Lake Prince Woods at Home LLC

“It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by document review and interview revealed the written Patient Bill of Rights confirmed that the right for the patient to choose his or her attending physician was not included. In an interview with the Hospice Administrator on 01/14/2025, it was confirmed that the written Patient Bill of Rights which was provided to all hospice patients did not include the right for the patient to choose his or her own attending physician. The review of the written Patient Bill of Rights confirmed that the right for the patient to choose his or her attending physician was not included.”

“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 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 and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment include an updated medication profile to include pain management medications, which resulted in the medication reconciliation being incomplete. CLINICAL RECORD 13: This patient elected the hospice benefit on 08/14/2024 with a terminal diagnosis of late onset Alzheimer’s Disease and expired on 09/26/2024. A review of the IDG notes dated 09/23/2024 revealed the Registered Nurse documented that the patient had been started on Morphine PRN, and this was helping to manage the patient’s pain. The medication administration records were reviewed for the dates of 08/27/2024-09/26/2024. There was no documented evidence of the Morphine noted in the medication administration records for these dates. In an interview with the Hospice Administrator on 01/15/2025, it was confirmed that the medication administration was not updated, which resulted in the medication reconciliation being incomplete.”

“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 14 of 14 (100%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment to assess 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 1: This patient elected the hospice diagnosis on 07/01/2024 with a terminal diagnosis of hypertensive heart failure and chronic kidney failure. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 2: This patient elected the hospice benefit on 04/30/2024 with a terminal diagnosis of senile degeneration of the brain A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 3: This patient elected the hospice benefit on 10/09/2024 with a terminal diagnosis of senile degeneration of the brain. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 4: This patient elected the hospice benefit on 10/07/2024 with a terminal diagnosis of COPD. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 5: This patient elected the hospice benefit on 12/22/2023 with a hospice diagnosis of acute diastolic (congestive) heart failure. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 6: This patient elected the hospice benefit on 09/25/2024 with a terminal diagnosis of amyotrophic lateral sclerosis. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 7: This patient elected the hospice benefit on 12/16/2024 with a terminal diagnosis of senile degeneration of the brain. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/05/2024 with a terminal diagnosis of cirrhosis of the liver. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 9: This patient elected the hospice benefit on 09/30/2024 with a terminal diagnosis of atrial fibrillation. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 10: This patient elected the hospice benefit on 11/20/2024 with a hospice diagnosis of malignant neoplasm of the lung. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 11: This patient elected the hospice benefit on 04/30/2024 with a terminal diagnosis of senile degeneration of the brain. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/22/2024 with a terminal diagnosis of intestinal obstruction. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 13: This patient elected the hospice benefit on 08/14/2024 with a terminal diagnosis of late onset Alzheimer’s Disease. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 14: This patient elected the hospice benefit on 12/05/2024 with a terminal diagnosis of refractory cytopenia with multilineage dysplasia. A review of the clinical record revealed there was no documented evidence that an initial bereavement assessment was completed. The Hospice Administrator was interviewed on 01/15/2025 and confirmed that the comprehensive assessment did not include the initial bereavement assessment.”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated 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 revealed the agency did not ensure that patients received education and training, provided by hospice, as appropriate for their responsibilities for care as stated in the plan of care. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/05/2024 with a terminal diagnosis of cirrhosis of the liver. The initial comprehensive assessment dated 04/05/2024 documented wounds on the right ankle, right medial foot, right heel, left knee, left mid flank, and a lumbar incision. The plan of care dated 04/05/2024, included the following goal: pt/cg will demonstrate appropriate wound care technique after instruction. There was no documented evidence of instructions in the clinical records reviewed from 04/05/2024 to date of revocation on 04/20/2024. In an interview conducted with the Hospice Administrator on 01/15/2025, the Administrator confirmed that the clinical record did not include documentation that the patient or caregiver received instructions on appropriate wound care technique.