First Choice Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; . Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 5 (20%) clinical records reviewed the agency did not ensure the drug profile was reviewed and updated at each comprehensive assessment or when medications were added or changed. CONTINUING PRIOR REQUIRED ACTION. Clinical Record 4: The patient in a skilled nursing facility (SNF) elected hospice on 08/15/2024 with a diagnosis of ATRIOVENTRICULAR BLOCKAGE. During a home visit (Home Visit 1) with the Registered Nurse (RN) (Personnel Record 4), a medication review was completed by comparing the hospice medication profile with the medication administration record from the SNF. The SNF MAR included trazadone HCL oral tablet 50 mg give 1 by mouth at bedtime for insomnia. The order was written on 08/20/2024. The hospice plan of care dated 08/20/2024 and current medication profile did not include trazadone. During a joint clinical record reviews and interviews on 09/03/24, The Team Leader confirmed that the drug profile for the clinical record identified did not include all medications reviewed during the comprehensive assessment. CONTINUING PRIOR REQUIRED ACTION.”

“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 associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that the hospice care and services provided to patients and families followed the individualized plan of care established by the Interdisciplinary Group (IDG) {HCPC.19. I/L543}; Failed to ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments {HCPC.21. I/L545}; Failed to ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21. I/L548; Failed to ensure the individualized written plan of care included all medical supplies and appliances required to meet specific patient needs {HCPC.21. I/L550}; and Failed to ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the patient’s progress toward outcomes and goals specified in the written plan of care {HCPC.22. I/L553}. 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: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, and actual or potential drug interactions and duplicate drug therapy. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure but at minimum, at the time of each comprehensive assessment and or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 14 (29%) clinical records reviewed the agency did not ensure the drug profile was reviewed and updated at each comprehensive assessment or when medications were added or changed. Clinical Record 2: The patient elected the hospice benefit on 07/16/2024. The drug profile effective 07/23/2024 contained two orders for Dulcolax suppositories: Dulcolax (brand name) 10mg suppository daily as needed and Bisacodyl (generic name) 10mg suppository daily as needed. The clinical record did not contain documented evidence of a medication review that identified the duplicate drug therapy for the two Dulcolax orders. Clinical Record 3: The patient, a skilled nursing facility (SNF) resident, elected the hospice benefit on 07/10/2024. During Home Visit 3 with the Medical Social Worker (Personnel Record 3), a medication review was completed by comparing the hospice medication profile with the medication administration record (MAR) from the SNF. The SNF MAR included Dilaudid oral liquid 1MG/1ML every hour as needed for pain, Metoprolol tartrate 12.5MG tablet twice a day, Nexium 40MG delayed release capsule twice a day, and Senna-docusate sodium 8.6-50MG twice a day. The hospice plan of care dated 07/23/2024 and medication profile current 07/24/2024 did not include Dilaudid oral liquid, Metoprolol tartrate, Nexium, and Senna-docusate sodium. Clinical Record 5: The patient elected the hospice benefit on 05/01/2024. The initial nursing assessment dated 05/01/2024 included documentation that the patient had dyspnea at rest and on exertion, used Levalbuterol nebulizer treatments daily and was ordered oxygen for comfort. The plan of care and drug profile dated 05/01/2024 did not include Levalbuterol and oxygen. Clinical Record 10: The patient elected the hospice benefit on 01/12/2024. The initial nursing assessment dated 01/12/2024 included documentation that the patient had dyspnea at rest and required oxygen at two liters per minute continuously. The plan of care and drug profile dated 01/12/2024 did not include oxygen. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the drug profiles for the clinical records identified did not include all medications reviewed during the comprehensive assessments.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the comprehensive assessment was updated no less frequently than every 15 calendar days. Clinical Record 8: The patient was admitted to hospice services on 04/12/2024, and a “Palliative Care Admission Agreement,” outlining the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The initial nursing assessment dated 04/12/2024 included a spiritual assessment and identified the patient’s beliefs. The clinical record contained no evidence of updated comprehensive assessments every 15 calendar days from the initial comprehensive assessment completed on 04/12/2024 through the current date. Clinical Record 13: The patient was admitted to hospice services on 08/23/2023, and a “Palliative Care Agreement,” outlining the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The patient died at home on 12/11/2023. The initial nursing assessment dated 08/23/2023 included medical, psychosocial, emotional, and spiritual assessments. The clinical record contained no evidence of updated comprehensive assessments every 15 calendar days from 08/23/2023 until the patient’s death. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed the clinical records identified did not include updated comprehensive assessments at least every 15 calendar days. The leaders reported that, due to the strong religious and cultural beliefs of Clinical Records 8 and 13, the agency had agreed to provide nursing services only when requested and physician services for medication refills.”

