehensive assessments were not completed within five (5) calendar days of the patient elected the hospice benefit, as required.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment, as required per agency policy. Agency policy H:2-008, Bereavement Services, revised 2015, stated in part, “A bereavement risk assessment will be completed by the hospice social worker/counselor at the time of admission to hospice.” Clinical Record 2: The patient elected the hospice benefit on 03/05/2024. The Medical Social Worker (MSW) completed the psychosocial and emotional assessments on 03/07/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. Clinical Record 7: The patient elected the hospice benefit on 07/03/2024. An initial bereavement assessment was completed by the Registered Nurse (RN) on 07/03/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024. An initial bereavement assessment was completed by the RN on 04/26/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024. An initial bereavement assessment was completed by the RN on 06/26/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. Clinical Record 13: The patient elected the hospice benefit on 07/01/2024. An initial bereavement assessment was completed by the RN on 07/01/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. Clinical Record 16: The patient elected the hospice benefit on 07/03/2024. There was no evidence that the MSW or counselor completed a bereavement assessment at the time of admission. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the bereavement assessment was not completed by the MSW or counselor, per the policy.”

“It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician (if any), the patient or the patient representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 14 of 19 (74%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the IDG. Clinical Record 1: The patient elected the hospice benefit on 06/02/2024. The Medical Social Worker (MSW) completed the initial spiritual assessment on 06/03/2024. The plan of care (POC) dated 06/02/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 2: The patient elected the hospice benefit on 03/05/2024. The Chaplain completed the initial spiritual assessment on 03/06/2024. The POC dated 03/05/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 3: The patient elected the hospice benefit on 04/29/2024. The Chaplain completed the initial spiritual assessment on 05/03/2024. The POC dated 04/29/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 04/18/2024. The POC dated 04/11/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 6: The patient elected the hospice benefit on 05/26/2024. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 05/26/2024. The POC dated 05/26/2024, included an order for the Chaplain to visit once per month, and the Aide to visit once per week. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. The Aide provided visits twice weekly from 06/20/2024 to current. There was no documentation of the reason for exception to the POC. Clinical Record 7: : The patient elected the hospice benefit on 07/03/2024. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 07/16/2024. The POC dated 07/03/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided a visit in July 2024. There was no documentation of the reason for the missed visit. Clinical Record 8: The patient elected the hospice benefit on 02/28/2024. The Chaplain completed the initial spiritual assessment on 02/28/2024. The POC dated 02/28/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 11: The patient elected the hospice benefit on 08/07/2023. The Chaplain completed the initial spiritual assessment on 08/10/2023. The POC dated 06/02/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 06/28/2024. The POC dated 06/26/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. Clinical Record 13: The patient elected the hospice benefit on 07/01/2024. The MSW completed the initial psychosocial, emotional, and spiritual assessments on 07/02/2024. The POC dated 07/01/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided a visit in July 2024. There was no documentation of the reason for the missed visit. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The Chaplain completed the initial spiritual assessment on 11/07/2023. The POC dated 11/03/2023, included an order for the Chaplain to visit once per month, and the Aide to visit once a week. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reasons for the missed visits. The Aide completed visits twice weekly from 07/01/2024 to current. There was no documentation of the reason for exception to the POC. Clinical Record 16: The patient elected the hospice benefit on 06/20/2024. The patient revoked the hospice benefit on 07/22/2024 to seek aggressive treatment. The MSW completed the psychosocial, emotional, and spiritual assessments on 06/25/2024. The POC dated 06/20/2024, included an order for the Chaplain to visit once per month. There was no evidence that the Chaplain provided visits in June 2024 and July 2024. There was no documentation of the reason for the missed visits. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the services were not provided as ordered in the POC. The Clinical Director stated the chaplain visits were not completed because the Chaplain quit without notice.”

