Harmony Hospice Care LLC

“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 19 of 19 (100%) clinical records reviewed, the agency did not ensure that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The start of care was dated 03/14/2025. Primary diagnosis was senile dementia of brain. A clinical record review revealed that the Plan of Care (POC) dated 03/14/2025-06/11/2025 included the following goals: “Medications will be managed appropriately as evidenced by steady symptom control. Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Changes in neurologic status will be addressed appropriately. Caregiver will be knowledgeable in seizure precautions to keep patient safe. Bleeding/hemorrhage will be recognized early for management. Patient will have all safety needs met, fall precautions.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 2: The start of care was dated 03/27/2025. The primary diagnosis was Wernicke’s Encephalopathy. A clinical record review revealed that the POC dated 03/27/2025-06/11/2025 included the following goals: “Pain will be managed at a level acceptable to the patient. Patient will have safety needs met until resolved or upon patient passing. Patient will verbalize demonstrate reduction or relief of cardiopulmonary symptoms. Changes in neurologic status will be addressed appropriately. Patient will have safety needs met.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 3: The start of care was dated 01/27/2025. The primary diagnosis was cerebral infarct. A clinical record review revealed that the POC dated 04/27/2025-07/25/2025 included the following goals: “Pain will be managed at a level acceptable to the patient. Changes in neurologic status will be addressed appropriately. Indwelling urinary catheter will remain patent. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient will have safety needs met. Bleeding/hemorrhage will be recognized early for management.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 4: The start of care was dated 05/06/2025. The primary diagnosis was malignant neoplasm of bladder. A clinical record review revealed that the POC dated 05/06/2025-08/03/2025 included the following goals: “Signs/symptoms of infection will be identified and physician notified for prompt intervention to minimize associated risks. Medications will be managed appropriately as evidenced by steady symptom control. Pain will be managed at a level acceptable to the patient. The patient will have safety needs met until resolved or upon patient passing. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 5: The start of care was dated 04/28/2025. The primary diagnosis was senile degeneration of brain. A clinical record review revealed that the POC dated 04/28/2025-07/06/2025 included the following documented goals: “Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Patient will maintain optimal nutrition throughout benefit period. Changes in neurologic status will be addressed appropriately. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 6: The start of care was dated 03/14/2025. The primary and secondary diagnoses were senile degeneration of the brain, and malignant neoplasm of bone. A clinical record review revealed that the POC dated 03/14/2025-06/12/2025 included the following goals: “S/S of infection will be identified and physician notified for prompt intervention to minimize associated risks. Medications will be managed appropriately as evidenced by steady symptom control. Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will demonstrate independence in administration of inhalation therapy and care for equipment. Changes in neurologic status will be addressed appropriately. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient will have safety needs met.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 7: The start of care was dated 01/15/2025. The primary and secondary diagnoses were cerebral infarct and pneumonitis. A clinical record review revealed that the POC dated 04/15/2025-07/13/2025 included the following goals: “Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Changes in neurologic status will be addressed appropriately. Patient/caregiver will have decreased fear/anxiety regarding death and dying process. Patient/caregiver will feel relief from spiritual concerns.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 8: The start of care was dated 04/08/2025. The primary and secondary diagnoses were senile degenerations of the brain and protein calorie malnutrition. A clinical record review revealed that the POC dated 04/08/2025-07/06/2025 included the following goals: “Patient/caregiver will verbalize appropriate infection control measures to prevent infection or contamination. Medications will be managed appropriately as evidenced by steady symptom control. Pain will be managed at a level acceptable to the patient. Patient will have safety needs met until resolved or upon patient passing. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Facility staff is knowledgeable and involved in hospice plan of care for patient.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 9: The start of care was dated 03/25/2025. The primary diagnosis was heart failure. A clinical record review revealed that the POC dated 05/24/2025-07/22/2025 included the following documented goals: “Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Patient/caregiver will demonstrate independence in administration of inhalation therapy and care for equipment. Facility staff is knowledgeable and involved in hospice plan of care for patient.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 10: The start of care was dated 03/28/2025. The primary diagnosis was heart failure. A clinical record review revealed that the POC dated 03/28/2025-06/25/2025 included the following documented goals: “Patient/caregiver will verbalize appropriate infection control measures to prevent infection or contamination. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. Pain will be managed at a level acceptable to the patient. Patient will have safety needs met until resolved or upon patient passing. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence. Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event. Patient will maintain optimal nutrition throughout benefit period. Changes in neurologic status will be addressed appropriately. Patient will have all safety needs met.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 11: The start of care was dated 05/01/2025. The primary diagnosis was severe protein-calorie malnutrition. A clinical record review revealed that the POC dated 05/01/2025-07/29/2025 included the following goals: “Patient/caregiver will verbalize appropriate infection control measures to prevent infection or contamination. Pain will be managed at an acceptable level to the patient. Patient will have safety needs met until resolved or upon patient passing. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence. Patient will maintain optimal nutrition throughout benefit period. Caregiver will verbalize/demonstrate appropriate and safe wound care.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 12: The start of care was dated 12/21/2024. The primary diagnosis was senile degeneration of brain. A clinical record review revealed that the POC dated 03/21/2025-06/18/2025 included the following goals: “Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms within constraints of the disease. Changes in neurologic status will be addressed appropriately. Caregiver understands changes in level of consciousness as it relates to disease process and/or approaching end of life. Facility staff is knowledgeable and involved in hospice plan of care for patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient/caregiver will verbalize appropriate infection control measures to prevent infection or contamination.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 13: The start of care was dated 11/29/2024. The primary diagnosis was senile degeneration of brain. A clinical record review revealed that the POC dated 05/28/2025-07/26/2025 included the following documented goals: “Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event. Patient’s anxiety/agitation is minimized/controlled and caregiver verbalizes understanding of its effects origin/treatment. A medical social worker plan of care will be established. The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 14: The start of care was dated 04/15/2025. The primary and secondary diagnoses were COPD (chronic obstructive pulmonary disease) and heart failure. A clinical record review revealed that the POC dated 04/15/2025-07/13/2025 included the following goals: “Patient/caregiver will verbalize appropriate infection control measures to prevent infection or contamination. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. 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 how to use oxygen safely and effectively. Caregiver understands changes in level of consciousness as it relates to disease process and/or approaching end of life. Patient/Caregiver(s) understands instructions given by hospice staff through the use of the interpreter.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 15: The start of care was dated 02/19/2025. The primary diagnosis was Alzheimer’s Disease. A clinical record review revealed that the POC dated 02/19/2025-05/29/2025 included the following goals: “Patient/caregiver will verbalize/demonstrate appropriate pain management. demonstrates offering but not forcing food/fluids to patient. Changes in neurologic status will be addressed appropriately. Caregiver understands changes in level of consciousness as it relates to disease process and/or approaching end of life. Facility staff is knowledgeable and involved in hospice plan of care for patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient will have safety needs met. The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 16: The start of care was dated 05/06/2025. The primary diagnosis was cerebral infarct. A clinical record review revealed that the POC dated 05/06/2025-06/01/2025 included the following goals: Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate managing cardiopulmonary symptoms within constraints of the disease. Patient/caregiver will verbalize/demonstrate adequate knowledge of required care to manage indwelling catheter. Caregiver understands changes in level of consciousness as it relates to disease process and/or approaching end of life. Patient/caregiver will verbalize/demonstrate understanding of signs/symptoms of cerebral vascular accident and ability to manage effects of CVA as evidenced by decreased symptoms and utilization if safety measures. Changes in neurologic status will be addressed appropriately.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 17: The start of care was dated 01/02/2025. The primary diagnosis was Parkinson’s Disease. A clinical record review revealed that the POC dated 01/02/2025-05/02/2025 included the following goals: “Changes in neurologic status will be addressed appropriately. Patient/caregiver will demonstrate independence in administration of inhalation therapy and care for equipment. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed. Patient/caregiver will have decreased fear/anxiety regarding death and dying process. Patient/caregiver will feel relief from spiritual concerns. The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 18: The start of care was dated 04/07/2025. The primary diagnosis was malignant neoplasm anterior tongue. A clinical record review revealed that the POC dated 04/07/2025- 07/05/2025 included the following goals: “S/S of infection will be identified and physician notified for prompt intervention to minimize associated risks. Medications will be managed appropriately as evidenced by steady symptom control. Pain will be managed at a level acceptable to the patient. Patient will have safety needs met until resolved or upon patient passing. Patient will follow an effective bowel program to prevent/relieve constipation. Patient will maintain optimal nutrition throughout benefit period. Patient/caregiver will verbalize/demonstrate adequate knowledge of gastrostomy feedings and care. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 19: The start of care was dated 10/23/2024. The primary diagnosis was malignant neoplasm of stomach. A clinical record review revealed that the POC dated 10/23/2024-01/19/2025 included the following goals: “S/S of infection will be identified and physician notified for prompt intervention to minimize associated risks. Patient exhibits signs of symptom reduction or relief. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Patient will follow an effective bowel program to prevent/relieve constipation. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown.” The written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. The Administrator (Personnel Record 1) was interviewed on 06/09/2025 and stated, “[The EMR] doesn’t allow easy modification to the goals. I think we can change it to make the goals measurable. The new medical record will make it easier to individualize the goals.””

