Caris Healthcare

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 7: The patient elected the hospice benefit 06/11/2025 with a terminal diagnosis of Huntington’s Disease. The start of care comprehensive assessment did not include documentation of the initial bereavement assessment. There was no documentation in the record of an initial bereavement assessment that focused on the patient’s family and other individuals, needs related to social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care agreed there was no documentation in the clinical record of an initial bereavement assessment.”

“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 2 of 23 (9%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit 06/18/2025 with the terminal diagnosis of hypertensive heart without heart failure. The Registered Nurse (RN) documented on the initial assessment dated 06/18/2025 that the patient was unable to respond to the question “Are you uncomfortable because of pain?” The RN assessed the patient’s pain with a standardized pain tool and documented the FACE was 2-“hurts a bit.” The RN documented the physician was notified and orders were received for Hydrocodone 5mg-Acetaminophen 325 mg tablet one tablet every six hours PRN [as needed] and Morphine concentrate 20mg/ml 0.5 ml hourly as needed for generalized pain. The plan of care included the pain goal, “pain is managed at a level acceptable to patient.” The goal on the plan of care was not measurable when it did not include the patient’s acceptable level for pain. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with diagnoses of hypertensive heart disease, diabetic neuropathy, and arthritis. The RN documented on the comprehensive that pain was an active problem for the patient which occurred less than daily and had an effect on quality of life. The plan of care included the pain goal, “pain is managed at a level acceptable to patient.” The goal on the plan of care was not measurable when it did not include the patient’s acceptable level for pain. During a joint review of records and interview on 06/25/2025, the Patient Care Manager stated that the goals for pain were not individualized and measurable.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 3 (33%) clinical records reviewed for patients with a wound, the agency did not ensure the Registered Nurse documented skin integrity/wound assessment as required by agency policy. Agency policy titled Wound Care Treatment, required in part: “The nurse will perform a complete head-to-toe assessment of the patient’s skin integrity on a weekly basis and document findings in the EMR.” CLINICAL RECORD 4: The patient elected the hospice benefit on 03/28/2025 with a terminal diagnosis of senile degeneration of the brain. The Registered Nurse (RN) documented on the initial comprehensive assessment that the patient was admitted with a stage IV coccyx wound. The RN documented skin integrity/ wound assessments on the nursing visit notes dated 06/04/2025 and 06/16/2025. However, there was no documented evidence that the nurse assessed the patient’s skin integrity/wound the week of 06/08/2025 to 06/14/2025 as required by agency policy. During an interview and joint review of records on 06/26/2025, the Patient Care Manager stated that the RN did not assess the skin integrity/wound the week of 06/08/2025 and there was no documentation as to why the assessment was not completed in the clinical record.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the written certification included current subjective and objective medical findings. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023 with a diagnosis of senile degeneration of the brain. The physician written certification dated 04/21/2025 did not include current subjective and objective medical findings. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care agreed that the certification statement did not include current subjective and objective medical findings and stated that the hospice Medical Director had been counseled in the past related to including the required documentation in the written certifications.”

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 19: The patient elected the hospice benefit on 04/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease and revoked the hospice benefit on 05/04/2025. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 20: The patient elected the hospice benefit on 02/21/2025 with a terminal diagnosis of hypertensive heart disease without heart failure and was administratively discharged on 06/17/2025. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient’s attending physician. During an interview and review of findings with the Regional Vice President of Clinical Care (RVPCC) on 06/26/2025, there was an extensive search for documentation that the discharge summaries were sent to the receiving provider. The RVPCC explained the agency’s policy was to provide the discharge summary to the attending physician, but there was no evidence present in the clinical record, or the fax reports that the summaries had been sent to the providers.”

“It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment [DME] and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG [interdisciplinary group]. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the patient and/or caregiver(s) were instructed on the proper handling, storage, and safe utilization of durable medical equipment. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/24/2025 with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed physician orders for a wheelchair and an oxygen concentrator on 04/24/2025, an over the bed table and nebulizer on 04/25/2025, and an alternating air mattress and Hoyer lift on 04/28/2025. There was no documented evidence in the clinical record that the patient and/or caregiver were instructed on the proper handling, storage, and safe utilization of the durable medical equipment ordered for the patient. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care stated there was no documentation in the clinical record of DME education provided to the patient. She explained that the EMR [electronic medical record] did not have a designated section in the comprehensive assessment or plan of care to document this education, so the nurses were not prompted to document the training in the clinical record and sometimes forget to document the DME education.”