“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 and interview. In 19 of 19 (100%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions. Clinical Record 1: The patient elected hospice services on 06/02/2024 with a terminal illness of senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 06/02/2024, documented the following: anxiety rated seven out of ten; fall risk with a score of six out of ten, after a recent fall with an injury; incontinent of bowel and bladder; thin; frail; and cachectic. The Medical Social Worker (MSW) completed the psychosocial, emotional, and spiritual assessments on 06/03/2024, and documented to continue psychosocial and spiritual support. The written plan of care (POC) dated 06/02/2024, did not reflect patient and family goals and planned interventions associated with anxiety, fall risk, skin integrity risk, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 2: The patient elected hospice services on 03/05/2024 with a terminal illness of unspecified heart failure. The initial nursing assessment dated 03/05/2024, documented that the patient had dyspnea with minimal exertion, and edema to bilateral lower extremities. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 03/07/2024 and 03/06/2024 respectively, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 03/05/2024, did not reflect patient and family goals and planned interventions associated with dyspnea, edema, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 3: The patient elected hospice services on 04/29/2024 with a terminal illness of Alzheimer’s disease of late-onset. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 04/30/2024 and 05/03/2024 respectively, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 04/29/2024, did not reflect patient and family goals and planned interventions associated with the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 4: The patient elected hospice services on 04/11/2024 with a terminal illness of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 04/11/2024, documented that the patient had orthopnea that required multiple pillows to keep their head elevated, and pitting edema to bilateral lower extremities rated one to two plus. The MSW completed the psychosocial, emotional, and spiritual assessments on 04/18/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 04/11/2024, did not reflect patient and family goals and planned interventions associated with orthopnea, edema, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 5: The patient elected hospice services on 10/13/2023 with a terminal illness of Alzheimer’s disease with late-onset. The MSW completed the psychosocial, emotional, and spiritual assessments on 10/13/2023, and documented to continue psychosocial support at a frequency of one visit per month. The written POC dated 10/13/2023 and updated 12/10/2023, included visit frequency orders for MSW and Chaplain of one visit per month. The written POC did not reflect patient and family goals and planned interventions associated with the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 6: The patient elected hospice services on 05/26/2024 with a terminal illness of unspecified vascular disease of the intestine. The initial nursing assessment dated 05/26/2024, documented the following: patient was confused and agitated; required scheduled antipsychotics; had an anxiety score of seven out of ten; had difficulty with constipation; and had a lower gastrointestinal bleed. The MSW completed the psychosocial, emotional, and spiritual assessments on 05/29/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 05/26/2024, did not reflect patient and family goals and planned interventions associated with the patient’s confusion, agitation, anxiety, constipation, gastrointestinal bleeding, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 7: : The patient elected hospice services on 07/03/2024 with a terminal illness of unspecified pulmonary fibrosis. The MSW completed the psychosocial, emotional, and spiritual assessments on 07/16/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 07/03/2024, did not reflect patient and family goals and planned interventions associated with the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 8: The patient elected hospice services on 02/28/2024 with a terminal illness of unspecified Parkinsonism. The initial nursing assessment dated 02/28/2024, documented that the patient was lethargic, confused, and had garbled speech. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 02/29/2024 and 02/28/2024 respectively, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 02/28/2024, did not reflect patient and family goals and planned interventions associated with confusion, altered communication, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 9: The patient elected hospice services on 04/02/2024 with a terminal illness of unspecified malignant neoplasm of the vulva. The initial nursing assessment dated 04/02/2024, documented that the patient was bedbound and required opioids as needed for pain. The MSW completed the psychosocial, emotional, and spiritual assessments on 04/03/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 04/02/2024, did not reflect patient and family goals and planned interventions associated with the risk for opioid-induced constipation, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 10: The patient elected hospice services on 04/26/2024 with a terminal illness of unspecified protein-calorie malnutrition. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 05/02/2024 and 04/30/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 04/26/2024 did not reflect patient and family goals and planned interventions associated with the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 11: The patient elected hospice services on 08/07/2023 with a terminal illness of unspecified cerebral infarction. The initial nursing assessment dated 08/07/2023, documented the following: patient had dysphagia; was at risk for aspiration; required a pureed diet with thickened liquids; had a Percutaneous Endoscopic Gastrostomy (PEG) tube in place for feedings; had an indwelling urinary catheter; and was a fall risk with a score of seven out of ten. The Chaplain completed the spiritual assessment on 08/10/2023 and documented to continue spiritual support at a frequency of one visit per month. The written POC dated 08/07/2023, did not reflect patient and family goals and planned interventions associated with aspiration risk, PEG tube, indwelling urinary catheter, fall risk, and the spiritual issues identified in the comprehensive assessments. Clinical Record 12: The patient elected hospice services on 06/26/2024 with a terminal illness of Parkinson’s disease without dyskinesia, without mention of fluctuations. The initial nursing assessment dated 06/26/202, documented the following: patient was confused with garbled speech; had pitting edema to bilateral lower extremities; had an infection of the right leg; and had an indwelling urinary catheter. The MSW completed the psychosocial, emotional, and spiritual assessments on 06/28/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 06/26/2024, did not reflect patient and family goals and planned interventions associated with confusion, altered communication, edema, infection, indwelling urinary catheter, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 13: The patient elected hospice services on 07/01/2024 with a terminal illness of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side. The initial nursing assessment dated 07/01/2024, documented the following: patient was confused; had no meaningful verbal communication; was incontinent of bowel and bladder; had decreased mobility due to a flaccid right arm and weak right leg; and was a fall risk with a score of seven out of ten. The MSW completed the psychosocial, emotional, and spiritual assessments on 07/02/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 07/01/2024, did not reflect patient and family goals and planned interventions associated with confusion, altered communication, skin integrity risk, fall risk, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 14: The patient elected hospice services on 11/03/2023 with a terminal illness of other sequelae of cerebral infarction. The initial nursing assessment dated 11/03/2023, documented the following: patient had dyspnea with moderate exertion; was unable to bear weight, transfer, and ambulate; had severe peripheral vascular disease; peripheral arterial disease; and required scheduled hydrocodone 5mg/acetaminophen 325mg every six hours. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 11/07/2023, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 11/03/2024, did not reflect patient and family goals and planned interventions associated with dyspnea, pain, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 15: : The patient elected hospice services on 11/09/2023 with a terminal illness of senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 11/09/2023, documented the following: patient was constantly confused, minimally responsive, sedated and withdrawn; had an anxiety score of five out of ten; and required scheduled anti-anxiety medications. The MSW completed the psychosocial, emotional, and spiritual assessments on 11/13/2023, and documented to continue psychosocial support at a frequency of one visit per month. The written POC dated 11/09/2023, did not reflect patient and family goals and planned interventions associated with neurological disease progression, anxiety, and the psychosocial issues identified in the comprehensive assessments. Clinical Record 16: The patient elected hospice services on 06/20/2024 with a terminal illness of malignant neoplasm of unspecified part of unspecified bronchus or lung. The patient revoked the hospice benefit on 07/22/2024 to seek aggressive treatment. The initial nursing assessment dated 06/20/2024, documented that the patient struggled with anxiety. The MSW completed the psychosocial, emotional, and spiritual assessments on 06/25/2024, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 06/20/2024, did not reflect patient and family goals and planned interventions associated with anxiety, psychosocial, and the spiritual issues identified in the comprehensive assessments. Clinical Record 17: The patient elected hospice services on 06/20/2023 with a terminal illness of unspecified severe protein-calorie malnutrition. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 06/20/2023 and 06/22/2023, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 06/20/2023, did not reflect patient and family goals and planned interventions associated with the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 18: The patient elected hospice services on 01/19/2024 with a terminal illness of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 01/19/2024, documented the following: patient had an anxiety score of three out of ten; was restless and agitated at times; and was a fall risk with a score of eight out of ten. The Chaplain and MSW completed the psychosocial, emotional, and spiritual assessments on 01/19/2024 and 02/20/2024 respectively, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 01/19/2024, did not reflect patient and family goals and planned interventions associated with anxiety, agitation, fall risk, and the psychosocial and spiritual issues identified in the comprehensive assessments. Clinical Record 19: The patient elected hospice services on 04/19/2024 with a terminal illness of Neurocognitive disorder with Lewy bodies. The patient died at home on 05/13/2024. The initial nursing assessment dated 04/19/2024, documented that the patient had a large coccyx pressure wound and an indwelling urinary catheter. The MSW and Chaplain completed the psychosocial, emotional, and spiritual assessments on 04/19/2024 and 04/22/2024 respectively, and documented to continue psychosocial and spiritual support at a frequency of one visit per month. The written POC dated 04/19/2024, did not reflect patient and family goals and planned interventions associated with the patient’s wound, indwelling urinary catheter, and the psychosocial and spiritual issues identified in the comprehensive assessments. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the plans of care did not reflect patient and family goals and interventions based on the issues identified in the comprehensive assessments.”

