Iph Hospice Care Inc.

“Based on record review and interview, the Hospice failed to develop an individualized plan of care (POC) for 3 (Patient #2, Patient #11, and Patient #14) of 15 Patients whose records were reviewed in that: 1. The Hospice failed to develop a plan of care for wound care provided to Patient #2 from 04/11/25 through 07/08/25. 2. Patient #11 did not have an individualized plan of care for certification period 03/08/24 through 05/06/24.3. The Hospice failed to develop a POC the services necessary for the palliation and management of the terminal illness and related conditions including interventions to manage pain and symptoms, a detailed scope and frequency of services necessary to meet the specific patient and family needs, and measurable outcomes anticipated from implementing and coordinating the plan of care for Patient #14. This deficient practice failed to ensure that individualized, patient-specific information pertinent to the provision of care was incorporated into the plan of care as required by regulatory standards, placing patients at risk for inadequate and noncompliant care delivery. The findings included: 1. Record review of Patient #2 electronic medical record (EMR) included a “Patient Profile” that documented an admission date of 04/11/25. Further review of Patient #2’s EMR included a “Plan of Care (POC) Order” signed and dated 04/11/25 that documented a “benefit period” as 04/11/25 through 07/09/25 and a terminal diagnosis of “cerebral infarction, unspecified”, (type of blockage of blood vessels in the brain leading to tissue damage due to lack of oxygen). The POC documented the following orders for care: · SN (skilled nurse) frequency 2 times per week (2/wk.)Record review of Patient #2 EMR documented a nurse performed wound care to bilateral heels (deep tissue injuries or DTIs). The nurse documented the following wound care, “Patient is presenting with DTIs to bilateral heels. Cleanse heels with saline or wound cleanser then tap dry. May apply Vitamin A&D ointment cream 2 times per day as needed, then apply dressing and secure with retention tape. Apply heel protectors to both feet. Presents with old bruises to head and left lower leg on this visit”. Record review of Patient #2’s EMR documented the nurse performed wound care on the following home visits 04/11/25, 04/12/25, 04/15/25, 04/17/25, 04/22/25,04/24/25, 04/28/25, 05/01/25, 05/05/25, 05/09/25, 05/12/25, 05/15/25, 05/19/25, 05/26/25 05/29/25, 06/02/25, 06/06/25, 06/09/25, 06/13/25, 06/16/25, 06/23/25, 06/27/25, 07/01/25, 07/03/25, and 07/08/25. Record review of Patient #2 EMR failed to develop a plan of care for wound care of bilateral heel deep tissue injuries. In a simultaneous record review and interview on 08/13/25 at 10:40 a.m., the Adm/DON confirmed a SOC of 04/11/24 and certification period of 04/11/25 through 07/09/25 for Patient #2. The Adm/DON reviewed the skilled nurse visits conducted and confirmed wound care was performed on those dates. The Adm/DON stated the ADON was the nurse who performed the home visits for Patient #2. The Adm/DON confirmed home visits performed for Patient #2. In a telephone interview on 08/13/25 at 10:45 a.m., the ADON confirmed wound care was performed for Patient #2. The ADON stated no order was obtained for the wound care performed. The ADON confirmed Patient #2 had wounds to bilateral heels. The ADON stated he applied Vitamin A&D ointment to bilateral heels. 2. Record review of Patient #11’s EMR included a “Patient Profile” that documented an admission date of 03/14/23. Further review included a “Plan of Care Order” dated 02/29/24 that documented a benefit period as 01/08/24-03/07/24 and a terminal diagnosis of Alzheimer’s disease (progress brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks). The plan of care documented the following orders for care: physician 1 visit PRN, skilled nursing 2 times a week and 3 PRN visits, medical social worker 1 time a week and 1 PRN visit, Chaplain 1 time a week, and volunteer for 4 PRN visits signed by MD and ADON on 02/29/24.Review of Patient #11 record revealed a “Certification of terminal illness recertification” dated 03/21/24 for an 80-year-old female. “Narrative/Comments: Certification 6th 03/08/24 to 05/06/24. Pt…with an admitting diagnosis of Alzheimer’s disease (AD)…according to NP visit on 02/07/24 pt