Every finding on record at Advantage Hospice Company

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 6 of 14 (43%) clinical records reviewed the agency did not ensure that the Master of Social Worker (MSW) and/or the Spiritual Counselor (SC) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/17/2025. The record lacked evidence that the SC completed the initial comprehensive assessment during the 5-day window. The SC initial comprehensive assessment was completed on 07/30/2025 (13 days). The record lacked supportive evidence of the patient/family refusing SC services or requesting a later visit during the five (5) day window. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/21/2024. The record lacked evidence that the SC completed the initial comprehensive assessment during the 5-day window. The SC initial comprehensive assessment was completed on 11/11/2025 (21 days). The record lacked supportive evidence that the patient/family refused SC services or requested a later visit during the five (5) day window. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/26/2025. The record lacked evidence that the MSW completed the initial comprehensive assessment during the 5-day window. The MSW initial comprehensive assessment was completed on 05/12/2025 (16 days). The record lacked supportive evidence that the patient/family refused MSW services or requested a later visit during the five (5) day window. The record lacked evidence that the SC completed the initial comprehensive assessment during the 5-day window. The SC initial comprehensive assessment was completed on 05/20/2025 (24 days). The record lacked supportive evidence that the patient/family refused SC services or requested a later visit during the five (5) day window. CLINICAL RECORD 5: The patient elect4/16/25ed the hospice benefit on 03/27/2024. The record lacked evidence that the SC completed the initial comprehensive assessment during the 5-day window. The SC initial comprehensive assessment was completed on 04/16/2024 (20 days). The record lacked supportive evidence that the patient/family refused SC services or requested a later visit during the five (5) day window. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/23/2025. The record lacked evidence that the MSW completed the initial comprehensive assessment during the 5-day window. The MSW initial comprehensive assessment was completed on 10/30/2025 (7 days). The record lacked supportive evidence that the patient/family refused SC services or requested a later visit during the five (5) day window. CLINICAL RECORD 11: The patient elected the hospice benefit on 09/18/2025. The record lacked evidence that the MSW completed the initial comprehensive assessment during the 5-day window. The MSW initial comprehensive assessment was completed on 10/03/2025 (15 days). The record lacked supportive evidence that the patient/family refused MSW services or requested a later visit during the five (5) day window. The record lacked evidence that the SC completed the initial comprehensive assessment during the 5-day window. The SC initial comprehensive assessment was completed on 10/02/2025 (14 days). The record lacked supportive evidence of the patient/family refused SC services or requested a later visit during the five (5) day window. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/17/2025 that they both agreed the records were missing completed MSW and/or SC initial assessments during the required 5-day window.

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. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/17/2025. The record lacked evidence that the initial bereavement assessment was completed as part of the comprehensive assessment. There was evidence of a completed initial bereavement assessment on 08/01/2025. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/11/2025. The record lacked evidence that the initial bereavement assessment was completed as part of the comprehensive assessment. There was evidence of a completed initial bereavement assessment on 12/17/2025. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/26/2025. The record lacked evidence that the initial bereavement assessment was completed as part of the comprehensive assessment. There was evidence of a completed initial bereavement assessment on 05/12/2025. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/23/2025. The record lacked evidence that the initial bereavement assessment was completed as part of the comprehensive assessment. There was evidence of a completed initial bereavement assessment on 10/30/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 09/18/2025. The record lacked evidence that the initial bereavement assessment was completed as part of the comprehensive assessment. There was evidence of a completed initial bereavement assessment on 10/07/2025. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record review on 12/17/2025 that they both agreed the records were missing initial bereavement assessments completed during the comprehensive assessment.

