Masonic Village 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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 10 of 19 (53%) clinical records reviewed, the agency did not ensure that all of the medical supplies and appliances required to meet the patient’s needs were included on the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/16/2025. The initial comprehensive assessment, dated 12/16/2025, documented that the patient was incontinent and used adult briefs. Additionally, a home-visit observation was conducted with the Spiritual Counselor (Personnel Record 5). During the visit, the patient was observed lying in a hospital bed, and there was a wheelchair in the room. The initial Plan of Care, dated 12/16/2025, did not include any medical supplies or appliances necessary to meet the patient’s needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/30/2025. The initial comprehensive assessment dated 12/30/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 12/30/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/25/2025. The initial comprehensive assessment dated 11/25/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 11/25/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/19/2025. The initial comprehensive assessment dated 08/19/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 08/19/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/03/2025. The initial comprehensive assessment dated 10/03/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 10/03/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/15/2025. The initial comprehensive assessment dated 10/15/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 10/15/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 12: The patient elected the hospice benefit on 12/19/2025. The initial comprehensive assessment dated 12/19/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 12/19/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 16: The patient elected the hospice benefit on 06/19/2025. The initial comprehensive assessment dated 06/19/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 06/19/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 17: The patient elected the hospice benefit on 10/28/2025. The initial comprehensive assessment dated 10/28/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 10/28/2025, did not include oxygen and the related oxygen supplies. CLINICAL RECORD 18: The patient elected the hospice benefit on 09/29/2025. The initial comprehensive assessment dated 09/29/2025 included documentation that the patient required oxygen and oxygen supplies. The initial Plan of Care (POC) dated 09/29/2025, did not include oxygen and the related oxygen supplies. The Clinical Manager (Personnel Record 2) was interviewed on 01/09/2025 and stated, “We need to figure out a way to get the supplies on the plan of care.””

“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 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 1 of 18 (6%) clinical records reviewed where the patient received hospice aide services, the agency did not ensure that written patient care instructions were prepared by a Registered Nurse (RN). CLINICAL RECORD 3: The patient elected the hospice benefit and was admitted to hospice care on 11/25/2025. The initial comprehensive assessment documented on 11/25/2025 indicated that the patient initially declined hospice aide (HA) services. HA services were subsequently ordered at the Interdisciplinary Group meeting on 12/23/2025, with a start date of 12/23/2025 and a frequency of two visits per week. HA visits were documented from 12/16/2025 through 01/08/2025; the only documented HA plan of care was dated on 01/08/2026. There were no written patient care instructions for the HA prepared by a Registered Nurse prior to 01/08/2026. The Administrator (Personnel Record 1) was interviewed on 01/08/2026 and stated, “We looked at the chart, and the nurse didn’t write a care plan before January 8th.””

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) records reviewed where the patient received Hospice Aide (HA) services, the agency did not ensure that the HA provided care as included in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit and was admitted on 12/16/2025. The initial Plan of Care, dated 12/16/2025, included orders for Hospice Aide (HA) services with a frequency of three visits per week. The HA plan of care developed by the Registered Nurse and dated 12/17/2025 included, in part, the tasks, “Personal Care- 3 times a week: Assist with dressing, Bed bath, Check Pressure Areas, Comb/Brush Hair, Foot Care, Oral Care / Denture Care, Perineal Care, and Skin Care.” The HA visit note dated 12/17/2025 indicated that the following tasks were not documented as performed during the visit: Assist with dressing, Bed bath, Check Pressure Areas, Comb/Brush Hair, Foot Care, Oral Care / Denture Care, Perineal Care, and Skin Care. The HA note contained no documentation indicating why the services were not provided, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. CLINICAL RECORD 2: The patient elected the hospice benefit and was admitted on 12/30/2025. The initial Plan of Care, dated 12/30/2025, included orders for Hospice Aide (HA) services with a frequency of three visits per week. The HA plan of care developed by the Registered Nurse and dated 12/30/2025 included, in part, the tasks, “Personal Care Task 3x/week: Assist w/dressing, Bed bath, Foot Care, Oral Care.” The HA visit note dated 01/02/2025 indicated that the following tasks were not documented as performed during the visit: Assist w/dressing, Bed bath, Foot Care, and Oral Care. The HA note contained no documentation indicating why the services were not provided, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. CLINICAL RECORD 5: The patient elected the hospice benefit and was admitted on 09/16/2025. The initial Plan of Care, dated 09/16/2025, included orders for Hospice Aide (HA) services with a frequency of three visits per week. The HA plan of care developed by the Registered Nurse and dated 10/30/2025 included, in part, the task, “Personal Care Task 3x/week: Shower.” The HA visit note dated 12/29/2025 indicated that the shower was not documented as performed during the visit. The HA documented a comment, “Bed bath at sink.” The HA note contained no documentation indicating why the service was not provided in accordance with the plan of care, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. CLINICAL RECORD 11: The patient elected the hospice benefit and was admitted on 10/15/2025. The initial Plan of Care, dated 10/15/2025, included orders for Hospice Aide (HA) services with a frequency of 3 visits per week. The HA plan of care developed by the Registered Nurse and dated 11/07/2025 included, in part, the tasks, “Personal Care Task 3x/week: Assist with dressing, Bed Bath, Comb/Brush Hair, Foot Care, Oral Care/Denture Care, Skin Care.” The HA visit note dated 12/24/2025 indicated that the following tasks were not documented as performed during the visit: Assist with dressing, Bed Bath, Comb/Brush Hair, Foot Care, Oral Care/Denture Care, Skin Care. The HA note contained no documentation indicating why the services were not provided, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. CLINICAL RECORD 18: The patient elected the hospice benefit and was admitted on 09/25/2025. The initial Plan of Care, dated 09/25/2025, included orders for Hospice Aide (HA) services with a frequency of 3 visits per week. The HA plan of care developed by the Registered Nurse and dated 09/29/2025 included, in part, the tasks, “Personal Care Task 3x/week: Assist with dressing, Bed bath, Check pressure areas, Comb/brush hair, Foot care, Oral Care, Perineal Care, Shower” The HA visit note dated 09/30/2025 indicated that the following tasks were not documented as performed during the visit: Assist with dressing, Bed bath, Check pressure areas, Comb/brush hair, Foot care, Oral Care, Perineal Care, Shower. The note contained no documentation indicating why the services were not provided, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. CLINICAL RECORD 19: The patient elected the hospice benefit and was admitted on 08/19/2025. The initial Plan of Care, dated 08/19/2025, included orders for Hospice Aide (HA) services with a frequency of 1 visit for the first week, then 2 visits each week. The HA plan of care developed by the Registered Nurse and dated 08/19/2025 included, in part, the tasks, “Personal Care Task 3x/week: Assist with dressing, Bed bath, Check pressure areas, Comb/brush hair, Foot care, Perineal Care.” The HA visit note dated 08/22/2025 indicated that a Bed Bath was not documented as performed during the visit. The note contained no documentation indicating why the Bed Bath was not provided, nor was there documentation that the deviation from the written plan of care was reported to the Registered Nurse. The Clinical Manager (Personnel Record 2) was interviewed on 01/09/2025 and stated, “The aides should write a note in the comments section if tasks are not completed and that the nurse was notified.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review. In 1 of 18 (6%) clinical records reviewed where the patient was receiving Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. CLINICAL RECORD 5: The patient was receiving Hospice Aide (HA) services as ordered by the Interdisciplinary Group on 12/09/2025, with a visit frequency of three visits each week. A HA note dated 12/29/2025 included documentation in the “General Information Note” as follows: “Her left leg is swollen. She is short of breath. I put her shoes on. I do her hair for her and clean her glasses. She is confused with everything. Even our routine of getting ready is a mess. She never knows what time or day it is. She has plans later with her family. I try to stay on task with her and it continues to turn into her experiencing it as if it is the first time she is getting ready with me every visit. She finds a way to shrug and laugh it off, but I believe it is getting to her.” There was no documentation that the HA reported the physical and psychosocial observations to the Registered Nurse as required.”