continues with further functional decline, pt is unable to dress or feed herself, cognition worsening progressively, pt is aphasic…Appetite has been declining…KPS (Karnofsky Performance Status, an assessment tool used to evaluate a patient’s functional status) and PPS (Palliative performance Scale, an assessment tool used to evaluate a patient’s functional status in palliative care) 30% FAST 7D LMUAC (Left Mid-Upper arm circumference, a measurement used to assess nutritional status) 27cm for all of the above pt meets criteria for hospice care...” signed by MD on 05/21/24.Further review of Patient #11 documented “Revocation of Election to Hospice Care” with an effective revocation date of 03/29/24 signed by FM A on 03/29/24.Upon further review of Patient #11’s records the IDG failed to reveal a plan of care for certification period 03/08/24 to 05/06/24. An interview was conducted with the Adm/DON on 08/13/25 at 11:30 am, the findings above were reviewed and discussed for Patient #11. The Adm/DON confirmed that there was no plan of care for certification period 03/08/24 to 05/06/24 and the client should have a plan of care for every election benefit per agency policy. Adm/DON further confirmed that he was responsible for the plan of cares. Surveyor asked did Patient #11 have a written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician for certification period 03/08/24-03/29/24. Why not. Adm/DON stated, “Yes however they forgot to change the election period date on the plan of care for 02/29/24 from 01/08/24-03/07/24 to the new certification period of 03/08/24 to 05/06/24. So, whenever the staff did recertifications there was a drop-down menu and if you don’t change it will stay for the same certification period. Yes, there is a plan of care, but it is not showing the correct certification period.” Surveyor further asked for clarification, again, does Patient #11 have a plan of care for certification period of 03/08/24 to 05/06/24. Adm/DON stated, “there is one but having that date it looks like there isn’t one because they forgot to change the certification drop down to the current certification. Technically, no I guess it was overlooked.” 3. Record review of Patient #14’s EMR included a “Patient Profile” that documented an admission date of 01/17/23. Further review of Patient #14’s EMR included a POC signed and dated 01/17/23 that documented a “benefit period 01/17/23 through 04/16/23 and a terminal diagnosis of “secondary malignant neoplasm of unspecified lung”, (malignant tumor that has originated from a primary cancer that has spread to the lung). Record review of Patient #14’s EMR included a “Patient Medication Record” that included the following medications for pain morphine sulfate oral solution 20 mg/5ml. The POC failed to include interventions to manage pain and symptoms, a detailed scope and frequency of services necessary to meet the specific patient and family needs, and measurable outcomes anticipated from implementing and coordinating the plan of care for Patient #14. Further review of Patient #14 EMR documented the nurse performed the following home visits 01/17/23, 01/19/23, 01/20/23, 01/21/23, 01/22/23, 01/23/22/, 01/24/23, 01/1/26/23, 01/31/23, 02/02/23, 02/07/23, 02/09/23, 02/14/23, 02/15/23, 02/16/23, 02/17/23, 02/18/23. In a continued interview on 8/13/25 at 11:35, the Adm/DON confirmed a SOC for Patient #14 of 01/17/23 and a certification period of 01/07/23 through 04/16/23. The Adm/DON confirmed the POC was signed and dated 01/17/23 and was missing the interventions to manage pain and symptoms, the frequency of services, and measurable outcomes and or coordination. The Adm/DON confirmed home visits conducted for Patient #14. The Adm/DON stated the POC was updated every 14 days during IDG/IDT and that the following POC was signed and dated 01/25/23, but that “each one was missing components”. The Adm/DON stated, “we need to be more vigilant, and I need to sit down with them [staff]” to ensure that all components were included in the POC. In a subsequent interview on 08/13/25 at 11:45 a.m., the Adm/DON referred to the Hospice policy to dictate what components were required on the POC. The Adm/DON (reading from the Hospice policy) quoted the policy in part, “interventions to manage pain and symptoms, detailed scope and frequency of services, measurable outcomes, drugs