Elegant Hospice

“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 1 of 13 (8%) clinical records reviewed revealed the agency did not ensure that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/16/2024. There was no documented evidence that an initial spiritual care comprehensive assessment was completed within 5 days of the date of election of hospice care up to review date 10/14/2025. During an interview and a joint clinical records review on 10/14/2025 with the Director of Nursing (Personnel Record 4), she agreed that an initial spiritual care comprehensive assessment was not completed within 5 days of election of hospice services. No further information was provided.”

“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 4 of 14 (29%) clinical records reviewed revealed the agency did not ensure the patient/family received an initial bereavement assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025. There was no documented evidence that an initial bereavement risk assessment was completed as of the record review date 10/14/2025. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/02/2025. There was no documented evidence that an initial bereavement risk assessment was completed as of the record review date 10/14/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/16/2024. There was no documented evidence that an initial bereavement risk assessment was completed as of the record review date 10/14/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/28/2025. There was no documented evidence that an initial bereavement risk assessment was completed as of the record review date 10/14/2025. During an interview and a joint review of clinical records with the Director of Nursing (Personnel Record 4) on 10/14/2025 agreed with the finding.”

“The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed, revealed that the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/30/2025. The plan of care dated 09/30/2025-12/28/2025 included the order for hospice aide services with a frequency of three (3) time a week and one (1) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/24/2025. The plan of care dated 07/24/2025-10/21/2025 included the order for hospice aide services with a frequency of three (3) time a week and two (2) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025. The plan of care dated 09/19/2025-12/17/2025 included the order for hospice aide services with a frequency of two (2) time a week and two (2) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 7: The patient elected the hospice benefit on 09/06/2025. The plan of care dated 09/06/2025-12/04/2025 included the order for hospice aide services with a frequency of two (2) time a week and one (1) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/11/2025. The plan of care dated 10/09/2025-12/07/2025 included the order for hospice aide services with a frequency of two (2) time a week and one (1) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/16/2024. The plan of care dated 09/09/2025-11/07/2025 included the order for hospice aide services with a frequency of three (3) time a week and one (1) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 10: 1 The patient elected the hospice benefit on 10/04/2025. An order dated 10/14/2025 was for hospice aide services five (5) times a week and one (1) prn. There was no documented evidence for the reason for the prn hospice aide visit. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/01/2025. An order dated 05/01/2025 was for hospice aide services three (3) times a week and three (3) prn visits. There was no documented evidence for the reason for the prn hospice aide visit. During an interview and a joint review of clinical records on 10/14/2025 with the Director of Nursing agreed that the hospice aide frequencies were not specific and stated, “I was not aware of this requirement.” No further information was provided.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per 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 revealed the agency did not ensure that nursing care and services were provided as required by agency policy. Document 1: Agency policy Titled: Wound Care Assessment Policy and procedure, stated in part, “ Initial Assessment: conduct head-to- toe skin assessment upon admission; document all wounds and notify Physician. ongoing assessment: evaluate wound size, type, drainage, odor, surrounding skin, and pain level at each dressing change. Plan of care: update and individualize treatment orders based on wound progress and IDG review. The patient elected the hospice benefit on 07/16/2024. The plan of care dated 09/09/2025-11/07/2025 included an order for the skilled nurse one (1) time a week. The hospice registered nurse documented weekly visit on 09/26/2025, 10/02/2025, 10/07/2025 and 10/13/2025. There was no documented evidence of wound assessment on those visits as required by agency policy. During an interview and a joint clinical record review with the Director of Nursing on 10/14/2025 and agreed that the wound assessments were not completed.”

“It is required that the hospice assumes responsibility for the professional management of the SNF/NF or ICF/IDF resident’s hospice services including ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (100%) clinical records reviewed of patients who resided in a skilled nursing facility (SNF) revealed the agency did not ensure that the hospice assumed responsibility for the professional management of the SNF patient’s hospice services in accordance with the hospice plan of care (POC). CLINICAL RECORD 9: The patient’s election of benefits was 07/16/2024 with diagnosis of Alzheimer’s Disease and Sacral Wound. The patient resided in a skilled nursing facility (SNF.) During the initial comprehensive assessment date 07/16/2024, the registered nurse (RN) documented that the patient had a sacral wound with wound measurements and included a plan of care that included alteration in skin integrity. On 07/16/2024, the Physician gave the RN a verbal order for the SNF staff to provide wound care. The RN delegated the wound care to the SNF staff, however, there was no documented evidence in the clinical record that the hospice registered nurse evaluated the progress or ensured the effectiveness of the wound care. During an interview and a joint record review on 10/14/2025 with the DON, she agreed.”