Bayada Hospice

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #0-944 “Client Care Coordination” (reviewed 03/24/2023) read in part, “Coordination of client services is the shared responsibility of the Client Services Manager and the Clinical Manager...Care coordination involves identification of additional services needed, contacting community resources for those services, discussions of the client’s needs, and status and follow-up as appropriate.” In 6 of 7 (86%) clinical records reviewed of patients with documented volunteer needs, the agency did not ensure that a Registered Nurse (RN) provided coordination of care to ensure continuous assessment of the patient and family needs and implementation of the interdisciplinary plan of care. Clinical Record 8: The patient elected hospice care on 10/19/2024 with a diagnosis of heart failure. The Registered Nurse (RN) Hospice Start of Care clinical note dated 10/19/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support, family respite, household support, companionship.” The patient accepted volunteer services. There was no evidence that the RN requested volunteer services, coordinated with the Volunteer Coordinator (VC) to ensure a follow-up assessment was completed, or that a care plan was initiated to address the patient’s volunteer needs. Clinical Record 9: The patient elected hospice care on 02/21/2023 with a diagnosis of cerebrovascular disease. The RN Hospice Start of Care clinical note dated 02/21/2023 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support.” The patient accepted volunteer services. There was no evidence that the RN requested volunteer services, coordinated with the VC to ensure a follow-up assessment was completed, or that a care plan was initiated to address the patient’s volunteer needs. Clinical Record 11: The patient elected hospice care on 11/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The skilled nursing (SN) visit note dated 12/20/2024 documented, “Volunteer request put in.” Volunteer services were added to the patient’s care plan on 12/20/2024. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/24/2024 identified the problem “Volunteer.” The patient accepted volunteer services. There was no evidence that the RN coordinated with the VC to ensure a follow-up assessment was completed or that a care plan was initiated to address the patient’s volunteer needs. Clinical Record 16: The patient elected hospice care on 09/05/2024 with a diagnosis of communicating hydrocephalus. The RN Hospice Start of Care clinical note dated 09/05/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: companionship.” The patient accepted volunteer services. There was no evidence that the RN requested volunteer services, coordinated with the VC to ensure a follow-up assessment was completed, or that a care plan was initiated to address the patient’s volunteer needs. Clinical Record 19: The patient elected hospice care on 11/13/2024 with a diagnosis of chronic kidney disease. The RN Hospice Start of Care clinical note dated 11/13/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: companionship.” The patient accepted volunteer services. There was no evidence that the RN requested volunteer services, coordinated with the VC to ensure a follow-up assessment was completed, or that a care plan was initiated to address the patient’s volunteer needs. Clinical Record 20: The patient elected hospice care on 08/10/2024 with a diagnosis of chronic systolic heart failure. The RN Hospice Start of Care clinical note dated 08/10/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support, household support, companionship, life review.” The patient accepted volunteer services. There was no evidence that the RN requested volunteer services, coordinated with the VC to ensure a follow-up assessment was completed, or that a care plan was initiated to address the patient’s volunteer needs. In a joint record review and interview on 01/29/2025, the Division Director confirmed that the clinical record lacked evidence that the RN, Client Services Manager, or Clinical Manager coordinated with the Volunteer Coordinator regarding volunteer needs identified in the initial and updated comprehensive assessments.”

“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, document review, and interview. Agency policy #0-4556 “Care Plan-Hospice Services” (revision 06/03/2024) read in part, “The comprehensive care plan reflects client/family goals based on problems identified in the initial/updated assessments and includes all the services necessary for palliation and management of the terminal illness and related conditions...Plan of care content includes, but is not limited to... Individualized interventions to assist with end-of-life care.” In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that the patient’s 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 7: The patient elected hospice care on 09/15/2024 with a diagnosis of Alzheimer’s Disease. The skilled nursing (SN) visit dated 12/09/2024 documented, “Appears to have scratched healing skin tear to L forearm. Area cleansed and covered with Mepilex 4x4.” The Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 12/11/2024 and 12/24/2024 did not document patient and family goals and planned interventions for the identified skin tear. Clinical Record 16: The patient elected hospice care on 09/05/2024 with a diagnosis of communicating hydrocephalus. The SN visit note dated 12/13/2024 documented, “Dr. James concerned for potential abscess given intermittent dental pain. Verbal order obtained from Dr. (name) to start Penicillin VK ...” A physician order was obtained on 12/13/2024 for “Penicillin VK 250mg 4x day for 7 days for infection.” A physician order was obtained on 12/16/2024 for 2 liters (L) as needed (prn) oxygen (O2) for comfort. The SN visit note dated 12/16/2024 documented, “This writer notified PCP office of reports of intermittent dyspnea and requested order to be sent to facility for 2L prn O2 for comfort.” The Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 12/11/2024 and 12/24/2024 did not document patient and family goals and planned interventions for the infection, oxygen, and dyspnea. During the joint record review and interview on 01/29/2025, the Division Director confirmed that the plan of care did not include goals or interventions related to the infection and oxygen/dyspnea.”