and treatments, medical supplies and equipment, designation of disciplines, the level of understanding of the plan of care”. The Adm/DON stated the nurse, and the Adm/DON were responsible for ensuring all components were included in the POC. The Adm/DON stated the POC was not complete and that “we need to clean it up” so that all components can be included in one POC. The Adm/DON stated not having a complete POC could affect the patients in a negative way because the patient could be missing out on valuable information, visits on disciplines, interventions, how the Agency assesses, and the outcomes of their interventions. The Adm/DON stated he saw the importance of having all components “in one” complete POC. Record review of [Agency Name] Administrative Policy Manual titled “Timelines IM.40” with a revision date of 09/01/24, quoted in part…Purpose: To establish timely parameters for medical information…Policy…The Hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations…Procedure…The interdisciplinary Group/Team (IDG/IDT), in consultation with the attending physician, will complete the comprehensive health assessment no later than 5 calendar days after the start of hospice care…The IDG/IDT Plan of Care (POC) will be developed within 15 days of the start of care and updated at least every 15 days…”Record review of [Agency Name] Administrative Policy Manual titled “Plan of Care Process” with a revision date of 09/01/24, quoted in part…Purpose: To establish timely parameters for medical information…Policy…The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of terminal illness and related conditions…Procedure…The IPOC will be developed and established by the hospice RN, the Hospice physician or the Hospice Medical Director, the patient, the patient’s caregiver, and the patient’s chosen attending physician…” Record review of Hospice Policy titled, “Plan of Care Process PC.30” with a revised date 09/01/24, quoted in part, “The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal and related conditions…. I. Information will be gathered from the initial assessment and be used by the Hospice to develop the Initial Plan of Care (IPOC)/Physician’s Orders and to provide care and services to treat a patient’s and patient’s family’s immediate care and support needs….” Record review of Hospice Policy titled, “Plan of Care Process PC.30”, with a revised date 09/01/24, quoted in part, “The Hospice will develop an individualized written POC for each patient…II. The IPOC (initial plan of care) will be developed and established by the Hospice RN, the Hospice Physician or the Hospice Medical Director, the patient, the patient’s caregiver, and the patient’s chose attending physician (if any) after the initial assessment and prior to delivering care… III. A comprehensive assessment will be completed by the IDG/IDT no later than five calendar days after the election of hospice care in consultation with attending physician (if any) …A. The contents of the comprehensive assessment will identify patient demographic information, along with the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the Hospice patient’s well-being, comfort and dignity throughout the dying process…1. Information gathered from the initial bereavement assessment will be incorporated into the POC and considered in the bereavement POC….2. The need for a hospice aide (HA) to assist with the patient’s activity of daily living and instrumental activity of daily living…3. The environmental component for identification of safety issues and/or health hazards…4. The need for referrals and further evaluation by appropriate health professionals, and/or referrals to appropriate financial, economic and community resources…5. Data elements that allow for measurement of outcomes, measuring and documenting data in the same way for all patients. The data elements to take into consideration aspects of care related to hospice and palliation…Record review of Hospice Policy titled, “Plan of Care Process PC.30” with a revised date 09/01/24, quoted in part, “The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal and related conditions…. VI. The POC includes but is not limited to… A. Interventions to manage pain and symptoms and identified issues/problems… B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care…. C. Measurable outcomes anticipated from implementing and coordinating the POC… D. Drugs and treatments necessary to meet the needs of the patient…E. Medical Supplies, equipment, and appliances necessary to meet the needs of the patient… F. Designation of discipline(s) responsible, for providing specific services; and… G. The IDG/IDT’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC, in the clinical record…””