“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. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Document review revealed the hospice did not ensure that hospice volunteer services equaled five percent of the total patient care hours. The agency’s Volunteer Program was reviewed, and documentation was provided on the utilization of volunteer services. Documented utilization of hospice volunteers was 1% annually. Hospice volunteers did not 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. An interview was conducted with the agency’s Volunteer Coordinator (Personnel Record 11) on 06/12/2025. The Volunteer Coordinator confirmed that utilization was 1% annually. The Administrator (Personnel Record 1) was interviewed on 06/12/2025, confirmed that volunteers were not used to provide day-to-day administrative or direct care services to equal 5% and stated, “Our current Volunteer Coordinator is new and working to build up the program and increase the use of volunteers.””

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) discharged clinical records reviewed, where the patient was admitted to a hospital, it was revealed that the agency did not ensure a hospice discharge summary was provided to the receiving facility. CLINICAL RECORD 19: A review of the clinical record revealed that the patient revoked the hospice benefit and was admitted to the hospital on 12/02/2024. A coordination note written by the RN on 12/02/2024 documented a phone conversation with the patient’s daughter. The documented note indicated that the daughter was taking the patient to the hospital for further treatment. There was a discharge summary in the record and documentation that the summary was provided to the patient’s physician. However, there was no documentation that the summary was provided to the receiving facility. The Administrator (Personnel Record 1) was interviewed on 06/12/2025 and stated, “The discharge summary was not sent to the hospital.””