“It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients and families followed the individualized plan of care established by the hospice Interdisciplinary Group (IDG). Clinical Record 5: The patient elected the hospice benefit on 05/01/2024. The plan of care dated 05/01/2024 included a frequency order for the Hospice Aide to visit twice a week starting the week of 05/05/2024. The hospice aide documented a completed visit on 05/06/2024. The clinical record contained no evidence that the aide provided a second visit for the week of 05/05/2024 and no documentation of why the visit was missed. Clinical Record 9: The patient, a skilled nursing facility resident, elected the hospice benefit on 04/25/2024. The hospice nurse transcribed a physician’s verbal order dated 07/12/2024 that included instructions for wound care to be provided to skin tears on the patient’s left arm and leg daily for seven days and as needed. The clinical record contained no evidence that the hospice nurse had provided daily wound care as ordered from 07/13/2024 through 07/18/2024. Clinical Record 11: The patient elected the hospice benefit on 12/08/2023. The patient was discharged from hospice services on 07/10/2024. The hospice nurse transcribed a physician’s verbal order dated 07/05/2024 that included instructions for wound care to be provided to a pressure wound on the patient’s right post-medial inner buttock daily and with soiling or displacement. The clinical record contained no evidence that the hospice nurse had provided daily wound care as ordered from 07/06/2024 through 07/10/2024. Clinical Record 14: The patient elected the hospice benefit on 10/19/2023 with a terminal diagnosis of malignant neoplasm of the pancreas. The patient died at home on 02/13/2024. The bereavement plan of care dated 02/14/2024 included interventions for the Bereavement Coordinator to assess the caregiver’s needs and assist the caregiver in working through the stages of grief. The Bereavement Coordinator documented on 02/14/2024 that a phone call was made and a sympathy card was mailed to the bereaved. The bereavement plan of care did not include instructions to provide a phone call or mail a sympathy card to the bereaved. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that hospice care and services, including daily wound care and bereavement care, were not provided to patients and families as ordered and as written in the plan of care.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice services on 06/28/2024 with a terminal diagnosis of acute chronic diastolic (congestive) heart failure. The initial nursing assessment dated 06/28/2024 included documentation that the patient was dyspneic with minimal exertion, oxygen-dependent at 4.5 liters per minute continuous, and a Fentanyl 12mcg patch was added to help improve dyspnea. The written plan of care dated 06/28/2024 did not reflect patient and family goals and planned interventions associated with the patient’s dyspnea and oxygen safety needs identified in the comprehensive assessment. Clinical Record 6: The patient elected hospice services on 11/21/2023 with a terminal diagnosis of unspecified Alzheimer’s disease. The initial nursing assessment dated 11/21/2023 included documentation that the patient was bedbound, incontinent of bowel and bladder, and a fall risk with a risk score of six out of ten. The written plan of care dated 11/21/2023 did not reflect patient and family goals and planned interventions associated with the patient’s fall risk and potential for skin breakdown identified in the comprehensive assessment. Clinical Record 7: The patient elected hospice services on 04/19/2024 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 04/19/2024 included documentation that the patient was non-ambulatory, incontinent of bowel and bladder, and had contractures of all extremities. The written plan of care dated 04/19/2024 did not reflect patient and family goals and planned interventions associated with the patient’s risk for skin breakdown identified in the comprehensive assessment. Clinical Record 8: The patient was admitted to hospice services on 04/12/2024, and a “Palliative Care Admission Agreement,” that outlined the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The initial nursing assessment dated 04/12/2024 included documentation that the patient’s non-verbal pain score was three out of ten. The comprehensive assessment also included documentation that the patient had increased anxiety, required changes in anxiolytic medications, and was a fall risk with a risk score of six out of ten. The written plan of care dated 04/12/2024 did not reflect patient and family goals and planned interventions associated with the patient’s pain, anxiety, and fall risk identified in the comprehensive assessment. Clinical Record 9: The patient elected hospice services on 04/25/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The initial nursing assessment dated 04/25/2024 included documentation that the patient had a cardiac pacemaker in place, two plus pitting edema to bilateral hands, and three plus pitting edema to bilateral lower extremities. The written plan of care dated 04/25/2024 did not reflect patient and family goals and planned interventions associated with the patient’s cardiac pacemaker and pitting edema identified in the comprehensive assessment. Clinical Record 10: The patient elected hospice services on 