A Path of Care Tendercare Hospice

“Based on record review and interview, the hospice failed to:1. ensure completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for one (Patient #2) of 14 patients; and2. ensure completion of the initial social work assessment no later than 5 calendar days after the election of hospice care for one (Patient #9) of 14 patients. Findings:Patient #2A review of the clinical record showed an election of the hospice benefit on 04/22/25 with no completion of the initial spiritual assessment from 04/22/25 to 06/04/25 (43 days after the election of the hospice benefit). Documentation showed no patient or caregiver refusal initial spiritual assessment.Patient #9A review of the clinical record showed an election of the hospice benefit on 04/02/25 with no completion of the initial social work assessment from 04/02/25 to 04/09/25 (7 days after the election of the hospice benefit), Documentation showed no patient or caregiver refusal of the initial social work assessment.On 06/04/25 at 2:39 pm., Staff C stated:1. the initial comprehensive assessment was to be completed within five days of the election of the hospice benefit;2. the initial spiritual assessment for Patient #2 was not completed within the first five days of the election of the hospice benefit; and3. the initial social work assessment for Patient #9 was not completed within the first five days of the election of the hospice benefit.”

“Based on record review and interview, the hospice failed to ensure hospice aide visits were provided in accordance with the plan of care for two (Patients #4 and 10) of 14 patients. Findings:Patient #4A review of the plan of care dated 01/27/25 showed a hospice aide frequency of two visits per week for thirteen weeks. A review of the clinical record showed the following:A hospice aide visit dated 02/20/25 for the week of 02/16/25 to 02/22/25 (one of two completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule visits and no physician orders to change the ordered frequency.A hospice aide visit dated 03/04/25 and a hospice aide missed visit note dated 03/06/25 (due to the facility giving the patient a shower while the aide was assisting another hospice patient) for the week of 03/02/25 to 03/08/25 (one of two completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.Patient #10A review of the plan of care dated 01/17/25 to 04/16/25 showed a hospice aide frequency of one visit per week for one week, five visits per week for 12 weeks and three visits per week for one week. A physician order dated 02/05/25 showed a hospice aide frequency of three visits per week for nine weeks and two visits per week for one week.A hospice aide visit 02/10/25 and two hospice aide missed visits dated 02/12/25 (due to severe weather) and 02/13/25 (due to refused and weather) for the week of 02/09/25 to 02/15/25 one of three completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visits and no physician orders to change the ordered frequency.Hospice aide visits dated 02/20/25, 02/22/25 and one hospice aide missed visit dated 02/18/25 (due to weather) for the week of 02/16/25 to 02/22/25 (two of three completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.Hospice aide visits dated 03/05/25, 03/06/25 and one hospice aide missed visit dated 03/07/25 (due to patient with Alzheimer’s refusing) for the week of 03/02/25 to 03/08/25 (two of three completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.Hospice aide visits dated 03/11/25, 03/13/25 and one hospice aide missed visit dated 03/14/25 (due to patient with Alzheimer’s refusing) for the week of 03/09/25 to 03/15/25 (two of three completed visits). Documentation showed no patient/caregiver refusal of the visits, no attempt to reschedule the missed visit and no physician orders to change the ordered frequency.On 06/04/25 at 2:37 pm., Staff C stated the hospice aide frequency was not followed as ordered for Patients #4 and 10.”

“Based on record review and interview, the hospice failed to ensure supervisory aide visits were completed every 14 days for one (Patient #1) of 14 patients. Findings:Patient #1A review of the plan care dated 03/03/25 t0 05/01/25 showed a hospice aide frequency of two visits per week for nine weeks. A review of the clinical record showed the following:Hospice aide visits were completed on 03/11/25 and 03/13/25 for the week of 03/09/25 to 03/15/25.A supervisory aide visit was completed on 03/11/25 for the week of 03/09/25 to 03/15/25.Hospice aide visits were completed on 03/18/25 and 03/20/25 for the week of 03/16/25 to 03/22/25.Hospice aide visits were completed on 03/25/25 and 03/27/25 for the week of 03/23/25 to 03/29/25.Hospice aide visits were completed on 04/01/25 and 04/04/25 for the week of 03/30/25 to 04/05/25.A supervisory aide visit was completed on 04/04/25 (23 days after the last supervisory aide visit) for the week of 03/30/25 to 04/05/25.Hospice aide visits were completed on 04/07/25 and 04/10/25 for the week of 04/06/25 to 04/12/25.Hospice aide visits were completed on 04/15/25 and 04/17/25 for the week of 04/13/25 to 04/19/25.Hospice aide visits were completed on 04/21/25 and 04/23/25 for the week of 04/20/25 to 04/26/25.Hospice aide visits were completed on 04/28/25 and 05/01/25 for the week of 04/27/25 to 05/01/25.A supervisory aide visit was completed on 04/29/25 (24 days after the last supervisory aide visit) for the week of 04/27/25 to 05/01/25.On 06/04/25 at 2:29 pm., Staff C stated the supervisory aide visits for Patient #1 were not completed every 14 days.”