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments and includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms. 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 that the plan of care documented all individualized interventions for problems identified in the initial comprehensive assessment or the updated assessments. CLINICAL RECORD 1: This patient elected the hospice benefit on 07/01/2024 with a terminal diagnosis of hypertensive heart and kidney disease. The MSW comprehensive assessment dated 07/02/2024 documented the patient was having nausea and vomiting. The medication administration record included Phenergan 12.5 mg rectal every 6 hours prn for nausea which was started on 07/03/2024 and changed to Phenergan 12.5 mg by mouth every 6 hours as needed for nausea on 07/14/2024. There was no documented evidence that the plan of care dated 07/01/2024-01/15/2025 included interventions to address nausea or vomiting. CLINICAL RECORD 5: This patient elected the hospice benefit on 12/22/2023 with a terminal diagnosis of acute diastolic (congestive) heart failure. A review of the medication administration profile, Lorazepam 2 mg/ml 0.5ml sublingual every 2 hours as needed for anxiety was ordered on 01/03/2024. A review of the plan of care dated 12/16/2024-02/13/2025 revealed there was no documented interventions added to address the patient’s anxiety. CLINICAL RECORD 6: This patient elected the hospice benefit on 09/25/2024 with a terminal diagnosis of amyotrophic lateral sclerosis. The comprehensive assessment dated 09/25/2024 documented the patient used a Trilogy CPAP machine to assist with breathing and a suction machine to assist patient in coughing up secretions. A review of the plans of care dated 09/25/2024 through 01/22/2025 revealed there was no documented interventions for the assistance with breathing using the Trilogy CPAP machine or documented interventions for suctioning for assistance with coughing up secretions. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/22/2024 with a terminal diagnosis of intestinal obstruction. A review of the comprehensive assessment dated 08/22/2024 revealed that the patient was admitted to the hospital on 08/11/22024 for bowel obstruction and underwent an exploratory laparotomy, small bowel resection and lysis of adhesions. An abdominal surgical incision with staples was assessed. A review of the plan of care dated 08/22/204-11/20/2024 revealed there was no documented interventions to care for the incision. In an interview with the Hospice Administrator on 01/15/2025, it was confirmed that the agency did not ensure that interventions were added to the plan of care for problems identified in the initial comprehensive assessment or the updated assessments.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations conducted revealed the agency did not ensure the staff followed the hospice policy for the use of standard precautions to prevent the spread of infection. DOCUMENT 2 : Agency Policy Hand Hygiene Policy and Compliance Program, stated in part; “Indications for hand hygiene are: before re-entering nursing bag...” HOME VISIT 3: During Home Visit 3 (Clinical Record 3) on 01/14/2025 to observe the Registered Nurse (Personnel Record 3), the Registered Nurse was observed to check the vital signs of the patient and return the blood pressure cuff and pulse oximeter back into the nursing bag without sanitizing hands. The Registered Nurse then sanitized her hands and assessed the patient’s feet. She then reached into the nursing bag without sanitizing hands. In an interview with the Hospice Administrator on 01/14/2025, it was confirmed that the agency policy for hand hygiene was not followed during the home visit.”

“It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. 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 interview and document review revealed the contract documents were reviewed and there was no documentation of a contract signed for a backup hospice physician. This agency did not ensure that the hospice designated a backup physician to assume the same responsibilities and obligations as the Medical Director in cases of the absence of the Hospice Medical Director. During an interview with the Administrator on 01/16/2025, the Administrator confirmed the agency did not have a backup physician assigned. She stated that the Hospice Medical Director was part of a physician’s medical group, so it was assumed that if a backup physician was needed, one of those physicians would step in. The Administrator confirmed that the agency did not have a backup hospice physician contracted or employed at the time of this visit. This agency did not ensure that the hospice designated a backup physician to assume the same responsibilities and obligations as the Medical Director in cases of the absence of the Hospice Medical Director.”

