Bluevine Hospice

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews which revealed the hospice: Failed to ensure the individualized plan of care was reviewed, revised, and documented by the IDG no less frequently than every 15 calendar days {HCPC.22.I/552 418.56(d)}; and Failed to ensure that the patient’s plan of care was updated to reflect new information from the patient’s updated comprehensive assessment {HCPC.22.I/553 418.56(d)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation, CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 6 of 11 (55%) clinical records reviewed of patients who received hospice services for more than 5 calendar days, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 3: The patient elected hospice benefit on 02/06/2026. The initial nursing assessment completed on 02/06/2026 did not have documented evidence of an initial psychosocial or spiritual assessment, and the lack of documentation that the services were declined on admission. CLINICAL RECORD 5: The patient elected hospice benefit on 02/14/2026. The initial nursing assessment was completed on 02/14/2026. Documentation on 02/18/2026 by the Chaplain stated, “Family felt overwhelmed with the amount of visits. Family requests an appointment on February 19, 2026.” There was no further documentation or visits for the Chaplain in the clinical record. The initial spiritual assessment was not completed within the 5 calendar days after election of benefit. CLINICAL RECORD 6: The patient elected hospice benefit on 06/19/2024. The initial nursing assessment was completed on 06/19/2024. The clinical record did not have documented evidence of an initial spiritual assessment, and no evidence that spiritual services were declined. CLINICAL RECORD 7: The patient elected hospice benefit on 11/14/2024. The initial nursing assessment was completed on 11/14/2024. The initial psychosocial assessment was completed on 11/21/2024, a total of 7 days after the election of benefit and two days outstanding. The clinical record did not have documented evidence of an initial spiritual assessment, and no evidence that spiritual services were declined. CLINICAL RECORD 8: The patient elected hospice benefit on 11/25/2024. The initial nursing assessment was completed on 11/25/2024. The initial psychosocial assessment was completed on 12/13/2024, a total of 18 days after the election of benefit and 13 days outstanding. The clinical record did not have documented evidence of an initial spiritual assessment, and no evidence that spiritual services were declined. CLINICAL RECORD 9: The patient elected hospice benefit on 12/05/2024. The initial nursing assessment was completed on 12/05/2024. The initial psychosocial assessment was completed on 12/12/2024, a total of 7 days after the election of benefit and 2 days outstanding. The clinical record did not have documented evidence of an initial spiritual assessment, and no evidence that spiritual services were declined. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated, “That some of the missing initial assessments were due to services being declined but that the information was not documented in the clinical record, and that she will need to provide education to the clinical staff.””

“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. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure documentation of an initial bereavement assessment that included 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. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/06/2026 with a diagnosis of Parkinson’s disease without dyskinesia. There was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/14/2026 with a diagnosis of Heart failure. There was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/19/2024 with a diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. There was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/14/2024 with a diagnosis of Multiple myeloma no having achieved remission. There was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/27/2026 with a diagnosis of Krabbe disease. There was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 14: The patient elected the hospice benefit on 12/07/2025 with a diagnosis of Malignant neoplasm of appendix. There was no documented evidence in the clinical record of an initial bereavement assessment. During an interview with the Supervising Nurse (Personnel Record 1) and the Alternate Administrator (Personnel Record 6) on 06/17/2026, they stated that they have updated the process so that the admitting nurse conducts the initial bereavement assessment, as social worker and chaplain services are not always accepted.”

