Every finding on record at Accord Health Group

The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: 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, includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/30/2024. During the initial nursing assessment dated 09/30/2024, the nurse documented that the patient had a 20 French 3-way catheter in place due to a history of clots in bladder. Also documented was the frequency of the catheter change every 30 days and an unknown date for when the catheter was last changed or the next change date. There was no documented evidence on the plan of care dated 09/30/2024-12/28/2024 that included foley catheter care interventions or goals . CLINICAL RECORD 16: The patient elected the hospice benefit on 12/05/2024. During the initial nursing assessment dated 12/05/20245 , the nurse documented that the patient had a foley catheter present draining clear, amber urine. There was no documented evidence on the plan of care dated 12/05/2024-03/04/2025 that included foley catheter care interventions or goals. During an interview with the Administrator (Personnel Record 6) and the Director of Nurses (Personnel Record 5) on 10/01/2025 they stated that a performance improvement plan for care plans would be written, and education would be provided to the clinical staff.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed for patients requiring a physician's recertification of terminal illness revealed that the agency did not ensure that the hospice medical director or physician designee signed the recertification of terminal illness no later than two calendar days after the first day of each benefit period and no more than fifteen days before the next benefit period begins. CLINICAL RECORD 3: The clinical record review lacked evidence that the recertification of terminal illness was signed timely, as evidence by the recertification of terminal illness for benefit period 08/24/2025 to 10/22/2025 was signed on 09/04/2025 (11 days after the benefit period began. CLINICAL RECORD 4: The clinical record review lacked evidence that the recertification of terminal illness was signed timely, as evidence by the recertification of terminal illness for benefit period 08/17/2025 to 10/15/2025 was signed 08/25/2025( 8 days after the benefit period began). During a joint review of the clinical record with the administrator (Personnel record 6) on 10/01/2025 she stated that was unaware of this happening but that she would be reviewing and educating staff on importance of obtaining signed recertification of terminal illness timely.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 19 (11%) clinical record reviewed revealed that the agency did not ensure that the clinical record contained past and current physician orders. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/30/2024. The initial nursing assessment documented that “patient has a 20 French 3 way catheter in place due to history of clots in bladder” and "frequency of change is q 30 days and unknown for last changed and next change date". There were no physicians orders for the Foley catheter to be changed or maintained in the clinical record for the benefit period 09/30/2024 to 12/28/2024. CLINICAL RECORD 16: The patient elected the hospice benefit on 12/05/2024. The initial nursing assessment documented that “patient has a foley cath present draining clear, amber urine”. ". There were no physicians orders for the Foley catheter to be changed or maintained in the clinical record for benefit period 12/05/2024 to 01/26/2025. During an interview with the Administrator (Personnel Record 6) and the Director of Nurses (Personnel Record 5) on 10/01/2025 they stated that a performance improvement plan would be written up, and education would be provided to the clinical staff.

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 a review of clinical records and interviews. In 12 of 13 (92%) records reviewed the medication profiles did not include documentation of all medications ordered on the plans of care. Clinical Record 2 - Initial plan of care dated 3/7/2022 included orders for, "Oxygen ordered 1-5 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 1 - The plan of care dated 10/31/2021 included orders for, "Oxygen ordered 1-5 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 9 - The plan of care dated 10/30/2022 included orders for, "Oxygen ordered 2-9 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 3 - The plan of care dated 8/10/2022 included orders for, "Oxygen ordered 2-5 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. Clinical Record 4 - The plan of care dated 3/6/2020 included orders for, "Oxygen ordered 2-5 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. Clinical Record 5 - The plan of care dated 9/23/2022 included orders for, "Oxygen ordered 2 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. Clinical Record 13 - The plan of care dated 12/4/2021 included orders for, "Oxygen ordered 2-5 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. Clinical Record 8 - The plan of care dated 8/16/2022 included orders for, "Oxygen ordered 2-5 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. Clinical Record 7 - The plan of care dated 10/10/2022 included orders for, "Oxygen ordered 2-5 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 11 - The plan of care dated 6/8/2022 included orders for, "Oxygen ordered 2-5 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 6 - The plan of care dated 9/26/2022 included orders for, "Oxygen ordered 2 liters per nasal cannula prn". Oxygen was not listed on the medication profile. Clinical Record 10 - The plan of care dated 1/11/2021 included orders for, "Oxygen ordered 2-5 liters per nasal cannula as needed". Oxygen was not listed on the medication profile. The Senior Executive Director stated during interview and joint review of the clinical records, that she was unaware that Oxygen was considered a drug and should be documented on the medication profile.

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 a review of clinical records. In 6 of 11 (55%) applicable records of patients who received hospice aide services, the registered nurse did not ensure the aide plans of care included written instructions for all aspects of the patients' care. Clinical Record 3 - The aide plan of care dated 8/10/2022 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". Clinical Record 8 - The aide plan of care dated 8/16/2022 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". Clinical Record 2 - The aide plan of care dated 3/7/2022 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". Clinical Record 10 - The aide plan of care dated 1/11/2021 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". Clinical Record 4 - The aide plan of care dated 3/6/2020 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". Clinical Record 5 - The aide plan of care dated 9/23/2022 did not include instructions related to the patient's use of oxygen that was ordered on the patient's plan of care. In the area on the aide plan designated for describing how oxygen was to be used, the nurse checked "NA". The Senior Executive Director stated in an interview and during joint review of the clinical records that the aide plans of care did not include information that the patient had orders for use of oxygen. see below