Hospice Care Team

“Based on record review and interview, the hospice failed ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs for 1 of 14 patients whose records were reviewed. (Patient #1) This failure has the potential of placing patients at risk of receiving ineffective and inappropriate hospice care and services. Findings include: Record review of the hospice plan of care for Patient #1 dated 03/20/25 to 06/17/25 included a physician’s order for skilled nursing services twice a month. Record review of the agency’s active patient roster indicated Patient #1 had a start of care date of 12/20/24. Record review of the nursing tab visit management calendar for Patient #1 dated 03/20/25 to 06/17/25 indicated SN visits were completed on Thursday 03/20/25, Tuesday 03/25/25, Thursday 03/27/25, Tuesday 04/01/25, Thursday 04/03/25, Monday 04/07/25, Thursday 04/10/25, and Tuesday 04/15/25. The nursing tab visit management calendar for Patient #1 dated 03/20/25 to 06/17/25 indicated SN visits were scheduled for Thursday 04/17/25, Monday 04/21/25, Thursday 04/24/25, Monday 04/28/25, Thursday 05/01/25, Monday 05/05/25, Thursday 05/08/25, Monday 05/12/25, Thursday 05/15/25, Monday 05/19/25, Thursday 05/22/25, Monday 05/26/25, Thursday 05/29/25, Monday 06/02/25, Thursday 06/05/25, Monday 06/09/25, Thursday 06/12/25, and Monday 06/16/25. SN visits were scheduled to be completed twice a week rather than twice a month. Record review of the IDG Meeting for Patient #1 dated 04/04/25 skilled nursing services frequency was twice a month. The summary/ comments indicated IDT/IDG met today discussion of patient’s occurred and we reviewed patient issues and concerns. Plan Of Care for each patient reviewed and addressed/updated as needed. No indication skilled nursing services had been updated to twice a week. During an interview and record review on 04/15/25 at 9:20 a.m., RN Case Manager I said Patient #1’s SN visit frequency was twice a week. RN Case Manager I said Patient #1’s visit frequency had been twice a week since early on when she went on services with the agency. RN Case Manager I said she increased Patient #1’s SN visits to twice a week after a couple of weeks of her being on service. RN Case Manager I reviewed Patient #1’s current POC visit frequency and acknowledged the POC reflected Patient #1’s SN visit frequency was twice a month. RN Case Manager I said Patient #1’s SN visit frequency on the POC was wrong. RN Case Manager I said the POC should accurately reflect the visit frequency for each discipline. RN Case Manager I said she did not know why Patient #1’s SN visit frequency was incorrect on the POC. RN Case Manager I said when orders such as visit frequency are entered, they become effective immediately. Attempted a telephone interview on 04/15/25 at 4:54 p.m., with Family Member Y no answer voicemail left identifying surveyor and requested a call back. During an interview on 04/16/25 at 12:45 p.m., the Alternate Supervising Nurse said the RN Case Manager was responsible for completing the plan of care. The Alternate Supervising Nurse said the patient’s plan of care should accurately reflect the patients care needs. The Alternate Supervising Nurse said the plan of care should be reviewed typically at least every 2 weeks. The Alternate Supervising Nurse said the plan of care should be reviewed and updated during IDG every two weeks as long as the change was not urgent. The Alternate Supervising Nurse said if the change was urgent the plan of care would be revised immediately. The Alternate Supervising Nurse said she thought when RN I entered Patient #1’s plan of care she miss-clicked the frequency drop down box to month rather than week. The Alternate Supervising Nurse said Patient #1’s plan of care should have been updated and reviewed. During an interview on 04/16/25 at 1:00 p.m., the Alternate Administrator/Supervising Nurse said the Case Manager was responsible for completing the plan of care. The Alternate Administrator/Supervising Nurse said the patient’s plan of care should accurately reflect the patient’s needs and care delivered. The Alternate Administrator/Supervising Nurse said the patient’s plan of care should be reviewed at every visit. The Alternate Administrator/Supervising Nurse said Patient #1’s plan of care should have been updated to reflect the SN visit frequency of twice a week. During an interview on 04/16/25 at 1:14 p.m., the Administrator said the RN Case Manager was responsible for completing the plan of care. The Administrator said the patient’s plan of care should accurately reflect the patient’s care. The Administrator said the plan of care should be reviewed every 14 days during IDG. The Administrator said Patient #1’s SN visit frequency should have been updated to twice a week. The Administrator said the RN Case Manager made a mistake when selecting the frequency.”