01/12/2024 with a terminal diagnosis of panlobular emphysema. The initial nursing assessment dated 01/12/2024 included documentation that the patient had significant hypertension with a blood pressure of 212/95, one plus pitting edema to bilateral calves, and a fall risk with a risk score of six out of ten. The written plan of care dated 01/12/2024 did not reflect patient and family goals and planned interventions associated with the patient’s hypertension, edema, and fall risk identified in the comprehensive assessment. Clinical Record 11: The patient elected hospice services on 12/08/2023 with a terminal diagnosis of chronic diastolic (congestive) heart failure. The initial nursing assessment dated 12/08/2023 included documentation that the patient was a fall risk with a risk score of eight out of ten, spoke only Spanish, and required a language interpreter. The written plan of care dated 12/08/2024 did not reflect patient and family goals and planned interventions associated with the patient’s fall risk and language and communication needs identified in the comprehensive assessment. Clinical Record 13: The patient was admitted to hospice services on 08/23/2023, and a “Palliative Care Admission Agreement,” that outlined the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The initial nursing assessment dated 08/23/2023 included documentation that the patient had intermittent anxiety and agitation that required anxiolytic medications and was a fall risk with a risk score of nine out of ten. The written plan of care dated 08/23/2023 did not reflect patient and family goals and planned interventions associated with the patient’s anxiety, agitation, and fall risk identified in the comprehensive assessment. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the plans of care identified did not reflect patient and family goals and planned interventions associated with problems identified in the comprehensive assessment including dyspnea, anxiety, agitation, fall and skin integrity risks, edema, and language barriers.”

“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 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 9 of 14 (64%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 06/28/2024 with a terminal diagnosis of acute on chronic diastolic (congestive) heart failure. The initial nursing assessment dated 06/28/2024 included documentation that the patient had chronic back and shoulder pain rated three out of ten with a pain goal of three out of ten, was dyspneic with exertion, and required continuous oxygen at 4.5 liters per minute. The plan of care dated 06/28/2024 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, “optimal” cardiac status would be achieved, and “satisfactory” control of symptoms would be expressed. The goals did not include the measurability of consistent, optimal, and satisfactory for the patient. Clinical Record 3: The patient elected the hospice benefit on 07/10/2024 with a terminal diagnosis of unspecified heart failure. The initial nursing assessment dated 07/10/2024 included documentation that the patient had right shoulder pain rated five out of ten with a pain goal of two out of ten. The plan of care dated 07/10/2024 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, “stable” cardiovascular status would be achieved, and “acceptable” pain level would be verbalized. The goals did not include the measurability of consistent, stable, and acceptable as identified by the patient. Clinical Record 4: The patient elected the hospice benefit on 09/09/2023 with a terminal diagnosis of Nonrheumatic aortic (valve) stenosis with insufficiency. The initial nursing assessment dated 09/09/2024 included documentation that the patient had chest and abdominal pain rated five out of ten with a pain goal of three out of ten, was dyspneic at rest, had a history of constipation, and required assistance with ambulating and frequent rest periods. The plan of care dated 09/09/2023 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, and “optimal” independence and bowel functioning would be achieved. The goals did not include the measurability of consistent and optimal as identified by the patient. Clinical Record 6: The patient elected the hospice benefit on 11/21/2023 with a terminal diagnosis of unspecified Alzheimer’s disease. The initial nursing assessment dated 11/21/2023 included documentation that the patient had mild pain, was bedbound, and was incontinent of bowel and bladder. The plan of care dated 06/28/2024 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, and an “optimal” level of functioning would be achieved. The goals did not include the measurability of consistent and optimal as identified by the patient and family. Clinical Record 7: The patient elected the hospice benefit on 04/19/2024 with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 04/19/2024 included documentation that the patient was lethargic, aphasic, disoriented, non-ambulatory, had contractures of all extremities, and had a history of aggression and combativeness. The plan of care dated 04/19/2024 identified goals that an “optimal” level of functioning would be achieved, and “satisfactory” control of symptoms would be expressed. The goals did not include the measurability of optimal and satisfactory as identified by the patient and family. Clinical Record 9: The patient elected the hospice benefit on 04/25/2024 with a terminal diagnosis of