Cardinal Hospice LLC

“It is required that the comprehensive assessment includes consideration of the following factors: complications and risk factors that affect care planning, including risk for drug diversion. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the comprehensive assessment included consideration and documentation of the risk for drug diversion. Clinical Record 1: The patient elected the hospice benefit on 11/27/2024 with a terminal diagnosis of severe protein malnutrition. Clinical record review revealed the comprehensive assessment dated 11/27/2024 did not include documentation of an assessment of the potential for drug diversion. Clinical Record 3: The patient elected the hospice benefit on 11/01/2024 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the comprehensive assessment dated 11/01/2024 did not include documentation of an assessment of the potential for drug diversion. The Administrator was interviewed on 12/12/2024 and confirmed there was no documentation of an assessment of the potential for drug diversion in the comprehensive assessments for clinical record 1 and clinical record 3 and explained the EMR [electronic medical record] template for the comprehensive assessment did not include an area to document assessment for potential for drug diversion. The agency addressed assessments of drug diversion in other comprehensive assessments in the narrative documentation.”

“It is required that the comprehensive assessment includes consideration of the following factors: Imminence of death. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the comprehensive assessment did not include evidence of assessment for imminence of death. Clinical Record 1: The patient elected the hospice benefit on 11/27/2024 with a terminal diagnosis of severe protein malnutrition. Clinical record review revealed the comprehensive assessment dated 11/27/2024 did not include documentation of an assessment for imminence of death. Clinical Record 3: The patient elected the hospice benefit on 11/01/2024 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the comprehensive assessment dated 11/01/2024 did not include documentation of an assessment for imminence of death. The Administrator was interviewed on 12/12/2024 and confirmed there was no documentation of assessment for imminence of death in the comprehensive assessments for clinical record 1 and clinical record 3 and explained the EMR [electronic medical record] template for the comprehensive assessment did not include an area to document assessment for imminence of death. The agency addressed assessment of imminence of death in the narrative documentation in the other comprehensive assessments.”

“It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 11/27/2024 with a terminal diagnosis of severe protein malnutrition. The comprehensive assessment dated 11/27/2024 documented the patient had generalized pain with the most severe rating on the pain scale at 8. An order for Tramadol 50 mg every 6 hours as needed was present in the medication profile and it was documented that the patient occasionally requested pain medication. The plan of care dated 11/27/2024 to 12/11/2024 did not include planned interventions to address the patient’s pain documented on the comprehensive assessment. Clinical Record 9: This patient elected the hospice benefit on 05/24/2024 with a hospice diagnosis of chronic obstructive pulmonary disease with a comorbidity of diabetes mellitus. The plans of care dated 05/24/2024 through 10/22/2024 included an order for Levemir FlexTouch solution Pen-injector 100u/ml 26 subcutaneous Q [every] HS [bedtime] for Type 2 Diabetes and Humalog Kwik Pen Subcutaneous Solution Pen injector 100 unit/ml 100 NIT/ml sliding scale subcutaneous prn [as needed]. The plan of care did not include planned interventions to address medications or blood sugar testing for diabetes. During an interview on 12/11/2024 the Administrator confirmed the plans of care did not include planned interventions for the problems identified in the initial and comprehensive assessments.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed with bereavement services provided, the agency did not ensure the bereavement plan of care was developed and included the type of bereavement services that were to be offered and the frequency of the service delivery. Clinical Record 4: The patient elected the hospice benefit on 09/28/2023 with a terminal diagnosis of malignant neoplasm of the parotid gland. The patient expired on 10/10/2023. Clinical record review revealed no documented evidence that a bereavement care plan was developed for the bereaved. The clinical record included documentation of bereavement progress notes dated 10/11/2023, 11//09/2023, 12/06/2023 and 01/05/2024. The bereavement progress note dated 01/15/2024 included documentation that the bereaved did not wish for continued bereavement support. Clinical Record 5: The patient elected the hospice benefit on 01/11/2024 with a terminal diagnosis of polycythemia vera. The patient expired on 01/20/2024. Clinical record review revealed no documented evidence that a bereavement care plan was developed for the bereaved. The clinical record included documentation that the bereaved received bereavement calls and mailed letters. During an interview on 12/12/2024 the Administrator confirmed the clinical records did not contain bereavement care plans and stated the Bereavement Coordinator provided bereavement counseling to the bereaved but did not complete bereavement care plans during the first couple of admissions as she was not familiar with the new electronic medical record system.”

“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 2 (50%) clinical records reviewed with patient transfer to a Medicare/Medicaid certified facility, the agency did not ensure the hospice discharge summary was forwarded to the receiving facility. Clinical Record 10: This patient elected the hospice benefit on 02/20/2024 with a terminal diagnosis of occlusion and stenosis of bilateral carotid arteries. The patient was discharged to the hospital on 05/26/2024. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the receiving hospital. During an interview on 12/12/2024, the Administrator confirmed the agency did not send the discharge summary to the receiving hospital.”