“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 to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency Policy #0-4849 “Frequency of Staff Supervision-Hospice” (revision 06/03/2024) read in part, “For clients receiving Home Health Aide (HHA) Services, an RN must make an on-site visit to the client’s home: 4.1 No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the client’s needs.” In 2 of 20 (10%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Clinical Record 9: The patient elected hospice care on 02/21/2023 with a diagnosis of cerebrovascular disease. The recertification plan of care dated 10/13/2024 through 12/01/2024 ordered HA services four (4) times weekly beginning 10/13/2024. The HA visits were provided beginning 10/13/2024 as ordered. The HA supervisory visits were provided on 11/07/2024 and 11/27/2024, with 20 days outstanding. Clinical Record 18: The patient elected hospice care on 05/09/2024 with a diagnosis of Alzheimer’s Disease. The recertification plan of care dated 11/05/2024 through 01/03/2025 ordered HA services two (2) times weekly beginning 11/05/2024. The HA supervisory visits were provided on 11/27/2024 and 12/18/2024, with 21 days outstanding. In a joint record review and interview on 01/29/2025, the Division Director confirmed that HA supervisory visits were not completed every 14 days per agency policy.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #0-4547 “Provision of Hospice Services” (revision 06/03/2024) read in part, “The Volunteer program is designed to meet federal regulations for the provision of volunteer services to (name of agency) clients and their caregivers. The volunteer program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the (name of agency) program and our clients.” Agency policy #0-4601 “Volunteer Services-Hospice” (revision 08/14/2023) read in part, “The duties of volunteers used in direct care services or helping clients and families must be reflected in the Hospice Interdisciplinary Group Care Plan and Volunteer Care Plan.” In 6 of 7 (86%) clinical records reviewed of patients with identified volunteer needs, the agency did not ensure volunteers were used in day-to day direct patient care roles and noted in the plan of care based on needs identified in the initial and updated comprehensive assessments. Clinical Record 8: The patient elected hospice care on 10/19/2024 with a diagnosis of heart failure. The Registered Nurse (RN) Hospice Start of Care clinical note dated 10/19/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support, family respite, household support, companionship.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. Clinical Record 9: The patient elected hospice care on 02/21/2023 with a diagnosis of cerebrovascular disease. The RN Hospice Start of Care clinical note dated 02/21/2023 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. Clinical Record 11: The patient elected hospice care on 11/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The skilled nursing (SN) visit note dated 12/20/2024 documented, “Volunteer request put in.” Volunteer services were added to the patient’s care plan on 12/20/2024. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/24/2024 identified the problem “Volunteer.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. Clinical Record 16: The patient elected hospice care on 09/05/2024 with a diagnosis of communicating hydrocephalus. The RN Hospice Start of Care clinical note dated 09/05/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: companionship.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. Clinical Record 19: The patient elected hospice care on 11/13/2024 with a diagnosis of chronic kidney disease. The RN Hospice Start of Care clinical note dated 11/13/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: companionship.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. Clinical Record 20: The patient elected hospice care on 08/10/2024 with a diagnosis of chronic systolic heart failure. The RN Hospice Start of Care clinical note dated 08/10/2024 documented, “Client is appropriate for volunteer services and would benefit from the following: patient support, household support, companionship, life review.” The volunteer services were accepted by the patient. A clinical record review revealed no evidence that the volunteer services were provided, a follow-up assessment was completed, or a care plan was initiated to address volunteer needs. During the joint record review and interview on 01/29/2025, the Division Director confirmed that the clinical records did not include evidence that volunteer services were implemented and noted in the plan of care based on needs identified in the initial and comprehensive assessments, stating in part, “It looks like there was a breakdown in the process, the volunteer needs were not entered on the volunteer coordination note which is how the volunteer coordinator is notified of needs.””

“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. The hospice 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. Agency policy #0-4601 “Volunteer Services-Hospice” (revision 08/14/2023) read in part, “12.1 The duties of volunteers used in direct care services or helping clients and families must be reflected in the Hospice Interdisciplinary Group Care Plan and Volunteer Care Plan. 14.0 (agency name) documents and maintains a volunteer staff sufficient to provide administrative or direct client care in an amount that, at a minimum, equals 5% of the total client care hours of all paid hospice employees and contract staff.” The Volunteer Activity report dated 01/01/2024 through 01/01/2025 was reviewed with the Volunteer Coordinator (personnel record 7) on 01/28/2025. The Volunteer Coordinator confirmed that the percentage of volunteers that provided day-to-day administrative and/or direct patient care services was 1.22% for 01/01/2024 through 01/01/2025, less than the required 5%. During an interview on 01/27/2025, the Division Director/Administrator confirmed that volunteer utilization was below the requirement of 5% and stated in part, “We have a newer Volunteer Coordinator, and he is focusing on recruitment and areas to increase volunteer utilization.” A review of the Volunteer Activity Report for 01/01/2024 through 01/01/2025 revealed that the agency did not ensure 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.”

“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, document review, and interview. Agency policy #0-4556 “Care Plan-Hospice Services” (revision 06/03/2024) read in part “4.0 Plan of care content includes, but is not limited to: 4.5 Treatments, drugs and interventions to manage pain and symptoms.” In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the patient’s clinical record contained physician orders for the care and services provided. Clinical Record 7: The patient elected hospice care on 09/15/2024 with a diagnosis of Alzheimer’s Disease. The skilled nursing (SN) visit note dated 12/09/2024 documented, “Appears to have scratched healing skin tear to L forearm. Area cleansed and covered with Mepilex 4x4.” A clinical record review revealed no evidence that a physician order was obtained for the wound care provided. During a joint record review and interview on 01/29/2025, the Division Director confirmed the findings, stating, “There should be orders for the wound care provided.””