Elara Caring Xiv

“Based on record review and interview, the hospice failed to ensure it completed an evaluation for services within 48 hours of referral for three (Patients #11, 13, 19) of 19 patients. Patient #11A review of the clinical record showed a referral date of 11/27/24 with an initial evaluation and election of the hospice benefits on 12/04/24. The clinical record showed no declined visits, no physician notification and no changes in orders.Patient #13A review of the clinical record showed a referral date of 06/05/26 with an initial evaluation and election of the hospice benefits on 07/02/26. The clinical record showed the patient requested SOC delayed until 06/15/26. The clinical record showed no physician notification of delay of care and no changes in orders.Patient #19A review of the clinical record showed a referral date of 12/02/25 with an initial evaluation and election of the hospice benefits on 12/07/25. The clinical record showed no changes to physician orders.On 07/21/26 from 4:55 p.m. to 5:55 p.m., Staff B stated there was a delay in the evaluation for services for patients #11, 13, 19.”

“Based on record review and interviews, the hospice failed to ensure the complete development of a bereavement POC or included bereavement goals in the overall POC at the time of initial assessment for five (Patients #1, 2, 9,10, 17) of 19 patients. Patient #1A review of the clinical record showed no Bereavement Care Plan and showed no bereavement goals in the overall POC.Patient #2A review of the clinical record showed no Bereavement Care Plan and showed no bereavement goals in the overall POC.Patient #9A review of the clinical record showed no Bereavement Care Plan and did not include bereavement interventions and goals in the overall POC.Patient #10A review of the clinical record showed no Bereavement Care Plan and showed no bereavement goals in the overall POC.Patient #17A review of the clinical record showed no Bereavement Care Plan and showed no bereavement goals in the overall POC.On 07/21/26 from 4:05 p.m., 4:40 p.m., Staff B stated that there were no bereavement interventions and goals in the overall POC and no interventions in the BCPs for Patients #1, 2, 9, 10, 17.”

“Based on record review and staff interview, the hospice failed to ensure:Hospice aide interventions and goals on the POCs for four (Patient # 2, 3, 4, 19) of 19 patients.A POC identified the site location of a gastrostomy tube for one (Patient #9) of 19 patients.The POC listed a date for a foley catheter to be changed for one (Patient #10) of 19 patients. Patient #2A review of a POC dated 07/01/26 to 08/29/26 with IDG updates on 06/30/26, 07/14/26, ordered hospice aide services of one time a week for eight weeks showed no hospice aide interventions and goals.Patient #3 A review of a POC dated 06/30/26 to 08/28/26 with IDG updates on 05/29/26, 06/12/26, 06/25/26, 07/10/26 ordered hospice aide services of two times a week for nine weeks showed no hospice aide interventions and goals.Patient #4A review of a POC dated 06/11/26 to 09/08/26 with IDG updates on 06/25/26, 07/10/26, ordered hospice aide services of two times a week for 12 weeks then one time a week for one week showed no hospice aide interventions and goals. Patient #9A review of a POC dated 5/20/26 to 8/17/26 with IDG updates dated 05/29/26, 06/12/26, 06/25/26, 07/10/26, 07/14/26 ordered SN to conduct gastrostomy site care and assess for site infection did not identify the gastrostomy site.Patient #10A review of a POC dated 04/25/26 to 07/23/26 with IDG updates dated 05/05/26, 05/19/26, 06/02/26, 06/16/26, 06/30/26, 07/14/26 ordered SN to conduct foley catheter 16 French 10 cubic centimeter change every month and showed no next due or last change date.Patient #11A review of a POC dated 05/28/26 to 07/26/26 with IDG updates 05/05/26, 05/19/26, 06/02/26, 06/16/26, 07/14/26 showed no interventions for the hospice diagnosis of Dementia.Patient #14A review of a POC dated 07/08/26 to 09/05/26 with IDG update 07/10/26 showed no interventions for the hospice diagnosis of Neoplasm of Ureter.Patient #16A review of a POC dated 04/10/26 to 06/08/26 with IDG updates 04/10/26, 04/24/26 showed no interventions for the hospice diagnosis of Cerebral Atherosclerosis.Patient #17A review of a POC dated 07/02/25 to 08/30/25 with IDG updates 07/11/25 showed no interventions for the hospice diagnosis of Dementia.Patient #19A review of a POC dated 1/25/26 to 03/25/26 with IDG updates on 1/27/26, ordered hospice aide services of two times a week for eight weeks then one time a week for one week showed no hospice aide interventions and goals.On 07/21/26 from 4:10 p.m. to 5:55 p.m., Staff B stated:1. The POC for patients #2, 3, 4 and 19 did not contain aide interventions and goals.2. The POC did not have a date the foley change was due for patient #10.3. The PEG tube site was not identified on the POC for patient #9.4. The POC did not contain interventions related to the hospice diagnoses for patients #11, 14, 16, 17.”

