Athc-Hospice LLC

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the written plan of care included individualized goals with measurable outcomes. CLINICAL RECORD 1: This patient elected the hospice benefit on 08/21/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The initial Registered Nurse (RN) comprehensive assessment documented that the patient was receiving tramadol 50 mg every six hours as needed for pain, gabapentin 100 mg, two (2) tablets at night for neuropathy, and lidocaine 4% topical patch, apply one patch to the back of neck at bedtime and remove in the am. The patient was alert and oriented to person, place, and time. The plan of care dated 08/21/2024 through 07/30/2025 documented the patient’s goal: pain will be managed for a patient who is unable to report or articulate pain. The patient’s goal for pain did not include a measurable outcome. CLINICAL RECORD 6: This patient elected the hospice benefit on 05/30/2025 with a terminal diagnosis of fracture of the right pubis. The initial Registered Nurse (RN) comprehensive assessment dated 05/30/2025 documented the patient stated experiencing pain at “3-8/10.” The RN nursing visit on 07/30/2025 documented that the patient had pain in both wrists. The plan of care was reviewed for the dates of 05/30/2025-07/30/2025, documenting the patient’s goal: pain is managed for a patient who is unable to verbally report or articulate pain as evidenced by patient/caregiver report or visual observation. The patient’s goal for pain did not include a measurable outcome. In an interview on 07/30/2025, the Regional Compliance Officer stated that the goals were not individualized and did not include measurable outcomes.”

“It is required that each patient’s individualized written plan of care: includes drugs and treatment necessary to meet the needs of the patient. 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 that the written plan of care included drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 1: This patient elected the hospice benefit on 08/21/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The initial Registered Nurse (RN) comprehensive assessment dated 08/21/2024 documented that the patient had a Foley catheter. The plan of care for the dates of 08/21/2024 through 11/05/2024 did not document orders for the care and maintenance of the Foley catheter. The plan of care, updated on 11/06/2024, ordered the assessment and management of the catheter but did not address the size of the catheter or how often it should be changed. During an interview on 07/30/2025, the Regional Compliance Officer stated that the care of the Foley catheter was not present in the plan of care.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit on 07/27/2024 with a terminal diagnosis of diastolic congestive heart failure and revoked the hospice benefit on 08/14/2024. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient’s attending physician. In an interview and a joint record review on 07/30/2025, the Regional Compliance Officer (RCO) stated that there was no documentation that the hospice forwarded the patient’s attending physician a copy of the hospice discharge summary.”

“It is required that the designated IDG member provide the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visits observed of a patient who resided in a skilled nursing facility (SNF), the agency did not ensure that the SNF received a copy of the patient’s most recent hospice plan of care. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 06/30/2025 with a terminal diagnosis of end-stage heart failure. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 07/29/2025, a review of the patient’s SNF hospice chart revealed no evidence of the patient’s most recent hospice plan of care. During an interview on 07/30/2025, the SNF Director of Nursing (DON) stated that this information was not included in the SNF hospice chart and that they had contacted the agency two weeks ago to request this missing documentation, with no response. The Regional Compliance Director was interviewed on 07/30/2025 and stated that the hospice agency did not have evidence that the most recent hospice plan of care was provided. The hospice agency emailed the most recent hospice plan of care to the SNF during the site visit.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits observed of a patient who resided in a skilled nursing facility (SNF), the agency did not ensure that the SNF was provided with the patient’s hospice election form. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 06/30/2025 with a terminal diagnosis of end-stage heart failure. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 07/29/2025, a review of the patient’s SNF hospice chart revealed no evidence of the patient’s hospice election form. During an interview on 07/30/2025, the SNF Director of Nursing (DON) stated that this information was not included in the SNF hospice chart and that they had contacted the agency two weeks ago to request this missing documentation, with no response. The Regional Compliance Director was interviewed on 07/30/2025 and stated that the hospice agency did not have evidence that the hospice election form was provided. The hospice agency emailed the hospice election form to the SNF during the site visit.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits observed of a patient who resided in a skilled nursing facility (SNF), the agency did not ensure that the SNF was provided with the physician certification and recertification of the terminal illness. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 06/30/2025 with a terminal diagnosis of end-stage heart failure. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 07/29/2025, a review of the patient’s SNF hospice chart revealed no evidence of the physician certification of terminal illness.. During an interview on 07/30/2025, the SNF Director of Nursing (DON) stated that this information was not included in the SNF hospice chart and that they had contacted the agency two weeks ago to request this missing documentation, with no response. The Regional Compliance Director was interviewed on 07/30/2025 and stated that the hospice agency did not have evidence that the physician certification of terminal illness was provided. The hospice agency emailed the physician certification of terminal illness to the SNF during the site visit.”