“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 1 of 18 (6%) clinical records reviewed where the patient received hospice aide services, the agency did not ensure that a Registered Nurse performed an on-site visit to the patient’s home for aide supervision 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) met the patient’s needs. CLINICAL RECORD 15: The patient elected the hospice benefit and was admitted on 09/03/2024. The Plan of Care (POC) dated 09/16/2025 included orders for a Hospice Aide (HA) with a visit frequency of 5 days per week. The Registered Nurse (RN) documented HA supervision in the nursing clinical notes. There was documented HA supervision on 09/29/2025 and again on 10/14/2025, exceeding the required 14-day interval. The RN’s on-site visit to the patient’s home to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) to meet the patient’s needs exceeded 14 days. The Administrator (Personnel Record 1) was interviewed on 01/08/2026 and stated, “We looked at the chart, and the supervision was greater than 14 days.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. 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 clinical record included all orders for the care to be provided. CLINICAL RECORD 15: The patient elected the hospice benefit and was admitted to service on 09/03/2024. Documentation in the initial comprehensive assessment dated 09/03/2024 indicated that the patient had an indwelling urinary catheter. There were no orders in the initial plan of care, nor were there any interim orders specifying when the catheter should be changed, its size, or the catheter balloon size. The Clinical Manager (Personnel Record 2) was interviewed on 01/09/2026 and stated, “We don’t change catheters at regular intervals, only when there’s a problem, and it needs to be changed. But that should be in an order.” CLINICAL RECORD 17: The patient elected the hospice benefit and was admitted to service on 10/28/2025. Documentation in the comprehensive assessment dated 10/28/2025 indicated that the patient had bilateral nephrostomy tubes. There were no orders on the initial plan of care or other wise documented regarding care of the tubes. The Clinical Manager (Personnel Record 2) was interviewed on 01/09/2026 and stated, “The tube care should be in an order.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) discharge clinical records reviewed, the agency did not ensure that a copy of the hospice discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 15: The patient elected the Hospice benefit on 09/23/2024. The patient signed the hospice revocation form on 12/01/2025 and was discharged on the same date. There was no documentation in the clinical record that a discharge summary was sent to the patient’s primary physician upon discharge, nor was the Administrator (Personnel Record 1) able to provide evidence that the summary was sent. CLINICAL RECORD 16: The patient elected the Hospice benefit on 06/19/2025. The patient was discharged from hospice care on 11/20/2025, as the Interdisciplinary Group (IDG) determined there was no continued need for hospice services as documented in the IDG team note dated 11/11/2025. There was no documentation in the clinical record that a discharge summary was sent to the patient’s primary physician upon discharge, nor was the Administrator (Personnel Record 1) able to provide evidence that the summary was sent. The Administrator (Personnel Record 1) was interviewed on 01/07/2026 and stated, “The discharge summary was not sent to the patient’s physician for these patients.””