“Based on record review and interview, the hospice failed to ensure care was followed according to the POCs for seven (Patients #3, 6, 10, 13, 14, 15, 16) of 19 patients. Patient #3A review of a POC dated 06/30/26 to 08/28/26 with IDG updates on 05/29/26, 06/12/26, 06/25/26, 07/10/26 ordered MSW visit frequency of one time a week for one week then once every four weeks for four weeks. The clinical record showed no MSW visits were conducted (two visits ordered, no visits conducted) and showed no patient refusal of visits or change in orders.Patient #6A review of a POC dated 06/08/26 to 08/06/26 with IDG updates dated 06/06/26, 06/30/26, 07/14/26 ordered MSW visit frequency of one time a week for one week then one time every two weeks for six weeks. The clinical record showed no MSW visits were conducted (four visits ordered, no visits conducted) and showed no patients refusal of visits and no change in orders.Patient #10A review of a POC dated 04/25/26 to 07/23/26 with IDG updates dated 05/05/26, 05/19/26, 06/02/26, 06/16/26, 06/30/26, 07/14/26 ordered MSW visit frequency of one time a week for one week. The clinical record showed no MSW visits were conducted (one visit ordered, no visits conducted) and showed no patient’s refusal of visits.Patient #13A review of a POC dated 07/02/26 to 09/29/26 with IDG updates dated 07/14/2026 ordered Chaplain visit frequency of one time a week for one week. The clinical record showed one Chaplain visit was conducted per week (one visit ordered, two visits conducted) and during the week of 07/05/26 to 07/11/26, there was a missed aide visit (three visits per week ordered, one visit conducted, one missed visit) and showed no patient refusal of visits or change in orders.Patient #14A review of a POC dated 06/30/26 to 08/28/26 with IDG updates on 05/29/26, 06/12/26, 06/25/26, 07/10/26 ordered MSW visit frequency of one time a week for one then once every four weeks for four weeks. The clinical record showed no MSW visits were conducted (two visits ordered, no visits conducted) and showed no patient refusal of visits or change in orders.Patient #15A review of a POC dated 08/06/25 to 10/4/25 with IDG updates dated 08/08/25, 08/22/25, 09/05/25 ordered Chaplain visit frequency of one time a week for one week then once every two weeks for six weeks. The clinical record showed one Chaplain visit was conducted during the weeks of 08/24/25 to 08/30/25 and 08/31/25 to 09/06/25 (two visits ordered, no visits conducted) and ordered MSW frequency of one time a week for one week then once every four weeks for four weeks. During the week of 08/24/26, there was a missed MSW visit (one visits per week ordered, no visits conducted) and no patient refusal of visits and no change in orders.Patient #16A review of a POC dated 04/10/26 to 06/08/26 with IDG updates dated 04/10/26 and 04/24/26 ordered MSW visit frequency of one time a week for one week then once every four weeks for eight weeks. The clinical record showed during the week of 04/12/26 to 04/18/26 there was no MSW visit conducted (one visits ordered, no visits conducted) and showed no patient refusal of visits and no change in orders.On 07/21/26 at from 4:12 p.m. to 5:20 p.m., Staff B stated:1. The patient had no MSW visits for patients #3,10,14,15 and 16.2. There were no Chaplain visits for patients #13 and 15..3. There were no aide visits for patient #13.”

“Based on record review and interview, the hospice failed to ensure an initial hire tuberculosis screening test was performed for one volunteer (Volunteer #3) of three volunteers. Findings: A policy titled, Infection Control TB [tuberculosis] Screening and Testing stated team members will require a baseline skin or blood test. Volunteer #3 A review of personnel records showed no results of an initial hire tuberculosis test result or records of health screenings from the hire date of 10/01/24. A request for additional request for personnel records yielded no results. 07/21/26 at 4:00 p.m., Staff B stated Volunteer #3 had no initial hire testing for tuberculosis.”