“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 and interview. In 12 of 19 (63%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected the hospice benefit on 03/05/2024 with a terminal diagnosis of unspecified heart failure. The initial nursing assessment dated 03/05/2024, documented that the patient was a fall risk with a score of seven out of ten, and no reported pain. The plan of care (POC) dated 03/05/2024, identified the risk for falls and pain, and documented goals to maintain safety and comfort. The POC did not include measurable outcomes related to falls and pain anticipated from implementing and coordinating the POC. Clinical Record 3: The patient elected the hospice benefit on 04/29/2024 with a terminal diagnosis of Alzheimer’s disease with late onset. The initial nursing assessment dated 04/29/2024, documented that the patient was a fall risk with a score of seven out of ten. The POC dated 04/29/2024, identified the risk for falls, and documented the goal to maintain safety. The POC did not include a measurable outcome related to falls anticipated from implementing and coordinating the POC. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 04/11/2024, documented that the patient had dyspnea with minimal exertion and required continuous oxygen at five liters per minute. The POC dated 04/11/2024, identified the problem of impaired gas exchange, and documented the goal to maintain comfort. The POC did not include measurable goals related to dyspnea, oxygen use, and oxygen safety anticipated from implementing and coordinating the POC. Clinical Record 5: The patient elected the hospice benefit on 10/13/2023 with a terminal diagnosis of Alzheimer’s disease with late onset. The initial nursing assessment dated 10/13/2023, documented the following: patient was constantly confused; had garbled speech; had a significant decrease in appetite; and was a fall risk with a score of eight out of ten. The POC dated 10/13/2023, identified the problems of at risk for falls, impaired nutrition, and impaired cognition. The POC included goals to maintain safety, a healthy weight, and comfort. The POC did not include measurable goals related to falls, disease progression, and nutritional and cognitive changes anticipated from implementing and coordinating the POC. Clinical Record 7: The patient elected the hospice benefit on 07/03/2024 with a terminal diagnosis of unspecified pulmonary fibrosis. The initial nursing assessment dated 07/03/2024, documented the following: patient had dyspnea with minimal exertion; required continuous oxygen at six liters per minute; and a fall risk with a score of six out of ten. The POC dated 07/03/2024, identified the problems of impaired gas exchange and fall risk, and documented the goals to maintain comfort and safety. The POC did not include measurable goals related to dyspnea, oxygen use, oxygen safety, and falls anticipated from implementing and coordinating the POC. Clinical Record 8: The patient elected the hospice benefit on 02/28/2024 with a terminal diagnosis of unspecified Parkinsonism. The initial nursing assessment dated 02/28/2024, documented the following: patient had dyspnea with minimal exertion; required continuous oxygen at four liters per minute; had a pain assessment in advanced dementia (PAINAD) with a score of three out of ten; and a fall risk with a score of seven out of ten. The POC dated 02/28/2024, identified the problems of impaired gas exchange, pain, and fall risk, and documented goals to maintain comfort and safety. The POC did not include measurable goals related to dyspnea, oxygen use, oxygen safety, pain, and falls anticipated from implementing and coordinating the POC. Clinical Record 9: The patient elected the hospice benefit on 04/02/2024 with a terminal diagnosis of unspecified malignant neoplasm of the vulva. The initial nursing assessment dated 04/02/2024, documented that the patient had burning pain and required the use of Lidoderm cream and oxycodone, as needed to manage pain. The POC dated 04/02/2024, identified the problem of pain, and documented the goal to maintain comfort. The POC did not include a measurable goal related to burning pain anticipated from implementing and coordinating the POC. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The initial nursing assessment dated 04/26/2024, documented the following: patient had intermittent generalized pain; a pressure wound on the left hip; and macerated areas to bilateral buttocks, left posterior thigh, and right abdomen. The POC dated 04/26/2024, identified the problems of pain and altered skin integrity, and documented the goals to maintain comfort and to prevent “worsening of skin integrity as able.” The POC did not include measurable goals related to pain and wounds anticipated from implementing and coordinating the POC. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024. The initial nursing assessment dated 06/26/2024, documented that the patient was a fall risk with a score of seven out of ten. The POC dated 06/24/2024, identified the problem of fall risk, and documented the goal to maintain safety. The POC did not include measurable goals related to falls anticipated from implementing and coordinating the POC. Clinical Record 15: The patient elected the hospice benefit on 11/09/2023 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 11/09/2023, documented that the patient was a fall risk with a score of eight out of ten. The POC dated 11/09/2023, identified the problem of fall risk, and documented the goal to maintain safety. The POC did not include measurable goals related to falls anticipated from implementing and coordinating the POC. Clinical Record 17: The patient elected the hospice benefit on 06/20/2023. The POC dated 06/20/2023, identified anxiety as a problem with the goal, “anxiety will be maintained with no adverse effects from psychoactive medications noted.” The POC did not include measurable goals related to anxiety anticipated from implementing and coordinating the POC. Clinical Record 18: The patient elected the hospice benefit on 01/19/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 01/19/2024, documented the following: patient had no reported pain; dyspnea with minimal exertion; and continuous oxygen use at six liters per minute. The POC dated 01/19/2024, identified respiratory and pain problems with the following goals: maintain the patient’s comfort with respirations; and maintain pain to patient tolerance. The POC did not include measurable goals related to dyspnea, oxygen use, oxygen safety, and pain anticipated from implementing and coordinating the POC. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the plans of care did not include measurable goals anticipated from implementing and coordinating the POC.”