“Based on record review and interview, the Hospice failed to ensure that a supervisory visit was conducted on the Hospice Aide no less frequently than 14 days for 3 (Patient #3, Patient #6, and Patient #10) of 15 patients whose records were reviewed and received hospice aide services. This deficient practice could result in placing patients who receive hospice aide services at risk of not receiving services in accordance with their plan of care and ineffective or inappropriate care and services. The findings included: 1. Record review of Patient #3’s electronic medical record (EMR) included a “Patient Profile” that documented an admission date of 02/09/25. Further review of Patient #3’s EMR included a “Plan of Care (POC) Order” signed and dated 05/02/25 that documented a “benefit period” as 05/10/25 through 08/07/25 and a terminal diagnosis of “chronic obstructive pulmonary disease with (acute) exacerbation”, a progressive lung disease with a sudden worsening of symptoms that make it difficult to breath due to airflow blockage. The POC documented the following orders for care: · SN (skilled nurse) frequency: 2 times per week (2/wk.)· Hospice Aide: 3 times per week (3/wk.) Record review of Patient #3’s EMR included an “Aide Care Plan” signed and dated 05/02/25 that documented an aide frequency of 3 times a week effective through 08/07/25. Record review of Patient #3’s EMR documented the hospice aide conducted the following home visits: 05/10/25, 05/13/25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, 05/27/25, 05/29/25, 05/31/25, 06/03/25, 06/05/25, 06/07/25, 06/10/25, 06/12/25, 06/14/25, 06/17/25, 06/19/25, 06/21/25, 06/24/25, 06/26/25, 06/28/25, 07/01/25, 07/03/25, and 07/05/25. Record review of Patient #3’s EMR failed to reveal documentation a registered nurse (RN) conducted a supervisory visit in the patient’s home every 14 days as required by Hospice policy. 2. Record review of Patient #6’s EMR included a “Patient Profile” that documented an admission date of 11/14/24. Further review of Patient #6’s EMR included a POC Order signed and dated 05/06/25 that documented a “benefit period” as 05/13/25 through 07/11/25 and a terminal diagnosis of “chronic obstructive pulmonary disease with (acute) exacerbation”, (a progressive lung disease with a sudden worsening of symptoms that make it difficult to breath due to airflow blockage). The POC documented the following orders for care: · SN frequency: 2 times per week (2/wk.)· Hospice Aide: 3 times per week (3/wk.) Record review of Patient #6’s EMR included an “Aide Care Plan” signed and dated 05/06/25 that documented an aide frequency of 3 times a week effective through 07/11/25. Record review of Patient #6’s EMR documented the hospice aide conducted the following home visits: 05/13,25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, 05/27/25, 05/29/25, 05/31/25, 06/03/25, 06/05/25, 06/07/25, 06/10/25, 06/12/25, 06/14/25, 06/17/25,06/19/25, 06/21/25, 06/24/25, 06/26/25, 06/28/25, 07/01/25, 07/03/25, 07/05/25, 07/08/25, and 07/10/25. Record review of Patient #6’s EMR documented supervisory visits by a nurse conducted on 05/13/25, 06/03/25, and 06/17/25. Record review of Patient #6’s EMR failed to reveal documentation a RN conducted a supervisory visit in the patient’s home every 14 days as required by Hospice policy. In a simultaneous record review and interview on 08/13/25 at 10:40 a.m., the Adm/DON confirmed a SOC of 02/09/25 and certification period of 05/10/25 through 08/07/25 for Patient #3. After reviewing Patient #3’s EMR the Adm/DON stated he did not see any supervisory visits conducted throughout the certification period. The Adm/DON stated the supervisory visits “populate on their own ” in the electronic medical system and therefore the nurses do not have to schedule the supervisory visits. The Adm/DON confirmed a SOC of 11/14/24 and a certification period of 05/13/25 through 07/11/25 for Patient #6. After reviewing Patient#6’s EMR the