Cella Bellas Hospice Corporation

“Based on record review and interview, the hospice failed to ensure that the care and services were provided in accordance with the plan of care in 1 out of 4 patient records reviewed (Patient 2) in that multiple visits were missed with no documented reason. This failure resulted in the patient not receiving care as ordered by the physician, which could result in a deterioration of the patient’s condition. Findings included: Review of the Patient 2’s record revealed a document titled, “Physician Orders for Palliative Patient,” dated 3/4/26, revealed an order that read as follows: “Hospice Aide Frequency - Start Date: Mar 04, 2026 - 5 visits ever 1 week(s) - Visits to start 3/5/26.” Review of Patient 2’s record revealed a tab labeled “Hospice Aide Notes,” that, when clicked, showed the following dates that Hospice Aide Visits occurred: March 5, 6, 9, 18, 19, 20, 23, 24, and 26 of 2026. Review of Patient 2’s record revealed a document titled, “Transfer/Discharge/Death Summary” signed by the Administrator on Marh 10, 2026, that showed Patient 2 was discharged on March 8. The Status read as follows: “Revocation: Went to hospital for aggressive treatment. “Review of Patient 2’s record revealed a document titled, “Nurse Progress Note Initial Assessment,” dated 3/13/26, revealed a nursing note by the Administrator showing that the patient was readmitted into hospice care. Based on the ordered frequency, Hospice Aide visits were missing for 3/16/26, 3/17/26, and 3/25/26. In an interview with the Administrator on 4/8/26 at 11:15 AM, she stated there was a safety concern in Patient 2’s residence on the night of 3/15/26. She stated that they received a call from [the local police] on Sunday night 11:45 PM that there was a homicide in the home between members of Patient 2’s family. The Administrator stated on Monday morning they collaborated as a team and were working with the family, to discuss a safety plan and potential placement for Patient 2 in a facility. The Administrator stated that they did not have the aide go in on Monday (3/16) or Tuesday (3/17) because they wanted to make sure the suspect was in custody and were working on transferring the patient to a facility for everyone’s safety. The Administrator stated Patient 2’s MPOA initially had agreed with placement at a facility, but when the ambulance came for transport she changed her mind, and new plan was made for Patient 2 to be placed with another family member (FM 2). The Administrator stated that Patient 2 was placed with FM 2 on 3/17 and that she (the Administrator) had the hospice aide go out the next day. Surveyor 1 asked her where this was documented in the chart, and the Administrator was unable to show the surveyor. In an interview with the Administrator on 4/8/26 at 3:20 PM, Surveyor 1 about Patient 2’s missing Hospice Aide Visits on 3/16/26, 3/17/26, and 3/25/26. She confirmed after reviewing the chart that it did not appear that visits happened those days. She stated that there is not a separate place to chart missed visits, but that it should have been changed on the schedule from blue to yellow and marked as a missed visit. She stated when they did that in the system, it prompted them to then select a reason the visit was missed and an option to add notes. Surveyor 1 asked why this was not done for the visits on 3/16, 3/17, and 3/25. The Administrator stated that sometimes they go back and do it at the end of the month and it had not been done yet for those visits. The Surveyor asked who was responsible for documenting the visits as missed, and the Administrator stated either the person that did the visit or the person who reviewed the chart at the end of the month. Surveyor 1 pointed out that 3/27/26 had already been charted on as a missed visit in the system and asked why had the other March dates not been documented as missed visits. The Administrator stated that she did not know.In an interview with the Administrator on 4/9/26 at 1:30 PM, Surveyor 1 asked what the agency’s policy was on ensuring the plan of care was followed, including providing all visits as ordered. Administrator stated that they “run the same as all places where missed visits should all be documented and then the physician should be notified. which we do at IDT meet. So those should absolutely be completed in the chart for [Patient 2].” Surveyor asked why it was important to ensure the plan of care is followed and all visits are made or documented if missed. The Administrator stated, “Well of course it’s a compliance issue but we also need it because it is in the plan of care, and we have to follow it. That’s why we have to report if it does not happen. Also just to make sure the patient is getting the care they need.”In an interview with Hospice Aide A on 4/10/26 at 4:19 PM, she stated that she did not go out to see Patient 1 on 3/16 or 3/17 because it was a safety concern. Surveyor 1 asked her how she typically documented a missed visit. She stated she usually just left them open, and that she thought the nurse of someone in the office documented them as missed. Surveyor 1 asked her if she recalled why the visit on 3/25/26 was missed. She stated that it was her day off. Surveyor 1 asked if someone usually covers for her on her day off. She stated that she would have typically seen patients the next day when she returned, but in this case since Patient 2 was ordered for 5 days a week, she believed they would have had someone else see Patient 2 that day. Review of the agency’s policy titled, “Plan of Care,” dated 01/31/15, revealed a policy that read in part: “The Hospice interdisciplinary group must prepare a written plan of care for each patient. The written plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs, as identified in the comprehensive assessment…” Further review of the document revealed the following: “The RN will coordinate the implementation of the plan of care for each patient…””

