Every finding on record at Accentcare Home Health of Mountain Valley, LLC

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, interview, and observation. In 1 of 4 (25%) clinical records reviewed, the agency did not ensure that the Registered Nurse provided the hospice aide with specific instructions on the hospice aide's plan of care. CLINICAL RECORD 2/HOME VISIT 1: The most recent hospice aide plan of care, dated 03/13/2025, was reviewed, and bathing; shower was assigned for every visit. The physician's order, effective 12/04/2025, ordered hospice aide services twice weekly. The hospice aide's visit documentation revealed that the aide showered the patient once weekly. The hospice aide visit on 12/08/2025 documented shower-no; patient showers only 1x. A shower was also documented on 12/17/2025 and 12/22/2025. The hospice aide visit on 01/16/2026 documented shower-no; patient only takes one shower per week. During the home visit on 01/21/2026, the hospice aide stated, "she only gets showers one time weekly, it's been this way for months, the RN knows but the plan still isn't updated." The Team Director was present for the home visit on 01/21/2026. During a joint record review and interview on 01/21/2026, the Director of Clinical Operations agreed that there was no documented evidence that the Registered Nurse updated the aide care plan to include the weekly showers. Additionally, the Director of Clinical Operations did not have any evidence that the hospice aide's plan of care was updated after 03/13/2025. During an interview on 01/21/2026, the Team Director stated that the aide's plan of care needs to be updated; it's not up to date.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 2 (50%) home visits observed, the agency did not ensure the hospice aide followed the plan of care as ordered. CLINICAL RECORD 2/HOME VISIT 1: During the Home Visit on 01/21/2026, the Hospice Aide (PR#1) was observed using an electric shaver to shave the patient's chin. The plan of care dated 03/13/2025 did not instruct the aide to shave the patient. After the visit, the Hospice Aide stated, "I thought shaving was ordered, but I see now that it wasn't." The Team Director observed the visit and agreed that shaving was not ordered on the plan of care. During an interview on 01/21/2026, the Team Director agreed that the hospice aide's plan of care did not include shaving. Additionally, the Team Director stated that only the tasks ordered should be completed. The plan of care needs to be updated if the patient wants to be shaved. During a joint record review and interview on 01/21/2026, the Director of Clinical Operations agreed that the hospice aide's plan of care did not include shaving.

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 1 of 16 (6%) clinical records reviewed of patients that received Hospice Aide (HA) services, the hospice did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/07/2025 with diagnoses of atherosclerotic heart disease of the native coronary artery without angina pectoris. The patient resided in a skilled nursing facility (SNF). The RN start-of-care visit note dated 01/07/2025 documented the patient's unstageable coccyx wound. On 01/08/2025, the RN visit note documented a plan of care (POC) update order for the SNF to provide wound care to the coccyx three (3) times a week. The RN wound care assessments dated 01/07/2025 through 04/10/2025 documented the patient's unstageable open coccyx wound. The plan of care dated 01/07/2025 ordered Hospice Aide (HA) services two (2) times a week. The HA care plan dated 01/07/2025, assigned the HA the relevant task of a shower every visit. The HA visit note dated 01/08/2025 (following the RN visit on the same date) documented that a shower was provided. The HA care plan was updated on 01/10/2025, changing the patient's bath to a bed bath. The HA care plans dated 01/07/2025 through 04/10/2025 did not alert the HA to the coccyx wound and did not provide the HA with specific written instructions for managing the dressing during showers or baths, nor did they instruct the HA to notify the RN if the wound dressing became soiled, dislodged, or wet during the bath. During a joint record review and interview on 07/18/2025, the Director of Clinical Operations agreed there was no documented evidence that the RN provided the HA with patient-specific written care instructions on the aide care plan related to how to manage and what to report related to the "Coccyx" wound while performing the ordered task: "Shower" and "Bed bath." Additionally, during an interview on 07/18/2025, the Director of Clinical Operations stated, "The RN missed it because the facility did the wound care. We need to be more specific with HA directives."

