Suncrest Hospice

“It is required that each patient’s individualized written plan of care: 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 8 of 19 (42%) clinical records reviewed, the agency did not ensure that the patient’s 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 01/01/2025 with diagnoses of cerebral atherosclerosis, major depressive disorder, and a comorbid diagnosis of Alzheimer’s Disease. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 01/01/2025 documented an unstageable ulcer measuring 3.2 cm x 2.1 cm on the patient’s left heel. The plan of care for the benefit period dated 01/01/2025 to 03/31/2025 documented the patient’s goal: patient and/or caregiver would be able to verbalize or demonstrate techniques to promote pressure ulcer healing as appropriate for the stage of disease. “As appropriate” is not a measurable outcome. The POC included interventions for the patient’s Alzheimer’s disease and documented the patient goal: patient’s symptoms will be consistent with the stage of the disease process, and problems will be managed as well as they can be within the stage of the disease process. “Consistent with the disease process” and “managed” are not measurable outcomes. Clinical Record 4: The patient elected the hospice benefit on 01/31/2025 with diagnoses of pulmonary fibrosis, congestive heart failure (CHF), and moderate dementia. The initial comprehensive assessment completed by the RN dated 01/31/2025 documented that the patient continuously required four (4) liters per minute of oxygen by nasal cannula. The plan of care for the benefit period dated 01/31/2025 to 04/30/2025 documented the patient’s goal: patient will maintain a respiratory baseline, as evidenced by the patient breathing at an optimal level within the disease parameters. “Optimal level” is not a measurable outcome. Clinical Record 5: The patient elected the hospice benefit on 01/08/2025 with the diagnosis of malignant neoplasm of the left breast. The initial comprehensive assessment completed by the RN dated 01/08/2025 documented that the patient had acute, intermittent generalized pain that was throbbing and intermittent each day. The plan of care for the benefit period dated 01/08/2025 to 04/07/2025 identified the problem of pain and pain management with related interventions. The plan of care documented the patient goal: the patient and/or family to express a satisfactory control of symptoms. “Satisfactory” is not a measurable outcome. Clinical Record 9: The patient elected the hospice benefit on 09/27/2024 with the diagnosis of unspecified protein-calorie malnutrition. The plans of care for the benefit periods dated 03/26/2025 to 05/24/2025 and 12/26/2025 to 03/25/2025 identified altered nutrition and hydration as problems and included associated interventions. However, the goal that the patient’s nutritional needs would be met did not include a measurable outcome. Clinical Record 10: The patient elected the hospice benefit on 03/04/2025 with the diagnosis of malignant neoplasm of the left lung. The physician’s certification of terminal illness for the benefit period dated 03/04/2025 to 06/01/2025 documented that “the CT scan... revealed that the lung cancer has metastasized to her spine. She has been having increased pain, especially with transfers.” The plan of care for the same benefit period identified pain and pain management as a problem for the patient and included related interventions. The plan of care documented the patient’s goal: patient to be pain-free or verbalize an acceptable pain level with the pain management regimen. “Acceptable” is not a measurable outcome. Clinical Record 11: The patient elected the hospice benefit on 04/19/2024 with diagnoses of cerebral vascular disease and unspecified protein-calorie malnutrition. The RN visit note dated 01/24/2025 documented, “She is able to feed herself at times but struggles and eventually gives up after most end up on her... She is eating 25-50% with max encouragement and assistance. She often skips meals due to sleeping through them.” The plans of care for the benefit periods dated 02/13/2025 to 04/13/2025 and 12/15/2024 to 02/12/2025 identified the problems of altered nutrition and hydration status with associated interventions. The plan of care documented the patient’s goal: patient’s nutritional needs to be met as the patient’s condition and comfort allow. “As condition and comfort allow” are not measurable outcomes. Clinical Record 13: The patient elected the hospice benefit on 02/25/2025 with a diagnosis of Alzheimer’s disease. The plan of care for the benefit period dated 02/25/2025 to 05/25/2025 included interventions for the patient’s Alzheimer’s and documented the patient’s goal: patient’s symptoms will be consistent with the stage of the disease process, and problems will be managed as well as the disease would allow. “Consistent with the stage of disease” and “managed” are not measurable outcomes. Clinical Record 19: The patient elected the hospice benefit on 10/24/2024 with diagnoses of multiple sclerosis, seizures, depressive disorder, edema, chest pain, and constipation. The updated comprehensive assessment completed by the RN dated 02/19/2025 documented a score of five (5) on the symptom assessment for depression. The skilled nursing (SN) visit note dated 02/21/2025 documented that the patient continued to refuse showers and to get out of bed. The problem of depression was identified with associated interventions included in the plans of care for the benefit periods dated 02/21/2025 to 04/21/2025 and 12/23/2024 to 02/20/2025. The plans of care documented the patient’s goal: patient and/or caregiver to be able to verbalize decreased signs and symptoms of depression and hopelessness. “Decreased” is not a measurable outcome. During an interview on 04/02/2025, the Senior Director of Clinical Quality confirmed that the patient’s plans of care did not include measurable outcomes. Additionally, no documentation during the Interdisciplinary Group Meetings would further document any measurable outcomes for the goals.”

