Optimal Care Hospice

“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 14 of 14 (100%) clinical records reviewed, the agency did not ensure that the Plan of Care (POC) included measurable goals. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit on 02/03/2026. The Plan of Care (POC) dated 02/03/2026-05/03/2026 included, in part, the following Skilled Nursing (SN) goals: “...Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Caregiver will verbalize understanding of effects of urinary incontinence. Patient caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence. Caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient. Caregiver will verbalize understanding to dementia disease process and demonstrate knowledge of s/sx to report and manage decline in cognitive, functional, behavioral, and emotional stress... “ An interim verbal order for Social Work (SW) was written on 02/06/2026, which included goals: “A medical social worker plan of care will be established. Patient/daughter will have decreased fears/anxiety regarding death and dying process. Problems concerning patient’s personal affairs will be resolved.” An interim verbal order for Spiritual Counselor (SC) was written on 02/06/2026, which included goals: “ A chaplain plan of care will be established. Patient/Caregiver will feel relief from spiritual concerns. Funeral/final arrangements acknowledged and completed per the patient’s/family’s wishes.” The POC did not include measurable goals for SN, SW, or SC services. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit on 04/17/2025. The Plan of Care (POC) dated 02/06/2026-04/06/2026 included, in part, the following Skilled Nursing (SN) goals: “...Pain will be managed at a level acceptable to the patient. Caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Changes in neurologic status will be addressed appropriately. Caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering, but not forcing food/fluids to patient...” The POC did not include measurable goals for SN services. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit on 01/17/2026. The Plan of Care (POC) dated 01/17/2026-04/16/2025 included, in part, the following Skilled Nursing (SN) goals: “...Patient/Caregiver verbalize/demonstrate compliance with medication regimen. Patient exhibits signs of symptom reduction or relief. Pain will be managed at an acceptable to the patient. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will have safety needs met. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize/demonstrate understanding of to use oxygen safely and effectively...” An interim verbal order for Social Work (SW) was written on 01/19/2026, which included goals: “A medical social worker plan of care will be established. A volunteer plan will be established based on the needs of the patient/caregiver.” An interim verbal order for Spiritual Counselor (SC) was written on 01/19/2026, which included goals: “ A chaplain plan of care will be established. Patient/Caregiver will feel relief from spiritual concerns. Funeral/final arrangements acknowledged and completed per the patient’s/family’s wishes.” The POC did not include measurable goals for SN, SW, or SC services. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit on 01/30/2026. The Plan of Care (POC) dated 01/30/2026-02/25/2025 included, in part, the following Skilled Nursing (SN) goals: “...Patient caregiver will verbalize/demonstrate compliance with medication regimen. Patient exhibits signs of symptom reduction or relief. Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will have safety needs met. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms...” The POC did not include measurable goals for SN services. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit on 10/21/2025. The Plan of Care (POC) dated 01/19/2026-04/18/2025 included, in part, the following Skilled Nursing (SN) goals: “...Patient caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Changes in neurologic status will be addressed appropriately. Patient caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient... Patient/caregiver will verbalize understanding of effects of urinary incontinence. Caregiver will verbalize/demonstrate measures to prevent manage skin breakdown...” The POC did not include measurable goals for SN services. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit on 02/04/2026. The Plan of Care (POC) dated 02/08/2026-04/08/2026 included, in part, the following Skilled Nursing (SN) goals: “...Caregiver will verbalize understanding to dementia disease process and demonstrate knowledge of signs/symptoms to report and manage declines in cognitive, functional, behavioral, and emotional stress. Caregiver will verbalize/demonstrate understanding of interventions related to understanding dementia and managing behaviors within the limits of the disease process... Indwelling suprapubic catheter will remain patent...” The POC did not include measurable goals for SN services. CLINICAL RECORD 7: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 02/13/2026. The Plan of Care (POC) dated 02/13/2026-05/13/2026 included, in part, the following Skilled Nursing (SN) goals: “... O2 levels will be monitored as appropriate. Patient will follow an effective bowel program to prevent relieve Constipation. Patient will transition peacefully through the dying process. Caregiver will verbalize understanding to dementia disease process and demonstrate knowledge of s/sx to report and manage declines in cognitive, functional, behavioral, and emotional stress...” An interim verbal order for Social Work (SW) was written on 02/17/2026, which included goals: “A medical social worker plan of care will be established. Problems concerning patient’s personal affairs will be resolved.” An interim verbal order for Spiritual Counselor (SC) was written on 01/19/2026, which included goals: “ A chaplain plan of care will be established. Patient/Caregiver will feel relief from spiritual concerns. Funeral/final arrangements acknowledged and completed per the patient’s/family’s wishes.” The POC did not include measurable goals for SN, SW, or SC services. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit on 10/17/2025. The Plan of Care (POC) dated 01/15/2026-04/14/2026 included, in part, the following Skilled Nursing (SN) goals: “... Patient and caregiver will verbalize understanding effects of urinary incontinence. Caregiver will verbalize and demonstrate measures to prevent manage skin breakdown. Patient will follow an effective bowel program to prevent relieve Constipation. Patient will have safety needs met. O2 levels will be monitored as appropriate...” The POC did not include measurable goals for SN services. CLINICAL RECORD 9: A review of the clinical record revealed that the patient elected the hospice benefit on 01/11/2026. The Plan of Care (POC) dated 01/11/2026-04/10/2026 included, in part, the following Skilled Nursing (SN) goals: “... Patient’s anxiety/agitation is minimized/controlled and caregiver verbalizes understanding of its effects origin/treatment. Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event. Patient/caregiver will verbalize and demonstrate understanding of changing nutritional needs of patient and limits of the disease process. Caregiver will verbalized/demonstrate appropriate and safe wound care. Wound will be managed without infection and pain will be controlled.” An interim verbal order for Social Work (SW) was written on 01/15/2026, which included goals: “A medical social worker plan of care will be established. A volunteer plan will be established based on the needs of the patient/caregiver.” An interim verbal order for Spiritual Counselor (SC) was written on 01/14/2026, which included goals: “Patient/Caregiver will feel relief from spiritual concerns. Funeral/final arrangements acknowledged and completed per the patient’s/family’s wishes.” The POC did not include measurable goals for SN, SW, or SC services. CLINICAL RECORD 10: A review of the clinical record revealed that the patient elected the hospice benefit on 01/23/2026. The Plan of Care (POC) dated 01/23/2026-04/22/2026 included, in part, the following Skilled Nursing (SN) goals: “... Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will have safety needs met. Patient/caregiver will verbalize understanding of the effects of urinary incontinence. Patient will follow an effective bowel program to prevent constipation...” An interim verbal order for Social Work (SW) was written on 01/27/2026, which included goals: “A medical social worker plan of care will be established. Patient care will express an increased sense of closure and peacefulness at the end of life.” The POC did not include measurable goals for SN or SW services. CLINICAL RECORD 11: A review of the clinical record revealed that the patient elected the hospice benefit on 03/28/2024. The Plan of Care (POC) dated 03/28/2024-06/25/2024 included, in part, the following Skilled Nursing (SN) goals: “...Hospice comfort kit will be provided to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Caregiver will verbalize understanding of effects of urinary incontinence...” The POC did not include measurable goals for SN services. CLINICAL RECORD 12: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 08/13/2025. The Plan of Care (POC) dated 11/11/2025-02/08/2026 included, in part, the following Skilled Nursing (SN) goals: “... Patient/Caregiver will demonstrate independence and administration of inhalation therapy and care for equipment. Patient will follow an effective bowel program to prevent/relieve constipation. Patient will have safety needs met. Caregiver verbalizes understanding of s/s imminent death, plan for symptom management and what to do at time of death...” The POC did not include measurable goals for SN services. CLINICAL RECORD 13: A review of the clinical record revealed that the patient elected the hospice benefit on 07/11/2025. The Plan of Care (POC) dated 07/11/2025-10/08/2025 included, in part, the following Skilled Nursing (SN) goals: “... Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will have safety needs met. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize understanding of effects of urinary incontinence...” An interim verbal order for Social Work (SW) was written on 07/14/2025, which included goals: “A medical social worker plan of care will be established... Patient/caregiver will have decreased fear/anxiety regarding death and dying process. Problems concerning patient’s personal affairs will be resolved...” An interim verbal order for Spiritual Counselor (SC) was written on 07/15/2025, which included goals: “A chaplain plan of care will be established. Patient/Caregiver will feel relief from spiritual concerns.” The POC did not include measurable goals for SN, SW, or SC services. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/10/2025. The Plan of Care (POC) dated 04/10/2025-06/08/2025 included, in part, the following Skilled Nursing (SN) goals: “... Caregiver verbalizes understanding of imminent death, plan for symptom management and what to do at time of death. Caregiver will verbalize knowledge of preventative measures/response in the event of hemorrhage. Bleeding/hemorrhage will be recognized early for management.” The POC did not include measurable goals for SN services. The Alternate Administrator (Personnel Record 2) was interviewed on 02/19/2026 and stated, “We’ll need to work with (software vendor) to figure out a way for clinicians to add measurable goals.””