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, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS 3-003 "Clinical Leadership Responsibilities and Supervision" stated in part, "The RN makes an on-site hospice aide supervisory visit to the patient's home no less frequently than every 14 days to assess the quality of care, adequacy of services provided by the hospice aide, and ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. The aide does not have to be present during the RN supervisory visit every 14 days." In 2 of 16 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the hospice did not ensure that the Registered Nurse (RN) supervised the HA at least every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/04/2023. The plan of care dated 04/21/2025 through 05/12/2025 ordered HA services twice weekly, with a bed bath assigned every visit. The HA documented visits on 04/21/2025, 04/24/2025, 04/28/2025, 04/30/2025, 05/05/2025, and 05/08/2025. The RN completed supervisory visits on 04/20/2025 and 05/12/2025, with 22 days outstanding. There was no documented evidence of a supervisory visit by the RN between 04/21/2025 through 05/11/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/18/2025. The plan of care dated 05/06/2025 through 06/10/2025 ordered HA services once weekly. A clinical record review revealed documented HA visit notes dated 05/06/2025, and weekly through 05/27/2025. The RN completed a supervisory visit on 05/28/2025, with 22 days outstanding. There was no documented evidence of a supervisory visit by the RN between 05/06/2025 through 05/27/2025. During a joint record review and interview on 07/18/2025, the Director of Clinical Operations agreed that there was no documented evidence of supervisory visits during the identified period. Additionally, during an interview on 07/18/2025, the Director of Clinical Operations stated, "These were missed. We did not follow our own policy."

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the chaplain completed the initial assessment within five (5) calendar days after the election of hospice care. Clinical Record 2: The patient elected hospice care on 11/8/2022. The initial plan of care ordered Chaplain services: "1x/1wk for evaluation." The Chaplain documented that contact was made, and a patient visit was attempted on 11/12/2022 with no success; a voicemail was left for the family. The Chaplain completed the spiritual assessment during the visit on 2/22/2023, 106 days after the election of hospice care. Clinical Record 4: The patient elected hospice care on 2/2/2023. The initial plan of care ordered chaplain services once a week for one week to evaluate patient needs. During a joint clinical record review and an interview, the Clinical Director confirmed the Chaplain was visit and the spiritual assessment were completed on 2/16/2023, 14 days after the election of hospice care. There was no evidence of contact with the patient before this date.

It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice 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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 2 of 5 (40%) clinical records reviewed revealed the hospice did not ensure the social worker followed the plan of care as ordered. Clinical Record 2: The patient elected hospice care on 11/8/2022. The initial plan of care ordered Chaplain services: "1x/1wk for evaluation." The Chaplain documented that contact was made, and a patient visit was attempted on 11/12/2022 with no success; a voicemail was left for the family. The Chaplain completed the visit on 2/22/2023. There was no evidence of communication with the physician or a documented missed visit. Clinical Record 4: The patient elected hospice care on 2/2/2023. The initial plan of care ordered chaplain services once a week for one week to evaluate patient needs. During a joint clinical record review and an interview, the Clinical Director confirmed the Chaplain completed the visit on 2/16/2023. There was no evidence of contact with the patient, a documented missed visit, or communication with the physician.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided services included in the plan of care. Clinical Record 2: The patient was admitted to hospice services on 11/8/2022. The plan of care ordered hospice aide services two times a week. The aide care plan assigned the tasks: bathing/seated shower...every visit. The hospice aide visit notes dated 5/23/2023, 5/30/2023, and 6/6/2023 did not document the task: bathing/seated shower as completed. There was no evidence of communication with the Registered Nurse or change in the aide care plan. During an interview and a joint record review, the Clinical Director agreed that the aide did not follow the care plan.

It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice 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. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure the social worker followed the plan of care as ordered. Record 2: This patient was admitted to hospice on 6/7/2022. The physician's order on 6/9/2022 ordered a visit frequency for the Medical Social Worker (MSW) 1wk2, 1every2wk10. There was a MSW visit on 6/9/2022. During the week 6/12/2022-6/18/2022, there was no documented evidence of a MSW visit. A missed visit note on 6/18 revealed: “already completed.” There was no documented evidence the visit was already completed. During the weeks 6/19/2022-6/25/2022, 6/26/2022-7/2/2022, and 7/3/2022-7/9/2022, there was no documented evidence of a MSW visit or documented reasons for the missed visits. Record 3: This patient was admitted to hospice on 5/11/2022. The physician's order on 5/11/2022 ordered a visit frequency for the MSW 1wk1, 1every2wk2. There was a MSW visit on 5/11/2022. During the week of 5/22/2022-5/28/2022, there was no documented evidence of a MSW visit or documented reasons for the missed visit. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed that the social worker did not follow the plan of care as ordered. Record 2: This patient was admitted to hospice on 6/7/2022. The physican’s order on 6/9/2022 ordered a MSW 1wk2, 1every2wk10. There was a MSW (Medical Social Worker) visit on 6/9/2022. During the week 6/12/2022-6/18/2022 there was no documented evidence of a MSW visit. A missed visit note on 6/18 revealed “already completed.” There was no documented evidence the visit was already completed. During the weeks 6/19/2022-6/25/2022, 6/26/2022-7/2/2022, 7/3/2022-7/9/2022 there was no documented evidence of a MSW visit or documented reasons for the missed visits. Record 3: This patient was admitted to hospice on 5/11/2022. The physican’s order on 5/11/2022 ordered a MSW 1wk1, 1every2wk2. There was a MSW (Medical Social Worker) visit on 5/11/2022. During the week 5/22/2022-5/28/2022 there was no documented evidence of a MSW visit or documented reasons for the missed visit. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, the social worker did not follow the plan of care as ordered.