“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 an 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 1 of 19 (5%) clinical records reviewed of patients that received Hospice Aide (HHA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 01/01/2025. The patient had a 0.5 cm x 0.5 cm stage two pressure ulcer to the coccyx, as documented in the Registered Nurse’s (RN) initial comprehensive assessment dated 01/01/2025 with a physician’s order to wash and dry the wound and cover it with a Duoderm dressing twice a week and as needed. The plan of care for the benefit period dated 01/01/2025 to 03/31/2025 ordered HA services five times a week. The skilled nurse (SN) visit note dated 03/04/2025 documented an additional stage two pressure ulcer to the right gluteal fold measuring 0.8 cm x 0.3 cm with a physician’s order to wash and dry the wound and cover it with a foam dressing twice weekly and as needed. The HA care plan dated 01/01/2025 assigned the HA the relevant tasks: provide incontinence care and perineal care, oral care, and a bed bath with shampoo on Tuesdays and Thursdays, and if feces or urine is present. The HA care plan was updated on 02/23/2025 with additional tasks: applying barrier cream after incontinent and perineal care, applying lotion, helping the patient with dressing, and two-person assistance to transfer to the bed/high back wheelchair. The RN did not include instructions for the HA regarding the dressings to the coccyx or right gluteal fold should they become soiled, wet, or dislodged during personal care. During a joint clinical record review and interview on 04/01/2025, the Senior Director of Clinical Quality confirmed that the HA did not have all instructions.”

“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 volunteers provided administrative or direct patient care services in an amount equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview and a review of the volunteer department and QAPI documents on 04/02/2025, the Volunteer Coordinator (hired in 08/2023), Administrator, and Senior Director of Clinical Quality confirmed that the average percentage of volunteer hours for 2024 was 1%. A Volunteer QAPI Performance Improvement Project (PIP) was identified and initiated on 05/03/2023 for a less than 5% volunteer percentage. The QAPI PIP was active with monthly documented initiatives to recruit new volunteers through flyers, colleges, churches, etc. Additionally, the retention activities were recorded monthly to show how the volunteer coordinator worked to keep the current volunteers engaged in the program. A review of the Volunteer Department and QAPI documents on 04/02/2025 revealed that the average percentage of volunteer hours for 2024 was 1%. A Volunteer QAPI Performance Improvement Project (PIP) was identified and initiated on 05/03/2023 for a less than 5% Volunteer percentage. An interview and document review on 04/02/2025 with the Volunteer Coordinator, Administrator (Personnel Record 1), and Senior Director of Clinical Quality confirmed the Volunteer hour percentage from 2024. The QAPI PIP was active with monthly documented initiatives to recruit new volunteers through flyers, colleges, churches, etc. Additionally, the retention activities were recorded monthly to show how the volunteer coordinator worked to keep the current volunteers engaged in the program. The Volunteer Coordinator was hired in August of 2023. The agency’s growth from 83 patients and an average daily census of 79.4 patients at the end of 2023 to 220 patients and an average daily census of 220 at the end of 2024 factored into the struggle to keep up the volunteer hour percentage hours.”