“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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 13 of 19 (68%) clinical records reviewed, the agency did not ensure the individualized written plan of care included all drugs and treatments. Clinical Record 2: The patient elected the hospice benefit on 03/05/2024 with a terminal diagnosis of unspecified heart failure. The initial nursing assessment dated 03/05/2024, documented that the patient had an oxygen concentrator and indwelling urinary catheter. The plan of care (POC) dated 03/05/2024, included interventions to irrigate and change the indwelling urinary device “as ordered,” and listed an oxygen concentrator for durable medical equipment. The POC did not include instructions for the following: type, frequency, and responsible caregiver to perform catheter irrigation; type, size, frequency, and responsible caregiver to perform catheter change; and an oxygen order to include dosage, route of administration, and frequency. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 04/11/2024, documented the following: patient used oxygen continuously at five liters per minute; wore thromboembolism-deterrent (TED) hose; and had an indwelling urinary catheter. The plan of care (POC) dated 04/11/2024, included interventions to irrigate and change the indwelling urinary device “as ordered.” The POC did not include the following: type, frequency, and responsible caregiver to perform catheter irrigation; type, size, frequency, and responsible caregiver to perform catheter change; an oxygen order to include dosage, route of administration, and frequency; and frequency and responsible caregiver to apply the TED hose. Clinical Record 7: The patient elected the hospice benefit on 07/03/2024 with a terminal diagnosis of unspecified pulmonary fibrosis. The initial nursing assessment dated 07/03/2024, documented that the patient required continuous oxygen at six liters per minute. The POC dated 07/03/2024, included interventions to administer oxygen, and assess the patient’s oxygen saturation as ordered. The POC did not include an order for oxygen saturation checks, and an oxygen order to include dosage, route of administration, frequency, and oxygen saturation checks. Clinical Record 8: The patient elected the hospice benefit on 02/28/2024 with a terminal diagnosis of unspecified Parkinsonism. The initial nursing assessment dated 02/28/2024, documented that the patient required continuous oxygen at six liters per minute. The POC dated 02/28/2024, included interventions to administer oxygen, and assess the patient’s oxygen saturation, as ordered. The POC did not include an order for oxygen saturation checks, and an oxygen order to include dosage, route of administration, frequency, and oxygen saturation checks. Clinical Record 9: The patient elected the hospice benefit on 04/02/2024 with a terminal diagnosis of unspecified malignant neoplasm of the vulva. The initial nursing assessment dated 04/02/2024, documented that the patient had an indwelling urinary catheter. The POC dated 04/02/2024, included interventions to irrigate and change the indwelling urinary device “as ordered.” The POC did not include instructions for the following: type, frequency, and responsible caregiver to perform catheter irrigation; and the type, size, frequency, and responsible caregiver to perform catheter change. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The initial nursing assessment dated 04/26/2024, documented the following: patient had a percutaneous endoscopic gastrostomy (PEG) tube; received Glucerna bolus feedings daily via PEG tube; had a pressure wound to the left hip; and had macerated areas to bilateral buttocks, left posterior thigh, and right abdomen. The POC dated 04/26/2024, did not include the following instructions: care and treatment of the PEG tube; and insertion site; care and treatment of pressure wound, and macerated areas; and the frequency and caregiver responsible to administer the Glucerna supplement. Clinical Record 11: The patient elected the hospice benefit on 08/07/2023. The initial nursing assessment dated 08/07/2023, documented that the patient had a PEG tube, and an indwelling urinary catheter. The POC dated 08/07/2023, did not include the following instructions: care and treatment of the PEG tube and insertion site; and care and treatment of the indwelling urinary catheter, including the frequency of treatment and caregiver responsible. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. The initial nursing assessment dated 06/26/2024, documented that the patient had an indwelling urinary catheter. The POC dated 04/26/2024, did not include instructions for the care and treatment of the indwelling urinary catheter, including the frequency of treatment and the caregiver responsible. Clinical Record 13: The patient elected the hospice benefit on 07/01/2024 with a terminal diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side. The initial nursing assessment dated 07/01/2024, documented the following: patient had a pressure reduction mattress; used incontinent supplies; was on a mechanical soft diet, and was ordered an emergency medication kit. The POC dated 07/01/2024 did not include a mechanical soft diet, and emergency medications. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The initial nursing assessment dated 11/03/2023, documented that the patient had a pressure wound to the sacrum and buttocks. The POC dated 11/03/2023, included the intervention to provide and educate on wound care, as ordered. The POC did not include instructions for wound care, including the type, frequency, and caregiver responsible. Clinical Record 16: The patient elected the hospice benefit on 06/20/2024 with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. The initial nursing assessment dated 06/20/2024, documented that Nystatin cream was applied to a fungal rash under the patient’s abdominal fold. The POC dated 06/20/2024, did not include Nystatin cream and instructions for use. Clinical Record 18: The patient elected the hospice benefit on 01/19/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 01/19/2024, documented that the patient required continuous oxygen at six liters per minute, and had skin tears to the right arm. The POC dated 01/19/2024 did not include wound care instructions, and an oxygen order to specify dosage, route of administration and frequency, . Clinical Record 19: The patient elected the hospice benefit on 04/19/2024. The initial nursing assessment dated 04/19/2024, documented that the patient had an indwelling urinary catheter and a large wound to the coccyx. The POC dated 04/19/2024, did not include instructions for the care and treatment of the indwelling urinary catheter, and wound care orders to specify the type, frequency, and caregiver responsible. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the plans of care did not include all drugs and treatments necessary to meet the patient’s needs.”

“It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care included medical supplies and appliances. Clinical Record 13: The patient elected the hospice benefit on 07/01/2024 with a terminal diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side. The initial nursing assessment dated 07/01/2024, documented that the patient had a pressure reduction mattress and used incontinent supplies. The POC dated 07/01/2024 did not include the pressure reduction mattress and incontinent supplies. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the plans of care did not include the medical supplies and appliances necessary to meet the needs of the patient.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 11 of 19 (58%) clinical records reviewed, the agency did not ensure the Registered Nurse completed a monthly patient visit to supervise the licensed practical nursing services. Agency policy H:3-003, Supervision of Clinical Services, dated May 2012, stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical nursing services. Supervisory contacts and visits will be documented, dated, and signed by the supervising professional. The results will be shared with the clinician, and a copy will be retained in the personnel file.” Clinical Record 1: The patient elected the hospice benefit on 06/02/2024 and remains on service. The Licensed Practical Nurse (LPN) performed nursing care for the patient on 07/11/2024, 07/18/2024, and 07/25/2024. There was no evidence that the Registered Nurse (RN) completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 2: The patient elected the hospice benefit on 03/05/2024 and remains on service. The LPN performed nursing care for the patient on 07/10/2024, 07/12/2024, and 07/19/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 3: The patient elected the hospice benefit on 04/29/2024 and remains on service. The LPN performed nursing care for the patient on 06/12/2024, 07/16/2024, 07/23/2024, and 07/31/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in June 2024 and July 2024. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024 and remains on service. The LPN performed nursing care for the patient on 07/18/2024, 07/23/2024, and 07/30/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 5: The patient elected the hospice benefit on 10/13/2023 and remains on service. The LPN performed nursing care for the patient on 06/14/2024, 06/19/2024, 06/28/2024, 07/12/2024, 07/15/2024, 07/25/2024, and 07/31/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in June 2024 and July 2024. Clinical Record 7: The patient elected the hospice benefit on 07/03/2024 and remains on service. The LPN performed nursing care for the patient on 07/09/2024, 07/11/2024, 07/18/2024, and 07/25/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024 and remains on service. The LPN performed nursing care for the patient on 06/05/2024, 06/14/2024, 06/24/2024, 07/05/2024, 07/18/2024, and 07/26/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in June 2024 and July 2024. Clinical Record 11: The patient elected the hospice benefit on 08/07/2023 and remains on service. The LPN performed nursing care for the patient on 06/26/2024, 07/18/2024, and 07/25/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in June 2024 and July 2024. Clinical Record 12: The patient elected the hospice benefit on 06/26/2024 and remains on service. The LPN performed nursing care for the patient on 07/17/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023 and remains on service. The LPN performed nursing care for the patient on 07/12/2024, and 07/26/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in July 2024. Clinical Record 16: The patient elected the hospice benefit on 06/20/2024. The patient revoked the hospice benefit on 07/22/2024 to seek aggressive treatment. The LPN performed nursing care for the patient on 06/21/2024, 06/27/2024, 07/11/2024, 07/15/2024, 07/17/2024, and 07/19/2024. There was no evidence that the RN completed a monthly visit to supervise LPN services performed in June 2024 and July 2024. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the monthly patient visits to supervise LPN services were not performed, as required per policy.”

