Goodwin House Palliative Care and Hospice

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services, the agency did not ensure the hospice aide provided services as ordered in the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025. The plan of care dated 04/03/2025 to 07/01/2025 included an order for hospice aide frequency of three times per week. A physician order dated 06/01/2025 changed the hospice aide frequency of visits to twice a week. Clinical record review revealed the hospice aide provided visits three times a week for the weeks of 06/01/2025 to 06/07/2025, 06/08/2025 to 06/14/2025, 06/15/2025 to 06/21/2025, and 06/22/2025 to 06/28/2025. During an interview on 07/09/2025, the Administrator stated that the visit frequency was never decreased to two times a week from three times a week, but that the clinical staff is fairly new and still learning the electronic medical record.”

“It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide was supervised by the Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/02/2025. The physician ordered Hospice Aide frequency two times a week starting on 06/03/2025. Clinical record review revealed one aide supervisory visit dated 07/07/2025. There was no documented evidence of an aide supervisory visit from 06/03/2025 through 07/06/2025, a total of 34 days and 20 days outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/25/2021. The plan of care for the benefit period dated 04/06/2025 to 06/04/2025 included an order for hospice aide frequency three times per week. The clinical record included documentation of hospice aide visits that were provided as ordered, three times per week. There was no documented evidence in the clinical record that the Registered Nurse completed aide supervisory visits for the benefit period dated 04/06/2025 to 06/04/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/16/2024. The plan of care for the benefit period dated 02/20/2025 to 05/20/2025 included an order for hospice aide visit frequency of two times a week. Clinical record review revealed an aide supervisory visit was documented on 01/23/2025 and the next aide supervisory visit was dated 03/27/2025, a total of 63 days and 49 days outstanding. There was an aide supervisory visit documented on 05/05/2025 and the next aide supervisory visit was dated 06/12/2025, a total of 38 days and 24 days outstanding. During an interview on 07/03/2025, the Administrator stated that the clinical staff is fairly new and still learning the electronic medical record and are not opening up the supervisory section to document the supervisory visit. He also stated that they will be providing additional education.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with volunteer services provided, the agency did not ensure that the volunteer services were provided as ordered in the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/30/2024. The recertification plan of care dated 03/29/2025 to 05/27/2025 included an order for volunteer services at a frequency of twice per month. Clinical record review revealed the hospice volunteer made one visit per month for March and April. The volunteer visit notes were dated 03/29/2025 and 04/26/2025. There was no documented evidence in the clinical record that the volunteer provided two visits per month for March and April as ordered on the plan of care. During an interview on 07/02/2025, the Administrator stated that he did not know how the second visit was missed during that time frame but that they would monitor the volunteer frequency more closely.”

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record included physician orders. CLINICAL RECORD 1: Clinical record review revealed the nursing assessment dated 07/03/2025 included documentation that the nurse inserted a 16 fr. Foley catheter. There was no documented evidence in the clinical record of a physician order to insert the Foley catheter. During an interview on 07/03/2025, the Administrator stated that the clinical staff is fairly new and were under the impression that an order was not required if a standing order was used. He stated that additional education would be provided for the clinical staff.”