“Based on record review and interview, the hospice failed to ensure continued review and update of hospice aide care plans for eight (Patients #2, 6, 10, 12, 14, 16, 18, 19) of 19 patients. Patient #2A review of a POC dated 07/01/26 to 08/29/26 with IDG updates on 06/30/26, 07/14/26 showed an aide visit frequency of one time a week for eight weeks. A review of the clinical record showed a physician order dated 07/19/26 for aide visits one time a week for six weeks. The clinical record showed an ACP last updated on 09/04/25.Patient #6A review of a POC dated 06/08/26 to 08/06/26 with IDG updates dated 06/06/26, 06/30/26, 07/14/26 showed an aide visit frequency of six times a week for eight weeks then one times a week for one week. A review of the clinical record showed a physician order dated 06/28/26 for aide visits two times a week for one week, three times a week for four weeks then two times a week for one week. The clinical record showed an ACP last updated on 04/24/26.Patient #10A review of a POC dated 04/25/26 to 07/23/26 with IDG updates dated 05/05/26, 05/19/26, 06/02/26, 06/16/26, 06/30/26, 07/14/26 showed an aide visit frequency of one time a week for 13 weeks. A review of the clinical record showed a physician order dated 05/04/26 for aide visits two times a week for 12 weeks. The clinical record showed an ACP last updated on 04/25/26.Patient #12A review of a POC dated 05/21/26 to 08/18/26 with IDG updates dated 06/02/26, 06/16/26, 06/30/26, 07/14/26 showed an aide visit frequency of one time a week for 12 weeks. A review of the clinical record showed a physician order dated 06/21/26 for aide visits two times a week for one week then one time a week for eight weeks. The clinical record showed an ACP last updated on 05/21/26.Patient #14A review of a POC dated 07/08/26 to 09/05/26 with IDG updates dated 07/10/26 showed an aide visit frequency of one time a week for eight weeks. A review of the clinical record showed a physician order dated 07/11/26 for aide visits one time a week for eight weeks. The clinical record showed an ACP last updated on 01/13/26.Patient #16A review of a POC dated 04/10/26 to 06/08/26 with IDG updates dated 04/10/26, 04/24/26 showed an aide visit frequency of two times a week for eight weeks then one time a week for one week. A review of the clinical record showed a physician order dated 04/10/26 for aide visits two times per week for eight weeks then one time a week for one week. The clinical record showed an ACP last updated on 12/29/25.Patient #18A review of a POC dated 04/03/26 to 06/01/26 with IDG updates dated 04/07/26, 04/21/26, 05/05/26 showed an aide visit frequency of one time a week for eight weeks. A review of the clinical record showed a physician order dated 04/20/26 for aide visits once every two weeks for two weeks. The clinical record showed an ACP last updated on 07/22/25.Patient #19A review of a POC dated 01/25/26 to 03/25/26 with IDG updates dated 01/27/26 showed an aide visit frequency of two times a week for eight weeks then one time a week for one week. A review of the clinical record showed a physician order dated 12/07/25 for aide visits one time a week for one week then two times a week for eight weeks. The clinical record showed an ACP last updated on 09/04/25.On 07/21/26 from 4:10 p.m. to 5:55 p.m., Staff B stated the ACPs for patients #2, 6, 10, 12, 14, 16, 18, and 19 were not reviewed and updated when their ordered aide frequencies changed.”

“Based on record review and interview, the hospice failed to ensure volunteer recruitment efforts in calendar years 2024 and 2025 for all patients, family members and staff. Findings: A review of volunteer program records showed a log of volunteer recruitment efforts dated 10/02/24, 10/21/24, 11/05/24 and 11/11/24 in calendar year 2024; and 02/10/25 to 02/15/25 and 02/17/25 to 02/20/25 in calendar year 2025. The volunteer program records showed no other active, ongoing or viable volunteer recruitment efforts in calendar years 2024 and 2025. On 07/21/26 at 1:20 p.m., Staff B stated:The electronic file of volunteer coordinator recruitment activity in 2024 was not accessible.There were no other program records in 2025.”

“Based on record review and interview, the hospice failed to ensure cost savings of 5% with the use of volunteers as a part of the hospice program in calendar years 2024 and 2025 for all patients and employees. Findings: A review of volunteer records showed a cost savings utilization rate of 0.61% in calendar year 2024 and a cost savings utilization rate of 0.47% in calendar year 2025. On 07/21/26 at 4:00 pm, Staff B stated the hospice did not meet the cost saving utilization rate of 5% in 2024 and 2025.”

“Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated or was included as a part of the overall POC after the initial and ongoing spiritual/bereavement assessments for 11 (Patients #2, 3, 5, 6, 7, 8, 9, 10, 11, 12 and #13) of 13 patients. Findings: Patient #2 A review of the clinical record showed an election of the hospice benefit on 10/05/23 with a completion of the initial spiritual/bereavement assessment on 10/10/23. A review of a POC dated 04/02/24 to 05/31/24 and IDG updates to the POC on 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit on 10/25/23 with a completion of the initial spiritual/bereavement assessment on 01/10/22. A review of a POC dated 04/22/24 to 04/24/24 and IDG updates to the POC on 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit on 10/30/23 with a completion of the initial spiritual/bereavement assessment on 10/30/23. A review of a POC dated 10/30/23 to 01/27/24 and IDG updates to the POC on 11/03/23 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit on 12/30/21 with a completion of the initial spiritual/bereavement assessment on 01/03/22. A review of a POC dated 08/27/22 to 10/25/22 and IDG updates to the POC showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit on 01/23/24 with a completion of the initial spiritual/bereavement assessment on 01/23/24. A review of a POC dated 03/28/24 to 05/21/24 and IDG updates to the POC on 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #8 A review of the clinical record showed an election of the hospice benefit on 10/23/23 with a completion of the initial spiritual/bereavement assessment on 10/23/23. A review of a POC dated 04/20/24 to 06/18/24 and IDG updates to the POC on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #9 A review of the clinical record showed an election of the hospice benefit on 09/13/23 with a completion of the initial spiritual/bereavement assessment on 09/13/23. A review of a POC dated 03/11/24 to 05/09/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #10 A review of the clinical record showed an election of the hospice benefit on 08/19/23 with a completion of the initial spiritual/bereavement assessment on 08/19/23. A review of a POC dated 03/07/24 to 05/05/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit on 01/10/23 with a completion of the initial spiritual/bereavement assessment on 01/12/23. A review of a POC dated 03/05/24 to 05/03/24 and IDG updates to the POC on 02/23/24, 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #12 A review of the clinical record showed an election of the hospice benefit on 07/20/22 with a completion of the initial spiritual/bereavement assessment on 07/24/22. A review of a POC dated 03/11/24 to 05/08/24 and IDG updates to the POC on 03/08/24, 03/22/24, 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #13 A review of the clinical record showed an election of the hospice benefit on 02/22/23 with a completion of the initial spiritual/bereavement assessment on 02/28/23. A review of a POC dated 04/17/24 to 06/15/24 and IDG updates to the POC on 04/05/24 and on 04/19/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 05/01/24 at 10:40 a.m., Staff D stated: all patients are given a bereavement risk score at the time of the initial spiritual/bereavement assessment and are advised of spiritual and bereavement services provided by the hospice and The bereavement program consists of intermittently timed mail outs and follow up telephone calls which begin after the patients death. On 05/01/24 at 10:50 a.m., Staff B stated the Hospice does not maintain a written POC for bereavement; bereavement is not included on the overall POC unless the patients family or caregiver is assessed at a moderate to high risk for bereavement, then social work and/or chaplain services are provided as needed and interventions and/or related goals for each discipline is added to the plan of care.”

“Based on record review and interview, the hospice failed to ensure completion and provision of a discharge summary of care for two (Patients #4 and #6) of 13 patients. Findings: Patient #4 A review of the clinical record showed the patient was transferred to residential care facility (Nursing Home) for respite care on 04/21/23 and then was subsequently discharged at the time of death on 05/04/23. Documentation showed no transfer/discharge summary of care was completed or provided to the attending physician or to the to residential care facility (Nursing Home). Patient #6 A review of the clinical record showed the patient was transferred to another hospice agency on 09/07/22. Documentation showed no transfer/discharge summary of care was completed or provided to the attending physician or to the receiving hospice agency. On 05/01/24 at 1:57 p.m., Staff B stated: 1. The hospice did not complete or provide a transfer/discharge summary of care to the attending physician for patients #4 and #6 or; 2. Provide a transfer/discharge summary of care to the to residential care facility (Nursing Home) for patient #4 or to the receiving hospice agency for patients #6.”

“Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility (Nursing Home) for one (Patient #4) of 13 patients. Findings: Patient #4 A review of the POC dated 04/05/23 to 07/03/23 showed orders for SN two times a week for 13 weeks, then one time a week for one week; hospice aide one time a week for one week, then two times a week for 12 weeks; medical social work one time a week for one week; and chaplain services one time a week for one week for palliation and management of terminal illness related to coronary artery disease. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home) at the time of placement for respite care on 04/21/23. On 05/01/24 at 1:55 p.m., Staff B stated documentation for patient #4 showed no IDG communications or coordination of care with the residential care facility (Nursing Home) at the time of placement for respite care.”