chronic systolic (congestive) heart failure. The initial nursing assessment dated 04/25/2024 included documentation that the patient had an indwelling urinary catheter in place due to urinary retention, two plus pitting edema to bilateral hands, and three plus pitting edema to bilateral lower extremities. The plan of care dated 04/25/2024 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, and urine output would be “appropriate” for the stage of the disease process. The goals did not include the measurability of consistent and appropriate as identified by the patient and family. Clinical Record 10: The patient elected the hospice benefit on 01/12/2024 with a terminal diagnosis of panlobular emphysema. The initial nursing assessment dated 01/12/2024 included documentation that the patient had dyspnea at rest, required continuous oxygen at two liters per minute, and had one plus pitting edema to bilateral calves. The plan of care dated 01/12/2024 identified goals that “satisfactory” control of symptoms would be expressed, breathing would be at an “optimal” level, and anxiety would be reduced and within a “manageable” level during dyspneic episodes. The goals did not include the measurability of satisfactory, optimal, and manageable as identified by the patient and family. Clinical Record 11: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of chronic diastolic (congestive) heart failure. The initial nursing assessment dated 12/08/2023 included documentation that the patient had moderate pain and was dyspneic with exertion. The plan of care dated 12/08/2023 identified goals that the patient’s symptoms would be “consistent” with the stage of the disease process, problems would be managed as well as the disease process would allow, and an “optimal” cardiac status would be achieved. The goals did not include the measurability of consistent and optimal as identified by the patient and family. Clinical Record 13: The patient was admitted to hospice services on 08/23/2023 with a terminal diagnosis of Stage 3 chronic kidney disease. The patient died at home on 12/11/2023. The initial nursing assessment dated 08/23/2023 included documentation that the patient was lethargic, had adventitious lung sounds, and had intermittent episodes of agitation and anxiety. The plan of care dated 08/23/2023 identified goals that the patient would achieve an “optimal” level of functioning and the cardiovascular status would be “stable.” The goals did not include the measurability of optimal and stable as identified by the patient and family. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed the written plans of care did not include measurable outcomes anticipated from the coordination, development, and implementation of the plan of care.”

“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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the individualized written plan of care included all medical supplies and appliances required to meet specific patient needs. Clinical Record 1: The patient elected hospice services on 06/28/2024. The initial nursing assessment dated 06/28/2024 included documentation that the patient was using intermittent heat to manage shoulder pain, required nursing to manage a pill box, and would receive a condom catheter to manage urinary frequency per the patient’s request. The written plan of care dated 06/28/2024 did not include orders for intermittent heat therapy, nursing management of a pill box with frequency, and specific instructions associated with the care and maintenance of an external urinary catheter. Clinical Record 3: The patient elected hospice services on 07/10/2024. During Home Visit 3 with the Medical Social Worker (Personnel Record 3), it was observed that the patient was using the following durable medical equipment (DME): hospital bed, alternating pressure pad and pump, over-the-bed table, wheelchair, and walker. The written plan of care dated 0710/2024 included DME orders for a walker and a wheelchair, and an intervention to teach the patient to wear Thromboembolic Deterrent (TED) hose or support stockings. The plan did not include orders for the hospital bed, over-the-bed table, alternating pressure pump and pad, and the application and removal frequency for TED hose/support stockings. Clinical Record 5: The patient elected hospice services on 09/09/2023. The initial nursing assessment dated 09/09/2023 included documentation that the patient was legally blind and required nursing to manage a pill box. The written plan of care dated 09/09/2023 did not include orders for nursing management of a pill box with frequency. Clinical Record 9: The patient elected hospice services on 04/25/2024. The initial nursing assessment dated 04/25/2024 included documentation that the patient had an indwelling urinary catheter in place due to urinary retention. The written plan of care dated 04/25/2024 did not include orders for the indwelling urinary catheter to remain in place and for the ongoing care and management of the indwelling catheter, including frequency and persons responsible. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the plans of care identified did not include all medical supplies and appliances required to meet the patient’s needs, including internal and external urinary catheter care and management, use and management of a pill box, all DME in use, and TED hose/support stocking application and removal.”