“It is required that the Interdisciplinary Group (IDG), in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the organization did not ensure the individualized plan of care was reviewed, revised, and documented by the IDG no less frequently than every 15 calendar days. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/06/2026. The benefit period from 02/06/2026 to 05/06/2026 had documented Interdisciplinary Group (IDG) dates of 03/05/2026 (27 days), 03/19/2026, 04/02/2026, and 04/30/2026 (28 days). The clinical record did not have documented evidence that the IDG reviewed, revised, and documented the individualized care plan no less frequently than every 15 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/14/2026. The benefit period from 02/14/2026 to 05/14/2026 had documented Interdisciplinary Group (IDG) dates of 03/05/2026 (19 days), 03/19/2026, 04/02/2026, 04/30/2026 (28 days), and 05/14/2026. The clinical record did not have documented evidence that the IDG reviewed, revised, and documented the individualized care plan no less frequently than every 15 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/19/2024. The benefit periods from 12/16/2024 to 02/13/2025, 02/14/2025 to 04/14/2025, 04/15/2025 to 06/13/2025, and 08/13/2025 to 10/11/2025 had no documented evidence of IDG meetings in the clinical record for any of these periods. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/14/2024. The benefit periods from 1/14/2025 to 02/11/2025, 05/13/2025 to 07/11/2025, 09/10/2025 to11/08/2025, and 11/09/2025 to 01/07/2026 had no documented evidence of IDG meetings in the clinical record for any of these periods. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/25/2024. The benefit periods from 11/25/2024 to 02/22/2025, 05/24/2025 to 07/22/2025, and 09/21/2025 to 11/19/2025 had no documented evidence of IDG meetings in the clinical record for any of these periods. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/05/2024. The benefit periods from 12/05/2024 to 03/04/2025, 06/03/2025 to 08/01/2025, 10/01/2025 to 11/29/2025, and 01/29/2026 to 03/29/2026 had no documented evidence of IDG meetings in the clinical record for any of these periods. During an interview with the supervising nurse (Personnel Record 1) on 06/17/2026, she stated, “She did not know how or why there were no IDGs in the clinical record.””

“It is required that a revise the plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the plan of care was revised based on the patient’s updated comprehensive assessments. CLINICAL RECORD 3: The patient was admitted to hospice on 02/06/2026 with a diagnosis of Parkinson’s disease without dyskinesia. The nurse documented on the visit note dated 05/27/2026, “Pt (patient) came back from a 5-day stay respite. (The patient) has a swollen right shoulder. Pt fell at the facility 4 times, but they only notified hospice of one fall. Spoke with DON (Director of Nursing) there, stated she will educate the nurses. Ordered shoulder X-ray.” The Interdisciplinary Group (IDG) meetings dated 05/14/2026, 05/28/2026, and 06/11/2026, did not include documentation of changes to the patient’s condition or information related to the patient’s respite stay. The clinical record did not have documented evidence that the plan of care was revised to include information from the patient’s updated comprehensive assessment. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated, “That she does remember discussing the changes in interoffice communication but does not know why the IDG or plan of care was not updated.””

“It is required that the hospice must designate a physician to serve as medical director. The medical director must be a Doctor of Medicine or osteopathy who is an employee or is under contract with the hospice. When the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. This standard was not met as evidenced by document review and interview. The agency did not ensure designation of an Alternate Medical Director who provided backup to the Medical Director. During a review of the contract list, it was noted that only the hospice medical director was listed; no alternate physician was listed. When interviewed on 06/16/2026, the Supervising Nurse (Personnel Record 1) and the Alternate Administrator (Personnel Record 6) stated that they were just discussing starting to look for a backup physician but had not yet begun, and that they would start. During a review of the contract list, it was noted that only the hospice medical director was listed; no alternate physician was listed.”

“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. 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 1 of 3 (33%) clinical records review of patients who died while on hospice services, the agency did not ensure documentation of a bereavement plan of care that included the types of bereavement services offered and the frequency of services. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/31/2026, and the patient’s death was dated 04/03/2026. The clinical record review did not have documented evidence of a bereavement plan of care. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated, “She does not know how the death was not followed by bereavement; it may have been due to missed communication, but she was not sure. They would review and update the process.””

“It is required that a hospice aide provides services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed with hospice aide services provided, the agency did not ensure hospice aide services were provided as ordered in the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/06/2026 with a diagnosis of Parkinson’s disease without dyskinesia. The plan of care dated 05/07/2026-08/04/2026 included orders for a hospice aide 5 times per week. The clinical record did not have documented evidence of a hospice aide visit completed on 05/08/2026, 05/11/2026, 05/12/2026, 05/13/2026, and 05/14/2026, with no documentation of a missed visit or a new order to change the frequency of the hospice aide. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated, “That she does not know why those visits were missed.””