It is required that each patient’s individualized written plan of care reflects patient and family goals 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 intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed, the hospice did not ensure the plan of care included planned interventions and measurable outcomes based on problems identified in the initial and updated comprehensive assessments. Record 1: This patient was admitted to hospice on 8/15/2022. Diagnosis of Atherosclerosis heart disease of the native coronary artery without angina pectoris. The Registered Nurse assessment on 8/15/2022 revealed “yes” uncomfortable due to pain, current pain level of 3 to lower extremity and coccyx, “yes” affects the quality of life, the goal of 0. The plan of care dated 8/15/2022 did not include interventions or goals to manage the pain. Record 4: This patient was admitted to hospice on 6/30/2022. Diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse assessment on 8/15/2022 documented 22 respirations, 99% O2 saturation with continuous 9 ½ liter oxygen, and dependence on supplemental oxygen. The plan of care dated 8/15/2022 did not identify respiratory problems or include interventions and goals to manage the patient’s respiratory status. Record 5: This patient was admitted to hospice on 8/2/2022. Diagnosis of Malignant Neoplasm of Prostate. The medication profile documented on 8/3/2022, Tramadol 50mg three times daily as needed for pain. The plan of care did not identify pain as a problem or include interventions and goals to manage the pain. The medication profile documented on 8/17/2022 Bactrim DS 800mg-160mg two times daily, reason for UTI. The plan of care identified altered genitourinary status as a problem on 8/2/2022. The plan of care dated 8/2/2022 did not include interventions or goals to manage the altered genitourinary status. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed, in the records identified, that the plan of care did not include interventions and goals based on the problems identified in the assessments. Record 1: This patient was admitted to hospice on 8/15/2022. Diagnosis Atherosclerosis heart disease of native coronary artery without angina pectoris. The plan of care dated 8/15/2022 was reviewed. The registered nurse assessment on 8/15/2022 revealed “yes” the pain is uncomfortable due to pain, current pain of 3 to lower extremity and coccyx, “yes” affects quality of life, goal of 0. The plan of care did not include interventions or goals to manage the pain. Record 4: This patient was admitted to hospice on 6/30/2022. Diagnosis Chronic Obstructive Pulmonary Disease. The plan of care dated 8/15/2022 was reviewed. The registered nurse assessment on 8/15/2022 revealed 22 respirations, 99% O2 saturation with 9 ½ liter oxygen, dependence on supplemental oxygen. The plan of care did not identify respiratory as a problem or include interventions and goals to manage the patient’s respiratory status. Record 5: This patient was admitted to hospice on 8/2/2022. Diagnosis malignant neoplasm of prostate. The plan of care dated 8/2/2022 was reviewed. The medication profile revealed 8/3/2022 Tramadol 50mg three times daily as needed for pain. The plan of care did not identify pain as a problem or include interventions and goals to manage the pain. The medication profile revealed 8/17/2022 Bactrim DS 800mg-160mg two times daily, reason UTI. The plan of care identified altered genitourinary status as a problem on 8/2/2022. The plan of care did not include interventions or goals to manage the altered genitourinary status. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed, in the records identified, the plan of care did not include interventions and goals based on the problems identified in the 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 a review of document reviews, interviews, and observations. 2 of 3 (66%) observations during home visits revealed the hospice did not ensure adherence to agency infection control policies and procedures for hand hygiene. Agency policy, “Infection Control: Hand Hygiene, Section 14.02,” stated in part, “Use a towel to turn off the faucet.” Agency policy, “Infection Control: Hand Hygiene, Section 14.02,” stated in part, “Hand hygiene must be performed before and after performing a procedure, e.g., wound care; before and after handling an invasive device, e.g., urinary or vascular catheter.” During observation of Home Visit #1 on 8/30/2022 at 8:30 am, Staff #7 washed her hands in the sink and turned off the faucet with her hand. The aide donned gloves and gave the patient a bed bath. The aide used the same washcloth to wash the peri and groin area, wash the face, place a shampoo cap on the patient’s head, and clean the nails. The aide was not observed replacing the washcloth or gloves. During observation of Home Visit #3 on 8/30/2022 at 1:00 pm, Staff #3 donned gloves, handled the urinary catheter tubing and dirty dressing on tubing, then adjusted bed height with the remote, removed the soiled dressing from the coccyx wound, cleaned with wound cleanser, wrote measurements on paper, applied cream, applied dressing, repositioned patient, adjusted bed height with the remote. The nurse was not observed performing hand hygiene after touching the catheter tubing, before wound care to the coccyx, or after wound care. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed that the staff did not follow the infection control policy on hand hygiene. Agency policy, “Infection Control: Hand Hygiene, Section 14.02,” stated in part, “Use towel to turn off faucet.” Agency policy, “Infection Control: Hand Hygiene, Section 14.02,” stated in part, “Hand hygiene must be performed before and after performing a procedure, e.g., wound care; before and after handling an invasive device e.g., urinary or vascular catheter.” During observation of Home Visit #1 on 8/30/2022 at 8:30am, Staff #7 washed her hands in the sink, and turned off the faucet with her hand. The aide donned gloves and gave the patient a bed bath. The aide used the same washcloth to wash the peri and groin area, then wash the face, then placed shampoo cap on the patient’s head, and cleaned the nails. The aide was not observed replacing the washcloth or gloves. During observation of Home Visit #3 on 8/30/2022 at 1:00pm, Staff #3 donned gloves, handled the urinary catheter tubing and dirty dressing on tubing, then adjusted bed height with the remote, removed dirty dressing from coccyx wound, cleaned with wound cleanser, wrote measurements on paper, applied calazime cream, applied dressing, repositioned patient, adjusted bed height with the remote. The nurse was not observed performing hand hygiene after touching the catheter tubing, before providing wound care to the coccyx or after providing wound care. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, the staff did not follow the infection control policy on hand hygiene.