“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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. 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 6 of 6 (100%) clinical records reviewed of expired patients revealed the agency did not ensure that a bereavement plan of care that included the types of services to be offered and the frequency of service delivery was developed. CLINICAL RECORD 9: This patient elected the hospice benefit on 09/30/2024 with a terminal diagnosis of atrial fibrillation and expired on 10/01/2024. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. CLINICAL RECORD 10: This patient elected the hospice benefit on 11/20/2024 with a terminal diagnosis of malignant neoplasm of the right lung and expired on 12/01/2024. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. CLINICAL RECORD 11: This patient elected the hospice benefit on 04/30/2024 with a terminal diagnosis of senile degeneration of the brain and expired on 07/07/2024. In review of the clinical record, documentation was noted from 07/10/2024-12/11/2024 that the Bereavement Coordinator made phone calls and sent letters to the bereaved. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/22/2024 with a terminal diagnosis of unspecified intestinal obstruction and expired on 09/15/2024. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. CLINICAL RECORD 13: This patient elected the hospice benefit on 08/14/2024 with a terminal diagnosis of late onset Alzheimer’s Disease and expired on 09/26/2024. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. CLINICAL RECORD 14: This patient elected the hospice benefit on 12/05/2024 with a terminal diagnosis of refractory cytopenia with multilineage dysplasia and expired on 12/21/2024. A review of the clinical record revealed there was no documented evidence of a bereavement care plan or that the bereaved family member or other individuals declined bereavement services as of the last day of the site visit 01/16/2025. In an interview with the Hospice Administrator in 01/15/2025, the Administrator confirmed that the clinical records did not include bereavement care plans that documented the types of bereavement services to be offered and the frequency of service delivery.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a 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 7 of 14 (50%) clinical records reviewed in which a hospice aide services were accepted revealed the agency did not ensure that the Registered Nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 2: This patient elected the hospice benefit on 04/30/2024 with a hospice diagnosis of senile degeneration of the brain. The hospice aide plan of care written by the Registered Nurse on 12/26/2024, ordered the following tasks as PRN: fingernail care, oral care, assist with ambulation, assist with transfers, and change bed linens. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 3: This patient elected the hospice benefit on 10/09/2024 with a hospice diagnosis of senile degeneration of the brain. The hospice plan of care written by the Registered Nurse on 10/09/2024, ordered the following hospice aide tasks as PRN: shower. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 4: This patient elected the hospice benefit on 10/07/2024 with a terminal diagnosis of COPD. The hospice plan of care written by the Registered Nurse on 11/23/2024, directed the Hospice Aide to provide a shower PRN. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 6: This patient elected the hospice benefit on 09/25/2024 with a terminal diagnosis of amyotrophic lateral sclerosis. The hospice plan of care written by the Registered Nurse on 09/25/2024, directed the hospice aide to perform a shower every visit and PRN. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 7: This patient elected the hospice benefit on 12/16/2024 with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care written by the Registered Nurse on 12/16/2924, directed the hospice aide to perform the following tasks as PRN: bed bath partial, bed bath complete, foot care, fingernail care, and oral care. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 8: This patient elected the hospice benefit 04/05/2024 with a terminal diagnosis of cirrhosis of the liver. The hospice plan of care written by the Registered Nurse on 04/05/2024, directed the hospice aide to perform the following tasks PRN: clean dentures. There was no documented evidence of specific instructions for frequency of these task. CLINICAL RECORD 11: This patient elected the hospice benefit on 04/30/2024 with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care written by the Registered Nurse on 04/30/2024, directed the hospice aide to provide the following tasks PRN: shower and shampoo. There was no documented evidence of specific instructions for frequency of these task. In an interview conducted on 01/15/2025 with the Hospice Administrator confirmed that hospice aide plans of care did not contain clear and specific instructions for the patient’s required care.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. This standard was not met as evidenced by the review of QAPI and interview with the Administrator. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The annual hospice volunteer percentage for 2024 documented in the QAPI data for value of volunteer hours was 3.92. The Hospice Administrator confirmed that this did not meet the requirement. This standard was not met as evidenced by the review of QAPI and interview with the Administrator. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator stated there was no documentation for 2023 that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The annual hospice volunteer percentage for 2024 documented in the QAPI data for value of volunteer hours was 3.92. The Hospice Administrator confirmed that this did not meet the requirement.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the clinical record contained physician orders. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/22/2024 with a terminal diagnosis of intestinal obstruction. The comprehensive assessment dated 08/22/2024 documented the patient was admitted with a foley catheter. The Registered Nurse charted she received an order to remove the foley catheter. In review of the physician’s orders in the clinical record, there was no documented evidence of a physician’s order to remove the foley catheter. CLINICAL RECORD 13: This patient elected the hospice benefit on 08/14/2024 with a terminal diagnosis of late onset Alzheimer’s Disease and expired on 09/26/2024. The IDG notes dated 09/23/2024 stated that the patient had been started on Morphine PRN and this was helping to manage the patient’s pain. In review of the physician’s orders in the clinical record, there was no documented evidence of a physician’s order for the administration of Morphine. In an interview conducted on 01/15/2025, the Hospice Administrator confirmed that the physician orders were not present in the clinical record.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record in which the patient was discharged revealed the agency did not ensure that the patient’s hospice plan of care was provided to the attending physician upon discharge. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/05/2024 with a terminal diagnosis of cirrhosis of the liver and revoked hospice services on 04/20/2024. In review of the documentation sent to the attending physician, there was no evidence in that the agency provided the attending physician with the hospice plan of care. In an interview with the Hospice Administrator on 01/15/2024, it was confirmed that the discharge summary sent to the physician did not include a hospice plan of care.”

“It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. 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 document in the clinical record that the patient, as appropriate, and the family and/or other caregivers received instructions on proper handling, storage, and safe utilization of durable medical equipment and/or supplies. CLINICAL RECORD 1: This patient elected the hospice benefit on 07/01/2024 with a terminal diagnosis of hypertensive heart failure and chronic kidney failure stage 4. In review of the clinical record, the patient was provided with a Geri-chair. There was no documented evidence that the patient, family and/or other caregivers received instructions on proper handling, storage, and safe utilization of the Geri-chair equipment provided. CLINICAL RECORD 5: This patient elected the hospice benefit on 12/22/2024 with a terminal diagnosis of acute diastolic (congestive) heart failure. In review of the clinical record, the patient was provided with a hospital bed, bedside table, mattress, O2 concentrator, oxygen tanks, and bedrails. There was no documented evidence that the patient, family and/or other caregivers received instructions on proper handling, storage, and safe utilization of durable medical equipment and/or supplies that were provided. CLINICAL RECORD 6: This patient elected the hospice benefit on 09/25/2024 with a hospice diagnosis of amyotrophic lateral sclerosis. In review of the clinical record, the patient owned the following equipment upon admission: mechanical wheelchair, Trilogy CPAP machine, and an adjustable bed. The agency provided an oxygen concentrator and suction machine. There was no documented evidence that the patient, family and/or other caregivers received instructions on proper handling, storage, and safe utilization of the oxygen concentrator and suction machine equipment provided. CLINICAL RECORD 12: This patient elected the hospice benefit on 08/22/2024 with a terminal diagnosis of unspecified intestinal obstruction. In review of the clinical record, the patient was provided with a hospital bed and a wheelchair. There was no documented evidence that the patient, family and/or other caregivers received instructions on proper handling, storage, and safe utilization of the hospital bed and a wheelchair equipment provided. In an interview conducted with the Hospice Administrator on 01/15/2025, it was confirmed that the instruction to the patient, family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies was not documented in the clinical record.”