“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, interview and observation. In 16 of 19 (84%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) prepared specific written patient care instructions for the aide. Clinical Record 1 / Home Visit 4: The patient elected hospice services on 06/02/2024. The hospice aide plan of care (POC) dated 06/02/2024, instructed the aide to provide peri-care during each visit. During the home visit with the hospice aide, it was observed that the patient had an indwelling urinary catheter. The aide reported that catheter care was performed during each visit, including site care and urinary bag drainage. However, the aide POC did not instruct the aide to perform catheter care. Clinical Record 2: The patient elected hospice services on 03/05/2024. The POC dated 04/19/2024, identified goals and interventions associated with the patient’s suprapubic catheter. The aide POC dated 03/05/2024 and 06/28/2024, did not include instruction regarding the suprapubic catheter and any care to be provided. Clinical Record 3: The patient elected the hospice benefit on 04/29/2024. The initial nursing assessment dated 04/29/2024, documented that the patient was confused, and a fall risk with a score of seven out of ten. The aide POC dated 04/29/2024, instructed the aide to perform the following tasks, as needed or tolerated: comb hair; foot care; oral hygiene denture care; nail care; shave; and assist with transfers. The POC did not provide specific instructions for use of the “as needed or tolerated” frequency. The POC did not alert the aide to the patient’s fall risk. Clinical Record 5: The patient elected the hospice benefit on 10/12/2023. The initial POC dated 10/12/2023, instructed the aide to visit once a week. The aide POC dated 10/12/2023, instructed the aide to perform the following tasks, as needed or tolerated: comb hair; foot care; oral hygiene; denture care; nail care; and assist with transfers. The POC did not provide specific instructions for use of the “as needed or tolerated” frequency. Clinical Record 7: The patient elected the hospice benefit on 07/03/2024. The initial nursing assessment dated 07/03/2024, documented that the patient had a history of convulsions. The aide POC dated 07/03/2024, did not alert the aide to the patient’s seizure risk, and measures to maintain the patient’s safety during seizure activity. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024. The initial nursing assessment dated 04/26/2024, documented the following: patient had a percutaneous endoscopic gastrostomy (PEG) tube; wounds to the left hip, leg, buttocks, and abdomen; and was a fall risk. The aide POC dated 04/26/2024, did not alert the aide to the following: PEG tube, and care to be provided, if any; wounds, and care to be provided, if any; and fall risk. Clinical Record 11: The patient elected the hospice benefit on 08/03/2023. The initial nursing assessment dated 08/03/2023, documented that the patient had a percutaneous endoscopic gastrostomy (PEG) tube and indwelling urinary catheter. The aide POC dated 08/03/2023, did not alert the aide to the patient’s PEG tube and indwelling urinary catheter, and any care to be provided. Clinical Record 17: The patient elected the hospice benefit on 06/20/2023. The aide POC dated 06/20/2024, instructed the aide to perform a complete bed bath, as needed. The POC did not include specific instructions for use of the “’as needed” frequency. Clinical Record 18: The patient elected the hospice benefit on 01/19/2024. The initial nursing assessment dated 01/09/2024, documented that the patient was a fall risk with a score of eight out of ten. The aide POC dated 01/19/2024, instructed the aide to provide a complete shower, and assist with transfers. The POC did not alert the aide to the patient’s fall risk. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the hospice aide care plans were missing the required elements.”

“It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care (POC). Clinical Record 3: The patient elected the hospice benefit on 04/29/2024. The aide POC dated 04/29/2024, instructed the aide to provide a shower on the first visit of the week. The aide visits dated 05/17/2024 and 05/24/2024, documented that the aide provided a bed bath. There was no documentation regarding the exception to the POC. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the aide did not follow the POC.”