“It is required that the Interdisciplinary Group, 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. A revised 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 2 of 14 (14%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the patient’s progress toward outcomes and goals specified in the written plan of care. Clinical Record 8: The patient was admitted to hospice services on 04/12/2024, and a “Palliative Care Admission Agreement,” that outlined the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The initial plan of care was established on 04/12/2024. The clinical record contained no evidence that the Interdisciplinary Group (IDG) had reviewed, revised, and documented the patient’s progress toward outcomes and goals specified in the plan of care no less frequently than every 15 calendar days since the plan was established. Clinical Record 13: The patient was admitted to hospice services on 08/23/2023, and a “Palliative Care Admission Agreement,” that outlined the purpose of hospice and palliative care and the agency’s hourly rate for nursing services, was signed by the patient’s representative. The patient died at home on 12/11/2023. The initial plan of care was established on 08/23/2023. The clinical record contained no evidence that the Interdisciplinary Group (IDG) had reviewed, revised, and documented the patient’s progress toward outcomes and goals specified in the plan of care no less frequently than every 15 calendar days since the plan was established through the patient’s date of death. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the plans of care identified were not reviewed, revised, and outcomes documented. The leaders stated they believed that because the patients had not elected the hospice benefit, the standards did not apply.”

“It is required that the counseling services provided 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. Bereavement services are available to the family and other individuals for up to one (1) year following the death of the patient. 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 2 of 2 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure bereavement services reflected the needs of the bereaved through a bereavement plan of care that included the types of services offered and frequency of service delivery. Clinical Record 13: The patient elected self-pay hospice services on 08/23/2023. The patient died at home on 12/11/2023. The clinical record contained no evidence that a bereavement plan of care was developed to reflect the needs of the bereaved and include the types and frequency of bereavement services to be delivered. The clinical record contained no evidence of why a bereavement plan of care was not developed and services were not delivered. Clinical Record 14: The patient elected hospice services on 10/19/2023. The patient died at home on 02/13/2024. The bereavement plan of care dated 02/14/2024 included a goal that the bereaved would receive the “Journeying Through Grief” book series during the yearlong bereavement program. The bereavement plan of care did not include the frequency at which the grief books would be provided. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed the bereavement records identified did not include bereavement plans of care that outlined the frequency at which services would be provided. The leaders reported that the religious and cultural beliefs of Clinical Record 13 prevented bereavement services from being provided; however, the leaders confirmed the clinical record contained no evidence of why a bereavement plan of care was not developed and services were not delivered.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 4: The patient elected the hospice benefit on 09/09/2023. The initial nursing assessment dated 09/09/2023 included documentation that the patient was at risk for falls and was legally blind. The hospice aide care plan dated 09/10/2023 included instructions for the aide to provide a shower every visit. The plan did not alert the aide to the patient’s fall risk and significant visual impairment. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the hospice aide care plans did not alert the aide to the patient’s fall risk and visual impairment.”

“It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group (IDG) and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 7 (14%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 06/28/2024. The hospice aide care plan dated 07/22/2024 included instructions for the aide to provide complete bath and nail care every visit. During Home Visit 1 with the nurse (Personnel Record 1) on 07/23/2024, the patient reported that the hospice aide had provided a shower and shampooed the patient’s hair. The plan did not include instructions for the aide to provide shampoo. The clinical record contained no evidence that the Registered Nurse verbally instructed the aide to perform the shampoo. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the aide’s care plan instructions did not include shampoo, and the clinical record contained no evidence of verbal instructions by the Registered Nurse or an updated care plan to perform a shampoo.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 7 (29%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported and documented changes in the patient’s care needs to the Registered Nurse. Clinical Record 1: The patient elected the hospice benefit on 06/28/2024. The hospice aide care plan dated 07/22/2024 included instructions for the aide to provide complete bath and nail care every visit. During Home Visit 1 with the nurse (Personnel Record 1) on 07/23/2024, the patient reported that the hospice aide had shampooed the patient’s hair. The clinical record contained no evidence that the Hospice Aide notified the Registered Nurse of the change in the patient’s care needs related to the plan of care and the addition of the shampoo. Clinical Record 5: The patient elected the hospice benefit on 05/01/2024. The plan of care dated 05/01/2024 included a visit frequency order for the aide of two visits per week. During the week of 05/06/2024, the aide performed and documented a completed visit on 05/06/2024. The clinical record contained no evidence of a second hospice aide visit and documentation that the Registered Nurse was notified of the missed visit for the week of 05/06/2024. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the clinical records identified contained no evidence that the hospice aide reported changes in the patient’s care needs and visits provided to the Registered Nurse.”