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 and interview. In 3 of 14 (21%) clinical records reviewed the agency did not ensure the patient's individualized written plan of care (POC) included patient and family goal(s) and intervention(s) based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The initial nursing assessment narrative completed on 07/18/2025 stated the patient had bladder and bowel incontinence. The record lacked evidence of goal(s) and intervention(s) for bladder and bowel incontinence. CLINICAL RECORD 3: The initial nursing assessment narrative completed on 10/21/2024 stated the patient had bladder incontinence. The record lacked evidence of goal(s) and intervention(s) for bladder incontinence. CLINICAL RECORD 4: The initial nursing assessment narrative completed on 04/26/2025 stated the patient had bowel incontinence. The record lacked evidence of goal(s) and intervention(s) for bowel incontinence. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/17/2025 that they both agreed the records were missing goal(s) and intervention(s) for problems identified during the initial nursing assessment.

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. 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 2 of 2 (100%) clinical records reviewed for patients that expired, the agency did not ensure a post-death bereavement plan of care (POC) that included the types of bereavement services to be offered and the frequency of services to be provided for the survivor(s) was documented. CLINICAL RECORD 4: The patient died on 06/28/2025. The record lacked a post-death bereavement POC. There was evidence of a post-death bereavement assessment and post-death bereavement interventions completed that included phone calls and in-person visits to the wife (survivor) by the bereavement coordinator (BC). Multiple progress notes completed by the BC were noted in the clinical record. Also, there was evidence of post-death support letters having been sent to the wife. CLINICAL RECORD 5: The patient died on 11/05/2025. The record lacked a post-death bereavement POC. There was evidence of a post-death bereavement assessment and post-death bereavement interventions completed that included phone calls to the wife (survivor) by the BC. Also, there was evidence of post-death support letters that were going to be sent to the wife. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/17/2025 that they both agreed the clinical records for patients that died were missing post-death bereavement POCs for the survivor(s).

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patient's that either revoked and transferred to the hospital or transferred to another hospice revealed the agency did not ensure the discharge summary was forwarded to the receiving facility. CLINICAL RECORD 6: The patient and family revoked the hospice benefit on 11/12/2025. The patient was transferred via ambulance to the hospital to pursue of curative treatment. The record lacked evidence that the agency forwarded the discharge summary to the receiving facility (hospital). CLINICAL RECORD 7: The patient was transferred to another hospice on 12/11/2025. The record lacked evidence that the agency forwarded the discharge summary to the receiving facility (hospice). There was evidence of the completed "Change of Designated Hospice-Transfer from Another Hospice to Crossroads Hospice and Palliative Care" having been forwarded to the receiving facility (hospice). The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/17/2025 that they both agreed the discharge summaries were not forwarded to the receiving hospital or receiving hospice.

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, and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patient's that revoked and transferred to the hospital or transferred to another hospice revealed the agency did not ensure the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient and family revoked the hospice benefit on 11/12/2025. The patient was transferred via ambulance to the hospital to pursue of curative treatment. The record lacked evidence of the agency having forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient transferred to another hospice on 12/11/2025. The record lacked evidence of the agency having forwarded the discharge summary to the patient's attending physician. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/17/2025 that they both agreed the discharge summaries were not forwarded to the patient's attending physician.

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, interview and observation. In 1 of 6 (17%) records reviewed it was revealed that the agency did not ensure the written plan of care included individualized patient and family goals and planned interventions for all of the problems identified in the comprehensive assessments. Clinical Record 1: This patient elected their hospice benefit on 2/9/23 with a hospice diagnosis of Congestive Heart Failure. The nursing comprehensive assessment dated 2/9/23 documented that the patient had pain described as “occasional, aching, throbbing", and rated the level of pain as "7 out of 10 at worst". The assessment also documented the patient was "at risk for falls" and “patient does have a Foley (catheter) that was placed at his last ER (emergency room) visit due to urine retention.” During a joint home visit with a registered nurse on 2/28/23, the patient's spouse stated, "(patient) has fallen several times in the past month and I had to call the ambulance service to come help get him up." The written plan of care for the patient did not contain documented evidence of individualized patient/family goals and/or planned interventions to specifically address the patient's pain, urinary retention, and safety risk and fall prevention. During an interview on 2/28/23, the registered nurse confirmed the identified problems were active problems for the patient and stated, "I did not include those in the patient's plan of care."