“It is required that the hospice aides 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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aides reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 3: The patient elected the hospice benefit on 04/29/2024. The aide plan of care (POC) dated 04/29/2024, instructed the aide to perform a shower on the first visit of the week. The aide visits dated 05/17/2024 and 05/24/2024, documented that the aide provided a bed bath. There was no evidence that the aide reported changes in the patient’s needs to warrant a change in the POC, to the RN. Clinical Record 4: The patient elected the hospice benefit on 04/11/2024. The aide POC dated 04/11/2024, instructed the aide to perform peri-care, skin care, oral hygiene, and denture care every visit; and shampoo and shower on the first visit of each week. The aide visits dated 06/27/2024 and 07/25/2024, documented that the aide did not provided peri-care, skin care, oral hygiene, denture care, shampoo, and shower, as the tasks were marked as NA (not applicable). There was no evidence that the aide reported changes in the patient’s needs to warrant a change in the POC, to the RN. Clinical Record 5: The patient elected the hospice benefit on 10/12/2023. The aide POC dated 10/12/2023, instructed the aide to provide shampoo and shower on the first visit of each week. The aide visits dated 07/26/2024 and 07/31/2024, documented that the aide did not provided shampoo and shower, as the task were marked as NA. There was no evidence that the aide reported changes in the patient’s needs to warrant a change in the POC, to the RN. Clinical Record 13: The patient elected the hospice benefit on 07/01/2024. The aide POC dated 07/01/2024, instructed the aide to provide peri-care, incontinence care, and document the patient’s last bowel movement, every visit. The aide visit dated 07/12/2024, documented that the aide did not provide peri-care, incontinent care, and document the patient’s last bowel movement, as the tasks were marked as NA. There was no evidence that the aide reported changes in the patient’s needs to warrant a change in the POC, to the RN. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed there was no evidence that the aid reported changes in the patient’s needs to the RN.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 8 of 10 (80%) personnel records reviewed, the agency did not ensure the assessment of skills and competencies of all individuals providing care, per the agency’s policy and procedure. Agency Policy C:3-023.1, Competency Program, revised April 2012, stated in part, “...Competencies must be successfully demonstrated before organization personnel complete orientation. The organization will clearly identify and define the skills, which are essential to observe for the determination of competence, for each job category.” Personnel Record 2: The record for the Nursing Aide with date of hire 06/03/2024, documented orientation training on 06/03/2024. There was no evidence of a completed assessment of the skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 3: The record for the Medical Social Worker (MSW) with date of hire 01/24/2024, documented orientation training on 01/24/2024. There was no evidence of a completed assessment of the skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 4: The record for the Licensed Practical Nurse (LPN) with date of hire 02/26/2024, documented orientation training on 2/26/2024. There was no evidence of a completed assessment of the skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 5: The record for the Clinical Director/Volunteer Coordinator with date of hire 05/22/2023, documented orientation training on 05/22/2023. There was no evidence of a completed assessment of the skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 7: The record for the Admission Coordinator with date of hire 03/06/2024, documented orientation training on 03/06/2024. There was no evidence of a completed assessment of the skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. The personnel assumed the position of Bereavement Coordinator in May 2024. There was no evidence of a completed assessment of skills and competencies for the employee’s job category. Personnel Record 8: The record for the Admission Coordinator with date of hire 02/20/2023, documented orientation training on 02/20/2023. There was no evidence of a completed assessment of skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 9: The record for the LPN with date of hire 06/03/2024, documented orientation training on 06/03/2024. There was no evidence of a completed assessment of skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. Personnel Record 10: The record for the Volunteer with date of hire 11/30/2023, documented orientation training on 11/30/2023. There was no evidence of a completed assessment of skills and competencies for the employee’s job category before the completion of hospice orientation, as required per policy. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed there was no documentation of completed assessments of skills and competencies, as required per agency policy.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with a discharge, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 15: The patient elected the hospice benefit on 11/09/2023 with a terminal illness of Senile degeneration of the brain, not elsewhere classified. The patient was discharged from hospice services on 03/07/2024, when determined to no longer be terminally ill. There was no evidence the hospice forwarded a discharge summary to the patient’s attending physician. Clinical Record 16: The patient elected the hospice benefit on 06/20/2024 with a terminal illness of malignant neoplasm of unspecified part of unspecified bronchus or lung. The patient revoked the hospice benefit on 07/22/2024 to seek aggressive treatment. There was no evidence the hospice forwarded a discharge summary to the patient’s attending physician. During a joint clinical record review and interview on 08/09/2024, the Clinical Director confirmed the discharge summary was not forwarded to the physician(s), as required.”