Every finding on record at Achs Hospice & Palliative Care

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the patient was informed about the scope of services the hospice provides and any specific limitations on those services. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/16/2025 for a diagnosis of Alzheimer's disease. The notification of non-covered items was requested upon admission. The clinical record did not contain documentation that it was given to the patient/representative within the required five days of the admission. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated, "she couldn't ensure that it was given as it wasn't scanned into the record."

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 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the Interdisciplinary Group completed 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. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/28/2024. A review of the clinical record indicated the initial social worker and spiritual counselor visits had not been completed. The initial nursing assessment dated 10/28/2024 left the psychosocial assessment blank. Under the spiritual assessment it was blank except to notate "chaplain to visit within 5 days." A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/14/2025 during which she stated, "if the social worker and chaplain are declined, the nurse should complete the initial assessment."

It is required that 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 18 (6%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan dated 08/05/2025 and updated 09/03/2025 included the following relevant tasks: "shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, external catheter care, empty drainage bag, moisture skin, walker, wheelchair, change bed linens (if soiled), make bed (if not made), straighten room, safety precautions, assist with transfers, fall risk, soak feet." All tasks were to be completed every visit. The Aide visit frequency was twice weekly. A physician's order dated 06/09/2025 noted the following: "ALF (assisted living facility) staff to apply size F Tubi grip in the morning, remove at night before bedtime. Wash and hang dry.." The hospice aide care plan did not notify the aide of the Tubi grips nor provide specific instructions for the care of the Tubi grips during tasks. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated "I'm not sure why soaking the feet would be added to the aide care plan but if it got on there, they should be given instructions regarding the Tubi grips. Even with just cleaning the feet."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 18 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure hospice aide provided services included in the plan of care. CLINCIAL RECORD 2/HOME VISIT 2: The hospice aide care plan dated 10/07/2025 included the following relevant tasks: "shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, moisture skin, walker, wheelchair, make bed, straighten room, safety precautions, assist with transfers, fall risk." All tasks were to be completed every visit. Aide visit frequency of twice weekly. The home visit was conducted on 11/12/2025 with the Hospice Aide (Personnel Record 7). The aide did not complete the tasks of filing the nails or making the bed. CLINICAL RECORD 11: The hospice aide care plan dated 05/16/2025 included the following relevant tasks: "shower, assist bath-chair, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, file nails, peri care, external catheter care, empty drainage bag, moisture skin, walker, wheelchair, change bed linens (if soiled), make bed (if not made), straighten bed, safety precautions, assist with transfers, fall risk." All tasks were to be completed every visit. Aide visit frequency of twice weekly. A hospice aide visit dated 05/22/2025 noted the following: "Bed bath given due to fall." This same aide note had noted the patient did not have a catheter. A hospice aide note dated 07/10/2025 noted "no" to the tasks of catheter care and empty drainage bag as "patient did not have a catheter." A review of the clinical record indicated the patient never had a catheter and these tasks were placed on the aide care plan dated 05/16/2025. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 11/13/2025 during which she stated that the "names in Clinical Record 9 the aide reported to appeared to be staff at the facility and not hospice staff." The DON also confirmed the patient in Clinical Record 11 did not have a catheter and was "not sure how the catheter care and empty drainage bag made it onto the aide care plan." She confirmed the aides should not "switch the bath types without an updated care plan."

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. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 11/14/2025, during which time the volunteer percentage for the last twelve (12) months (November 2024 to October 2025) averaged to 4.3%. The Volunteer Coordinator stated she was recently placed in the role (July 2025) and has been actively recruiting and onboarding volunteers since being hired. She has started using flyers with QR codes to help recruitment. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 11/14/2025, during which time the volunteer percentage for the last twelve (12) months (November 2024 to October 2025) averaged to 4.3%. The Volunteer Coordinator advised she was recently placed in the role (July 2025) and has been actively recruiting and onboarding volunteers since being hired. She has started using flyers with QR codes to help recruitment.

It is required that each patient’s individualized written plan of care reflects patient and family goals and have 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. 2 of 13 (15%) records reviewed revealed that the agency did not ensure the plan of care included documentation of measurable goals for the patients and their families. Clinical Record 2: On the plan of care for benefit period 3 dated 12/7/22-2/4/23, the goal for the problem, compromised cardiovascular status, stated in part, "Effect of (insert disease) on body systems and what to report." This is not a measurable goal. The goal for spiritual needs stated, "Spiritual supportive presence, provide a spiritual presence as requested by the family." This is not a measurable goal. Clinical Record 3: In the plan of care dated 1/17/23 for the current benefit period, the goal for the problem, risk for falls, stated in part, "Caregiver will be able to demonstrate improved safety awareness." This is not a measurable goal. In an interview during clinical record reviews on 1/24/23, the Director of Nursing (DON) agreed the goals were not measurable.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires. A revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) clinical records reviewed, revealed that the agency did not ensure the care plan was reviewed and revised when the patient's condition and living situation changed and included documentation of the patient's progress toward the goals specified in the plan of care. Clinical Record 2: The patient elected the Hospice Benefit on 6/10/22. The goal for pain management on the 6/10/22 plan of care stated, “Patient/Caregiver will verbalize understanding of pain management regimen by 12 weeks.” There was no documentation on subsequent plans of care to indicate this goal was met, not met, or extended. The living situation and functional limitations were not updated on the plan of care when the patient had a change in condition. The patient was living in a private residence with his wife when he elected the Hospice Benefit on 6/10/22. On 10/31/22, the patient moved into a skilled nursing facility (SNF). As of 1/24/23, the plan of care reflected the patient was still living in a private home. The 1/24/23 plan of care (POC) also reflected the patient required assistance with ambulation. The 1/2/23 nursing note indicated the patient was bed and chair bound. The POC was not updated on 1/4/23 to reflect the patient required the use of a Hoyer lift for chair transfers. The POC was not revised as the patient’s condition changed to include updated assessment information and documentation of progress toward outcomes and goals. Clinical Record 3: In the current benefit period care plan dated 1/17/23, the goal for the problem, emergency preparedness states in part, "Patient/caregiver will be able to self-identify emergency plan with home health staff on the day of admission." There was no documentation that this goal was met, not met, or extended. In an interview with the RN Case Manager (RNCM) during a home visit on 1/23/23 in the skilled nursing facility (SNF), the RNCM shared that the patient (Clinical Record 2), lived at home with his wife until he needed more care than she could provide. She also reported this patient could no longer ambulate and required a Hoyer lift for chair transfers. In an interview during clinical record reviews on 1/24/23, the Director of Nursing agreed that patient care plans were not updated when there was a patient condition change and did not include updated documentation of progress toward the goals specified in the POC.