Crossbridge Hospice

“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 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patients’ individualized written plans of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/26/2026. The plan of care dated 06/26/2026 through 09/23/2026 included orders that read in part “Hospice Nurse to instruct regarding tracheostomy care”. The plan of care did not include orders for the type or size of tracheostomy tube that was to be utilized or the frequency of tracheostomy tube changes. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/05/2026. The plans of care dated 06/05/2026 through 09/02/2026 and 09/03/2026 through 12/01/2026 included orders for “Enoxaparin 40mg subcutaneous injection daily”. The plans of care did not include interventions related to the patient being at risk for bleeding. During joint record reviews and interview on 09/10/2026, the Administrator confirmed that the plans of care did not include the type, size or frequency of change for the tracheostomy tube, or bleeding precautions.”

“It is required that Hospice Aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a Hospice Aide are prepared by a RN who is responsible for the supervision of the Hospice Aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure that all written patient care instructions were included in the Hospice Aide care plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/26/2026. The plan of care dated 06/26/2026 through 09/23/2026 ordered “Hospice Aide 2wk12”. The plan of care also included orders for “Continuous oxygen at 4.5 liters via ventilator”. The Hospice Aide care plan dated 06/26/2026 did not include oxygen precautions. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/06/2026. The plan of care dated 07/06/2026 through 10/03/2026 ordered “Hospice Aide 1wk1 and 2wk12”. The plan of care also included orders for “Bleeding precautions”. The Hospice Aide care plan dated 07/06/2026 did not include bleeding precautions. During joint record reviews and interview on 09/10/2026, the Administrator confirmed that the Hospice Aide care plans did not include bleeding or oxygen precautions.”

“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 4 of 15 (27%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure that Hospice Aide supervisory visits were completed by a Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/07/2026. The plan of care dated 08/07/2026 through 11/04/2026 included orders for “Hospice Aide 2wk12”. The first Hospice Aide visit was dated 08/12/2026. The first Hospice Aide supervisory visit was dated 08/27/2026 (15 days from the first Hospice Aide visit). CLINICAL RECORD 2: The patient elected the hospice benefit on 01/13/2026. The plan of care dated 01/13/2026 through 04/11/2026 ordered “Hospice Aide 1wk12”. The first Hospice Aide visit was dated 01/28/2026. Hospice Aide supervisory visits were dated 02/04/2026 and 02/12/2026. The next Hospice Aide supervisory visit was dated 03/03/2026 (19 days from the previous supervisory visit). The recertification plan of care dated 07/12/2026 through 09/09/2026 ordered “Hospice Aide 1wk13”. The first Hospice Aide visit was dated 07/17/2026. Hospice Aide supervisory visits were dated 07/22/2026 and 07/31/2026. The next Hospice Aide supervisory visit was dated 08/18/2026 (18 days from the previously supervisory visit). CLINICAL RECORD 9: The patient elected the hospice benefit on 07/11/2026. The plan of care dated 07/11/2026 through 10/08/2026 included orders for “Hospice Aide 1wk12”. The first Hospice Aide visit was dated 07/22/2026. The first Hospice Aide supervisory visit was dated 08/10/2026 (19 days from the first Hospice Aide visit). The next Hospice Aide supervisory visit was dated 08/26/2026 (16 days from the previous supervisory visit). CLINICAL RECORD 13: The patient elected the hospice benefit on 12/08/2024. The plans of care dated 04/02/2026 through 05/31/2026 and 06/01/2026 through 07/30/2026 included orders for “Hospice Aide 2wk9”. The first Hospice Aide visit was dated 04/03/2026. Hospice Aide supervisory visits were dated 04/14/2026, 04/23/2026, 04/29/2026, 05/07/2026, 05/13/2026, and 05/19/2026. The next Hospice Aide supervisory visit was dated 06/04/2026 (16 days from the previous supervisory visit). During joint record reviews and interview on 09/09/2026 and 09/10/2026, the Administrator confirmed that Hospice Aide supervisory visits were completed less frequently than every 14 days.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s report titled “Volunteer Cost Savings” for 2024, 2025 and 2026 revealed that the agency’s volunteer hours for January 2024 through December 2024 totaled 0.38%, and for January 2025 through December 2025, totaled 0.16%, and for January 2026 through August 2026 totaled 1.12%. During a joint review of the agency’s Volunteer Cost Savings reports for 2024-2026 the Administrator confirmed that the agency’s volunteer hours were less than 5%. The Administrator also stated “It has been difficult to find volunteers since the COVID pandemic. Our Volunteer Coordinator is working on recruiting more volunteers and we started a performance improvement plan this year regarding increasing our volunteer hours.” The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“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 1 of 10 (10%) personnel records reviewed, the agency did not ensure that the skills and competencies of all individuals providing care were assessed in accordance with agency policies and procedures. Agency Policy HOS.HSRM.14.I “Competency Testing Policy”, reviewed date 06/2025, read in part “All clinical staff, students, and volunteers during the orientation period prior to caring for patients will complete a competency checklist, test, or field competency, which is department specific. Annually all clinical staff will complete a competency checklist, test, or field competency.” PERSONNEL RECORD 10: This Volunteer’s date of hire was 05/05/2026. The personnel record lacked documentation of an initial competency checklist prior to caring for patients in 2026. During a joint personnel record review and interview on 9/11/2026, the Office Manager confirmed that the Volunteer did not have a competency assessment completed prior to starting patient care. The Office Manager also stated “I did not realize that volunteers needed a competency checklist.””