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 8 (63%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 2: This patient was admitted to hospice on 6/7/2022. The hospice aide plan of care dated 6/7/2022 ordered a visit frequency for the hospice aide 1wk13, and bathing, shower seated each visit. The hospice aide documentation on 7/6/2022 revealed bathing, shower seated with a note: completed bed bath. There was no documented evidence the Registered Nurse was notified. During the week 6/19/2022-6/25/2022, there was no documented evidence of a hospice aide visit. There was no documented reason for the missed visit. Record 3: This patient was admitted to hospice on 5/11/2022. The plan of care dated 5/12/2022 ordered a visit frequency for the hospice aide 2wk12. During the week 6/5/2022-6/11/2022, there was a hospice aide visit on 6/8/2022. There was no documented evidence of a second visit that week. During the week 6/12/2022-6/18/2022, there was a hospice aide visit on 6/14/2022. There was no documented evidence of a second visit that week. During the week 6/19/2022-6/25/2022, there was a hospice aide visit on 6/20/2022. There was no documented evidence of a second visit that week. There were no documented reasons for the missed visits. Record 4: This patient was admitted to hospice on 6/30/2022. The plan of care dated 6/30/2022 ordered a hospice aide 2wk8 effective 7/3/2022. During the week 7/31/2022-8/6/2022, there was a hospice aide visit on 8/4/2022. There was no documented evidence of a second visit that week. There were no documented reasons for the missed visits. Record 6: This patient was admitted to hospice on 11/29/2019. The hospice aide plan of care dated 9/20/2020 ordered for every visit: comb brush hair, shampoo, bathing (shower), and brush teeth. The hospice aide documentation on 1/25/2021 revealed tasks not completed with the note patient refused, task already completed: comb brush hair, shampoo, bathing (shower), and brush teeth. There was no documented evidence the Registered Nurse was notified. Record 7: This patient was admitted to hospice on 9/5/2021. The hospice aide plan of care dated 9/5/2021 ordered 2 x weekly: bathing (bed bath), shampoo. The hospice aide documentation on 2/14/2022 revealed tasks not completed with the note patient preference patient refused. The Registered Nurse assessment on 2/10/2022 revealed YES to cognitive impairment: could include patients with dementia, Alzheimer or stroke patients or patients who are confused, use poor judgement, have decreased comprehension, impulsivity, memory deficits, consider patients ability to adhere to the plan of care. There was no documented evidence the Registered Nurse was notified. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, the hospice aide did not follow the plan of care as ordered. Record 2: This patient was admitted to hospice on 6/7/2022. The hospice aide plan of care dated 6/7/2022 ordered a hospice aide 1wk13, bathing: shower seated each visit. The hospice aide documentation on 7/6/2022 revealed bathing: shower seated with a note: completed bed bath. There was no documented evidence the registered nurse was notified. During the week 6/19/2022-6/25/2022, there was no documented evidence of a hospice aide visit. There was no documented reason for the missed visit. Record 3: This patient was admitted to hospice on 5/11/2022. The plan of care dated 5/12/2022 ordered a hospice aide 2wk12. During the week 6/5/2022-6/11/2022, there was a hospice aide visit on 6/8/2022. There was no documented evidence of a second visit that week. During the week 6/12/2022-6/18/2022, there was a hospice aide visit on 6/14/2022. There was no documented evidence of a second visit that week. During the week 6/19/2022-6/25/2022, there was a hospice aide visit on 6/20/2022. There was no documented evidence of a second visit that week. There were no documented reasons for the missed visits. Record 4: This patient was admitted to hospice on 6/30/2022. The plan of care dated 6/30/2022 ordered a hospice aide 2wk8 effective 7/3/2022. During the week 7/31/2022-8/6/2022, there was a hospice aide visit on 8/4/2022. There was no documented evidence of a second visit that week. There were no documented reasons for the missed visits. Record 6: This patient was admitted to hospice on 11/29/2019. The hospice aide plan of care dated 9/20/2020 ordered for every visit: comb brush hair, shampoo, bathing (shower), and brush teeth. The hospice aide documentation on 1/25/2021 revealed tasks not completed with the note patient refused, task already completed: comb brush hair, shampoo, bathing (shower), and brush teeth. There was no documented evidence the registered nurse was notified. Record 7: This patient was admitted to hospice on 9/5/2021. The hospice aide plan of care dated 9/5/2021 ordered 2 x weekly: bathing (bed bath), shampoo. The hospice aide documentation on 2/14/2022 revealed tasks not completed with the note patient preference patient refused. The registered nurse assessment on 2/10/2022 revealed YES to cognitive impairment: could include patients with dementia, Alzheimer or stroke patients or patients who are confused, use poor judgement, have decreased comprehension, impulsivity, memory deficits, consider patients ability to adhere to the plan of care. There was no documented evidence the registered nurse was notified. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 8 (38%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide reported changes in patient needs to the Registered Nurse. Record 2: This patient was admitted to hospice on 6/7/2022. The hospice aide plan of care dated 6/7/2022 ordered bathing and shower seated each visit. The hospice aide documentation on 7/6/2022 revealed bathing, shower seated with a note: completed bed bath. There was no documented evidence the Registered Nurse was notified. Record 6: This patient was admitted to hospice on 11/29/2019. The hospice aide plan of care dated 9/20/2020 was ordered for every visit: comb, brush hair, shampoo, bathing (shower), and brush teeth. The hospice aide documentation on 1/25/2021 revealed tasks not completed with the note patient refused, task already completed: comb, brush hair, shampoo, bathing (shower), and brush teeth. There was no documented evidence the Registered Nurse was notified. Record 7: This patient was admitted to hospice on 9/5/2021. The hospice aide plan of care dated 9/5/2021 ordered 2 x weekly: bathing (bed bath) and shampoo. The hospice aide documentation on 2/14/2022 revealed tasks not completed with the note patient preference patient refused. The Registered Nurse assessment on 2/10/2022 revealed YES to cognitive impairment: could include patients with dementia, Alzheimer's or stroke patients, or patients who are confused, use poor judgment, have decreased comprehension, impulsivity, memory deficits, consider patients' ability to adhere to the plan of care. There was no documented evidence the Registered Nurse was notified. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed that the hospice aide did not report changes in patient needs to the Registered Nurse.