“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. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed where volunteer services were provided, the agency did not ensure that the volunteer services provided were documented in the patient’s clinical record. Clinical Record 4: The patient elected the hospice benefit on 09/09/2023. The plan of care updated on 05/06/2024 through the current date included a visit frequency order for the volunteer to visit two times a month. The Volunteer Coordinator documented that the volunteer completed visits on 05/27/2024, 06/13/2024, 07/01/2024, and 07/11/2024. The clinical record contained no evidence from the volunteer on the type of volunteer visits made, the services provided, and the patient’s response to the visits and services. Clinical Record 6: The patient elected the hospice benefit on 11/21/2023. The plan of care updated on 06/06/2024 through the current date included a visit frequency order for the volunteer to visit two times a month. The Volunteer Coordinator documented that the volunteer completed visits on 06/06/2024, 06/20/2024, 07/04/2024, and 07/16/2024. The clinical record contained no documented evidence from the volunteer on the type of volunteer visits made, the services provided, and the patient’s response to the visits and services. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the clinical records identified contained no documented evidence from the volunteer for the visits completed that included the visit type, services provided, and patient’s response.”

“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 where the patient was discharged from hospice services, the agency did not ensure that a copy of the hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of chronic diastolic (congestive) heart failure. The hospice Interdisciplinary Group (IDG) found the patient to no longer be terminally ill, and the patient was discharged from hospice services on 07/10/2024. The discharge summary completed by the Registered Nurse included documentation that the “patient and family were instructed to reach out to their prior primary care physician” for care needs including medications. The clinical record contained no evidence that a copy of the discharge summary was forwarded to the patient’s attending physician. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the discharge summary was not forwarded to the patient’s attending physician stating that the patient’s prior primary care physician was no longer practicing. The agency’s leaders stated that the discharge summary was usually only forwarded to the hospice medical director, the attending physician during hospice care.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 3: The patient, a skilled nursing facility resident, elected hospice services on 07/10/2024. The hospice plan of care dated 07/10/2024 included an order to provide wound care for an abrasion on the patient’s head daily. The plan did not identify the specific provider responsible for performing the wound care as ordered by the physician. Clinical Record 6: The patient, a skilled nursing facility resident, elected hospice services on 11/21/2023. The physician’s order written on 07/23/2024 included instructions to provide wound care to multiple wounds on the patient’s buttocks daily and as needed for each brief change. The plan did not identify the specific provider responsible for performing the wound care as ordered by the physician. Clinical Record 9: The patient, a skilled nursing facility resident, elected hospice services on 04/25/2024. The physician’s order written on 07/12/2024 included instructions to provide wound care to skin tears on the patient’s left arm and leg daily for seven days and as needed. The plan did not identify the specific provider responsible for performing the wound care as ordered by the physician. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed that the plans of care identified did not identify the specific provider responsible for performing the wound care as ordered by the physician.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care reflected the participation of the hospice and the SNF. Clinical Record 2: The patient, a skilled nursing facility resident, elected hospice services on 07/16/2024. The hospice plan of care was established on 07/16/2024 and included goals and interventions associated with identified skin integrity risk, aspiration risk, fall risk, and pain. The plan of care did not reflect the participation and collaboration of and between the hospice and skilled nursing facility. Clinical Record 3: The patient, a skilled nursing facility resident, elected hospice services on 07/10/2024. The hospice plan of care was established on 07/10/2024 and included goals and interventions associated with an identified wound, fall risk, and pain. The plan of care did not reflect the participation and collaboration of and between the hospice and skilled nursing facility. Clinical Record 6: The patient, a skilled nursing facility resident, elected hospice services on 11/21/2023. The hospice plan of care was established on 11/21/2023 and included goals and interventions associated with managing symptoms related to the progression of the patient’s disease. The plan of care did not reflect the participation and collaboration of and between the hospice and skilled nursing facility. Clinical Record 7: The patient, a skilled nursing facility resident, elected hospice services on 04/19/2024. The hospice plan of care was established on 04/19/2024 and included goals and interventions associated with identified skin integrity risk, aspiration risk, fall risk, agitation, and combativeness. The plan of care did not reflect the participation and collaboration of and between the hospice and skilled nursing facility. Clinical Record 9: The patient, a skilled nursing facility resident, elected hospice services on 04/25/2024. The hospice plan of care was established on 04/25/2024 and included goals and interventions associated with identified skin integrity risk and fall risk. The plan of care did not reflect the participation and collaboration of and between the hospice and skilled nursing facility. During joint clinical record reviews and interviews on 07/25/2024, the Administrator, Interim Administrator, and Hospice Team Leader confirmed the plans of care identified did not reflect the participation and collaboration of and between the hospice and skilled nursing facility.”