“Based on record review and interview, the hospice failed to ensure the registered nurse conducted 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 for 1 of 14 patients whose records were reviewed. (Patient #3) There were no hospice aide supervisory visit from 01/03/25 to 04/02/25 (90 days) for Patient #3. This failure has the potential of placing patients at risk of receiving ineffective and inappropriate hospice care and services. Findings include: Record review of the hospice plan of care for Patient #3 dated 01/03/25 to 04/02/25 included a physician’s order for skilled nursing services twice a week and hospice aide services twice a week. Record review of the aide tab visit management calendar for Patient #3 dated 01/03/25 to 04/02/25 gave no indication any RN visits for supervision of the hospice aide were conducted. Record review of the clinical record for Patient #3 did not include a hospice aide supervisory visit from 01/03/25 to 04/02/25 (90 days). During an interview and record review on 04/15/25 at 10:49 am RN Case Manager J said hospice aide supervisory visits should be conducted every 14 days. RN Case Manager J said aide supervisory visits were documented under the aide tab in the EHR system. RN Case Manager J reviewed the aide tab for Patient #3 for supervisory visits from 01/03/25 to 04/02/25 and said she did not see any aide supervisory visits. RN Case Manager J said the aide supervisory visits for Patient #3 were not put in from 01/03/25 to 04/02/25. RN Case Manager J said there should have been aide supervisory visits put in from 01/03/25 to 04/02/25. RN Case Manager J said she had no idea why the aide supervisory visits were not put in. RN Case Manager J said she was responsible for ensuring the aide supervisory visits were completed. RN Case Manager J said she should have checked the aide supervisory visits. During a telephone interview on 04/15/25 at 4:58 p.m., Patient #3 said the nurse ask her often if she is satisfied with the hospice aide’s care. Patient #3 said she could not remember exactly when the nurses had asked her about the hospice aide’s care. Patient #3 said she had been very satisfied with her hospice aide. During an interview on 04/16/25 at 12:45 p.m., the Alternate Supervising Nurse said the RN Case Manager was responsible for completing aide supervisory visits. The Alternate Supervising Nurse said the aide supervisory visit should be completed every 14 days. The Alternate Supervising Nurse said the agency typically conducts aide supervisory visits weekly to prevent an overage if there is a missed visit. The Alternate Supervising Nurse said Patient #3 should have had aide supervisory visits from 01/03/25 to 04/02/25. The Alternate Supervising Nurse said Patient #3 had just had aide services started and it was somehow missed in the EHR system. During an interview on 04/16/25 at 1:00 p.m., the Alternate Administrator/Supervising Nurse said the Case Manager was responsible for completing aide supervisory visits. The Alternate Administrator/Supervising Nurse said the aide supervisory visits should have been completed every 14 days. The Alternate Administrator/Supervising Nurse said the agency usually completes the aide supervisory visit every week to try to avoid missing one. The Alternate Administrator/Supervising Nurse said Patient #3 should have had aide supervisory visits from 01/03/25 to 04/02/25. During an interview on 04/16/25 at 1:14 p.m., the Administrator said the RN Case Manager was responsible for completing aide supervisory visits. The Administrator said Patient #3 should have had supervisory visits from 01/03/25 to 04/02/25. The Administrator said there should not have been stretch of time like that, that a patient did not receive an aide supervisory visit. The Administrator said it should not have happened. Record review of an Employee Supervision policy dated 09/01/24 revealed, “… 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 aide and to ensure that services ordered by the Hospice Interdisciplinary Group/Team (IDG/IDT) meet the patient’s needs. …””