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: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) clinical records reviewed, the hospice did not ensure the notification of hospice non-covered items were provided to the patient within five days of the request upon admission. Record 5: This patient was admitted to hospice on 8/2/2022. The hospice election statement was reviewed and identified the patient caregiver requested the addendum on 8/2/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 10: This patient was admitted to hospice on 7/19/2022. The hospice election statement was reviewed and identified the patient caregiver requested the addendum on 7/19/2022. The notification of hospice non-covered items was completed and provided to the patient on 7/27/2022. The Director of Clinical Operations was interviewed on 8/29/2022 and agreed that the hospice non-covered items were not provided to the patients identified within five days of their request at the time of admission. Record 5: This patient was admitted to hospice on 8/2/2022. The hospice election statement was reviewed and identified the patient caregiver requested the addendum on 8/1/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 10: This patient was admitted to hospice on 7/19/2022. The hospice election statement was reviewed and identified the patient caregiver requested the addendum on 7/18/2022. The notification of hospice non-covered items was completed and provided to the patient on 7/27/2022. The Director of Clinical Operations was interviewed on 8/29/2022 and agreed, the hospice non-covered items were not provided to the patients identified within 5 days of their request at the time of admission.

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 a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed, the hospice did not ensure the clinical record included a physician’s order for the urinary catheter. Record 1: This patient was admitted to hospice on 8/15/2022. The Registered Nurse visit note on 8/17/2022 documented a Foley catheter was placed. There was no documented evidence of a physician's order for the catheter. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, that there were no physician orders for the catheter. Record 1: This patient was admitted to hospice on 8/15/2022. The Registered Nurse visit note on 8/17/2022 revealed a foley catheter was placed. There was no documented evidence of a physican’s order for the catheter. The Director of Clinical Operations was interviewed on 8/30/2022 and agreed, there were no physician orders for the catheter.