Adm/DON stated, “we missed one (supervisory visit) there”. The Adm/DON stated there should have been a supervisory visit on 07/01/25. The Adm/DON stated, “I saw this (happen) on another patient…the aide care plan was updated and kicked off the supervisory visit”. The Adm/DON stated that Patient #6 had a supervisory visit on 07/01/25 and kicked off the supervisory visit that should have been scheduled then. The Adm/DON stated, “I don’t know why it [EMR system] kicks off the supervisory visits. The Adm/DON stated both patients were his scheduled patients, and he conducted home visits and supervisory visits for these patients. In a subsequent interview on 08/13/25 at 11:00 a.m., the Adm/DON stated per Hospice policy supervisory visits were conducted “before the end of the 14th day”. The Adm/DON stated, “I do not know what happened with these supervisory visits. The Adm/DON stated supervisory visits were conducted in the patient’s home. The Adm/DON stated that if a supervisory visit was scheduled on a day that he was not seeing a patient, he would try to change the supervisory visit back to a day he was seeing the patient so that the visits could be coordinated. The Adm/DON stated supervisory visits “did not happen” for Patient #3 and “only one was missing” for Patient #6. The Adm/DON confirmed supervisory visits should be conducted before the 14th day and that it was the responsibility of the RN case manager or nurse who was seeing the patient. The Adm/DON stated not conducting supervisory visits as every 14 days could negatively affect client care because the Hospice could fail to identify if the aide was not showing up or not performing as she/he should be. 3. Record review of Patient #10’s EMR included a “Patient Profile” that documented an admission date of 02/24/22. Further review included a “Plan of Care Order” dated 12/28/22 that documented a benefit period as 12/22/22-02/19/23 and a terminal diagnosis of Alzheimer’s disease (progress brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks). The plan of care documented the following orders for care: SN frequency of 2 times per week with 4 PRN visits and Hospice aide of 5 times a week.Further review of Patient #10’s “Aide Care Plan” signed and dated 12/14/22 revealed the hospice aide frequency of 2 times a week with an end date of 02/19/23. An updated “Aide Care Plan” signed and dated 02/08/23 documented an aide frequency of 7 times a week with an end date of 04/20/23. Record review of Patient #10’s clinical record revealed supervisory visits were conducted by a registered nurse dated 12/28/22, 01/11/23, and 01/25/23. The EMR failed to reveal documentation that a supervisory visit was conducted between 01/26/25-02/19/23 every 14 days per agency policy and regulations.An interview was conducted with the Adm/DON on 08/13/25 at 11:30 am, the findings above were reviewed and discussed for patient #10. The Adm/DON confirmed that there was a supervisory visit missing from certification period 12/22/22-02/19/23 and should have been conducted on 02/08/23 every 14 days per agency policy. Adm/DON further confirmed that there was no supervisory visit conducted for the hospice aide on 02/08/23 and he was responsible for supervisory visits. Surveyor asked why supervisory visits were not conducted every 14 days per agency policy and regulation. Adm/DON stated, “An aide care plan was done on 02/08/23 and when you do a care plan, [electronic medical record] made the next supervisory visit for 14 days after the care plan. The supervisory visit was overlooked but should have been done on 02/08/23.” Surveyor further asked, how cannot supervising your hospice aides every 14 days affect patient care. Adm/DON stated, “There could be a possibility of the hospice aide not showing up for her visits or not doing tasks per the care plan. It can affect the patient by receiving inadequate care.”Record review of Hospice policy titled, “Employee Supervision, HR.60”, with a revised date 12/06/24, quoted in part, “Supervision will be performed within the time frame defined by policy…A. Hospice Aides…1. A registered nurse (RN) must make 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 and to ensure that services ordered by the Hospice interdisciplinary Group/Team (IDG/IDT) meet the patient’s needs. The hospice aide does not have to be present during this visit…””