“It is required that the hospice medical director, physician-designee, or physician member of the IDG provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met, as evidenced by clinical record review and interview. In 9 of 9 (100%) clinical records reviewed, where recertification is required, the agency did not ensure recertification was completed no later than two calendar days after the first day of each benefit period. CLINICAL RECORD 1: The patient elected hospice benefit on 01/14/2025 with a diagnosis of Senile degeneration of the brain. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 01/14/2025 to 04/13/2025, 04/14/2025 to 07/12/2025, and 03/10/2026 to 05/08/2026. CLINICAL RECORD 2: The patient elected hospice benefit on 03/22/2025 with a diagnosis of Vascular dementia. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit period of 05/16/2026 to 07/14/2026. CLINICAL RECORD 3: The patient elected hospice benefit on 02/06/2026 with a diagnosis of Parkinson’s disease without dyskinesia. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit period of 05/07/2026 to 08/04/2026. CLINICAL RECORD 4: The patient elected hospice benefit on 10/31/2025 with a diagnosis of Vascular dementia. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 10/31/2025 to 01/28/2026 and 01/29/2026 to 04/28/2026. CLINICAL RECORD 5: The patient elected hospice benefit on 02/14/2026 with a diagnosis of Heart failure. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit period of 05/15/2026 to 08/12/2026. CLINICAL RECORD 6: The patient elected hospice benefit on 06/19/2024 with a diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 04/15/2025 to 06/13/2025 and 06/14/2025 to 08/07/2025. CLINICAL RECORD 7: The patient elected hospice benefit on 11/14/2024 with a diagnosis of Multiple myeloma not having achieved remission. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 05/13/2025 to 07/11/2025, 09/10/2025 to 11/08/2025, 11/09/2025 to 01/07/2026, 01/08/2026 to 03/08/2026, and 05/08/2026 to 07/06/2026. CLINICAL RECORD 8: The patient elected hospice benefit on 11/25/2024 with a diagnosis of Malignant neoplasm of connective and soft tissue of head, face, and neck. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 05/24/2025 to 07/22/2025, 09/21/2025 to 11/19/2025, 01/19/2026 to 03/19/2026, 03/20/2026 to 05/18/2026, and 05/19/2026 to 07/17/2026. CLINICAL RECORD 9: The patient elected hospice benefit on 12/05/2024 with a diagnosis of Malignant neoplasm of prostate. The clinical record does not include documented evidence of a signed recertification of terminal illness for the benefit periods of 06/03/2025 to 08/01/2025, 10/01/2025 to 11/29/2025, 01/29/2026 to 03/29/2026, 03/30/2026 to 05/28/2026, and 05/29/2026 to 07/27/2026. During an interview with the Supervising Nurse (Personnel Record 1) and the Alternate Administrator (Personnel Record 6) on 06/17/2026, they stated that they did not know why the recertifications of terminal illness were missing the Medical Director’s signature.”

“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 and interview. In 2 of 2 (100%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 13: The patient called for a revocation of the hospice benefit on 03/04/2026. The clinical record did not have documented evidence that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 14: The patient called for a revocation of the hospice benefit on 01/21/2026. The clinical record did not have documented evidence that the discharge summary was forwarded to the patient’s attending physician. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated, “She does not know why the discharge summary was not present in the record.””

“It is required that the facility offering respite care provides 24-hour nursing services that meet the needs of the patients and each patient’s plan of care (POC). Each patient receives all nursing services as prescribed in the plan of care and is kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient who received respite care, the agency did not ensure the patient was protected from accidents, injuries, and infections. CLINICAL RECORD 3: The patient elected hospice benefit on 02/06/2026. The nurse documented in clinical record on 05/27/2026, “Pt (patient) came back from a 5-day stay respite. (The patient) has a swollen right shoulder. Pt fell at the facility 4 times, but they only notified hospice of one fall. Spoke with DON (Director of Nursing) there, stated she will educate the nurses. Ordered shoulder X-ray.” The clinical record did not have documented evidence that the facility providing respite care protected the patient from accidents and injuries. During an interview with the Supervising Nurse (Personnel Record 1) on 06/17/2026, she stated that she did call the facility and speak with the Director of Nursing and updated the Medical Director.”