“Based on record review and interview, the agency failed to include physician orders for wound care in 1 out of 4 patients reviewed (Patient 2). The agency did not record verbal orders in the patient record and did not obtain new physician orders when the patient was readmitted after a discharge This failure resulted in the patient’s record missing orders, which could result in care not being consistently provided by all clinicians. Findings included:Review of the agency’s policy titled, “Physician Orders,” dated 01/13/15, revealed the following: “Prior to providing care, the hospice will: Obtain or renew (verbal or written) orders.” Further review of the document revealed the following: “If the order is verbal or given though electronic transmission: …the individual receiving the order will record and sign it immediately.” Review of the document tiled, “Physician Orders for Palliative Patient,” dated 3/4/26, revealed an order set for Patient 2. These orders included an order for Wound Care which read: “For small skin tears or wounds cleanse area with wound cleanser, pat drywith 4x4 gauze, apply thin layer of triple antibiotic ointment, and cover with non-adherent pad, may top with paper or silk tape, or wrap gently with Cobain (wrap). Discontinued by patient discharge on Mar 8, 2026.” Of note, every order on this document included the following: “Discontinued by patient discharge on Mar 8, 2026.” Review of the document tiled, “Physician Orders for Palliative Patient,” dated 3/17/26, revealed an order set for Patient 2 after he was readmitted on 3/13/26. These orders only included medications, an oxygen concentrator, an over bed table, and a hospital bed. No wound care orders were included. Further review of all orders in the patient’s record failed to review and orders for wound care besides the one listed above, which was discontinued on March 8, 2026. In an interview with the Administrator, who was also an RN, on 4/8/26 at 11:15 AM, she confirmed that Patient 2 had discharged on 3/8/26 to seek care in a hospital and revoked his hospice benefit. When the patient was discharged from the hospital, he was admitted to the agency on 3/13/26. The Administrator confirmed she was the nurse who did his readmission visit on 3/13/26. She stated that at that time he had a small wound on his back, hip and coccyx (bottom). She stated that she cleaned the wounds and covered them with foam pads for the hip and back wounds, and the plan was to do dressings every 3-5 days on the coccyx wound. In an interview with MD A on 4/8/26 at 1:45 PM, she stated that she was aware the patient had a wound on his coccyx after his return from the hospital on 3/13/26 and it was discussed at the IDT. When Surveyor 1asked why no wound orders were placed for this, she stated that she had given verbal orders. Unable to identify who she gave the orders to. In an interview with the Administrator on 4/8/26 at 3:20 PM, Surveyor 1 said she spoke with MD A who confirmed she knew about Patient 2’s wounds and had given verbal orders to provide wound care. Surveyor asked the Administrator where these verbal orders were documented in the chart and she was unable to show her. She stated they should have been in as standing orders upon admission, but it appeared they did not transfer over when he was discharged on 3/8 and readmitted on 3/13. She stated that it appeared that they did not have orders in for wound care after 3/8/26. In an interview with the Administrator on 4/9/26 at 1:30 PM, Surveyor 1 asked her who was responsible for ensuring the patient has active orders for all nursing tasks, including wound care. The Administrator stated that in Patient 2’s case it was her responsibility as the RN who admitted him and provided the care. She also stated that it was her responsibility as the Administrator to review the charts and make sure all patients had active orders. Surveyor 1 asked why it was important to always have physician orders for wound care and other nursing tasks. She stated it was important because nurses cannot technically do anything without an order, and they cannot place orders themselves so they must obtain from the physician. She stated that it was important to have physician orders to make sure the patient was receiving the correct care.”

“It is required if a patient transfers to a Medicare/Medicaid certified facility the hospice must forward a copy of the hospice discharge summary to the receiving facility. This standard was not met as evidence by clinical record review and interview. In 1 of 1 (100%) of record reviewed for patients transferring to another facility identified the discharge summary was not sent to the receiving facility. CLINICAL RECORD 14: The patient elected hospice on 08/06/2024. The patient elected to transfer to another hospice on 01/21/2025. The clinical record review identified no documented evidence of a discharge summary, or a discharge summary being sent to the receiving facility. During an interview with the Administrator/Director of Nurses on 02/20/2025, she stated that she would educate the staff and implement a discharge process.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1(100%) clinical records reviewed in which the patient revoked hospice services revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. Document 1: The agency policy titled Discharge from Hospice Care stated in part “If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of the following: the hospice Discharge Summary”. CLINICAL RECORD 13: The patient elected hospice on 10/04/2024 and was discharged to seek aggressive treatment on 01/03/2025. A review of the clinical record identified no documented evidence of a discharge summary completed or that a discharge summary was sent to the patient’s attending physician. During an interview with the Administrator/Director of Nurses on 02/20/2025, she stated that she would educate the staff and implement a discharge process.”