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 a review of clinical records and interview. 2 of 2 (100?%) discharged clinical records, the hospice did not ensure that the discharge summary was sent to the patient’s attending physician. Record 10: This patient was admitted to hospice on 7/19/2022. The discharge was reviewed and revealed the patient signed a revocation on 8/18/2022 with the reason for seeking treatment. There was no documented evidence the discharge summary was sent to the attending physician. Record 11: This patient was admitted to hospice on 8/5/2021. The discharge was reviewed and revealed the patient was discharged on 4/1/2022 with the reason no longer terminally ill/extended prognosis. There was no documented evidence the discharge summary was sent to the attending physician. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed that the discharge summary was not sent to the attending physician. Record 10: This patient was admitted to hospice on 7/19/2022. The discharge was reviewed and revealed the patient signed a revocation 8/18/2022 with the reason, seeking treatment. There was no documented evidence the discharge summary was sent to the attending. Record 11: This patient was admitted to hospice on 8/5/2021. The discharge was reviewed and revealed the patient was discharged on 4/1/2022 with the reason, no longer terminally ill/extended prognosis. There was no documented evidence the discharge summary was sent to the attending. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed, the discharge summary was not sent to the attending.

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: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) discharged clinical records, the hospice did not ensure that the discharge summary was completed and provided to the attending physician to include a summary of the patient’s stay, the current plan of care and latest physician’s orders. Record 10: This patient was admitted to hospice on 7/19/2022. The discharge was reviewed and revealed the patient signed a revocation on 8/18/2022 with the reason for seeking treatment. There was no documented evidence the discharge summary was completed. Record 11: This patient was admitted to hospice on 8/5/2021. The discharge was reviewed and revealed the patient was discharged on 4/1/2022 with the reason no longer terminally ill/extended prognosis. There was no documented evidence the discharge summary was completed. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed, that there were no discharge summaries in the records identified. Record 10: This patient was admitted to hospice on 7/19/2022. The discharge was reviewed and revealed the patient signed a revocation 8/18/2022 with the reason seeking treatment. There was no documented evidence the discharge summary was completed. Record 11: This patient was admitted to hospice on 8/5/2021. The discharge was reviewed and revealed the patient was discharged on 4/1/2022 with the reason no longer terminally ill/extended prognosis. There was no documented evidence the discharge summary was completed. The Director of Clinical Operations was interviewed on 9/1/2022 and agreed, there were no discharge summaries in the records identified.