“It is required that each patient’s individualized written plan of care include 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, interview, and observation. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure the plan of care included all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 1/HOME VISIT 1: A review of the clinical record revealed that the patient elected the hospice benefit on 02/03/2026. The Plan of Care (POC) dated 02/03/2026 included a nursing order, “Hospice nurse to instruct in safe use of oxygen and monitor its effectiveness”, a nursing goal, “O2 levels will be monitored as appropriate,” DME and Supplies included “O2 Concentrator, O2 tubing/nasal cannula, Safety Measures, “O2 Precautions”. A home visit observation was conducted with the hospice aide (Personnel Record 4)) on 02/19/2026. During the visit, an oxygen concentrator was observed in the patient’s room, although it was not in use at the time. There was no order for oxygen on the POC or in any subsequent orders. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. The Administrator was interviewed on 02/19/2026 and stated, “It was probably just missed. I’ll make sure it’s added to the medication list.” CLINICAL RECORD 2/HOME VISIT 2: A review of the clinical record revealed that the patient elected the hospice benefit on 04/17/2025. The Plan of Care (POC) dated 02/06/2026-04/06/2026 included an order for “Oxygen gas for inhalation 2–4-liter O2 Continuous via Nasal Cannula.” There were no parameters on the POC indicating how to titrate between 2 and 4 liters. Additionally, there were no interim orders that included oxygen titration parameters. A home observation visit was conducted with the Registered Nurse (RN) (Personnel Record 3). The patient was observed using 2 liters per minute of oxygen via nasal cannula. The RN was interviewed during the visit and was asked how the oxygen was to be titrated between 2 and 4 liters. The RN stated, “I check the patient’s pulse ox, and if it is below 95%, I would increase the oxygen to 3 liters. If it remained under 95%, I would increase it to 4 liters.” The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit on 01/17/2026. The Plan of Care (POC) dated 01/17/2026-04/16/2025 included an order, “Oxygen gas for inhalation, 2-4 liters, as needed/PRN, Reason: SOB, Use as needed.” The order did not include a route of administration, nor did it include titration parameters between 2 and 4 liters. Additionally, there were no interim orders that included oxygen titration parameters. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit on 02/04/2026. The Plan of Care (POC) dated 02/08/2026-04/08/2026 included an order, “Oxygen gas for inhalation, 2-4 Liter, O2 PRN/PRN O2 Nasal, Reason: SOB/COMFORT.” The order did not include titration parameters between 2 and 4 liters. Additionally, there were no interim orders that included oxygen titration parameters. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit on 10/17/2025. The Plan of Care (POC) dated 01/15/2026-04/14/2026 included, “Oxygen gas for inhalation, 2-4 Liter, O2 PRN/PRN O2 Nasal, Reason: Shortness of Breath.” The order did not include titration parameters between 2 and 4 liters. Additionally, there were no interim orders that included oxygen titration parameters. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 9: A review of the clinical record revealed that the patient elected the hospice benefit on 01/11/2026. The Plan of Care (POC) dated 01/11/2026-04/10/2026 included a nursing order, “Hospice nurse to instruct in safe use of oxygen and monitor its effectiveness”, a nursing goal, “O2 levels will be monitored as appropriate,” DME and Supplies included “O2 Concentrator, O2 tubing/nasal cannula, Safety Measures, “O2 Precautions”. There was no order for oxygen on the POC or in any subsequent orders. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. The Administrator was interviewed on 02/19/2026 and stated, “It was probably just missed. I’ll make sure it’s added to the medication list.” CLINICAL RECORD 10: A review of the clinical record revealed that the patient elected the hospice benefit on 01/23/2026. The Plan of Care (POC) dated 01/23/2026-04/22/2026 included a nursing order, “Hospice nurse to instruct in safe use of oxygen and monitor its effectiveness”, a nursing goal, “O2 levels will be monitored as appropriate,” DME and Supplies included “O2 Concentrator, O2 tubing/nasal cannula, Safety Measures, “O2 Precautions”. There was no order for oxygen on the POC or in any subsequent orders. The POC did not include all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. The Administrator was interviewed on 02/19/2026 and stated, “It was probably just missed. I’ll make sure it’s added to the medication list.” The Administrator (Personnel Record 1) was interviewed on 02/19/2026 and stated, “There should be instructions on the order on how oxygen should be administered when there is a range.””

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visit observations, the agency did not ensure that clinical staff followed the agency’s policies regarding hand hygiene. POLICY: The agency’s “Handwashing/Hand Hygiene” policy (Policy No. 7-009, Undated) stated in part, “Indications for hand hygiene: C. When there is prolonged or intense contact with the client (bathing the client). D. Between tasks on the same client. F. After removing gloves. G. After touching objects that are potentially contaminated. Q. Decontaminate hands after contact with inanimate objects, including equipment in the immediate vicinity of the client. R. Decontaminate hands after removing gloves.” POLICY: The agency’s “Bag Technique” policy (Policy No. 7-016, Undated) stated in part, “Bag Technique: 5. Perform hand hygiene (use proper hand hygiene technique) prior to reentering the bag for any reason. 7. When the visit is complete, reusable equipment will be cleaned using alcohol, soap, and water, or other appropriate solution; hand hygiene will be performed prior to cleaning equipment and being returned to the bag.” HOME VISIT 1: A home observation visit was performed with the hospice aide (Personnel Record 4) on 02/19/2026. During the visit, the hospice aide provided personal care to the patient wearing a pair of gloves. The hospice aide was observed removing the dirty gloves and putting on a clean pair. The hospice aide did not disinfect her hands after removing the dirty gloves per the agency’s policy. HOME VISIT 2: A home observation visit was performed with the Registered Nurse (RN) (Personnel Record 3) on 02/19/2026. During the visit, the RN used non-disposable equipment during the physical assessment. At the end of the visit, the RN disinfected all equipment and returned it to the clinical bag. However, the RN did not perform hand hygiene when re-entering the clinical bag to return the clean items per the agency’s policy. The Administrator (Personnel Record 1) was interviewed on 02/19/2026 and stated, “ Clinical staff should clean their hands every time they go into their bag and every time gloves are taken off.””