Every finding on record at Advantage Hospice Dba Corus Hospice

Based on observation, policy review, and interview, the Hospice failed to immediately investigate an allegation of abuse for one of one patient (Patient (P) 9) reviewed for abuse out of a total sample of 19. Failure to immediately investigate allegations of abuse has the potential for further abuse to occur. --- Findings include:During an onsite Recertification survey at the Hospice, the Surveyor accompanied the Social Worker (SW) on 04/29/25 at 11:00 AM, on a visit to an assisted living facility to observe the care provided to P9. P9 was observed in bed asleep with P9’s family member (Family Member (F) 9) present in the room. At one point during the visit, F9 told the SW that P9 had bruises on both forearms and showed the SW pictures he/she had taken of the bruises. F9 told the SW that he/she noticed the bruises the day after the Home Health Aide (HHA) provided care to P9, stating that the bruises looked like "fingerprints."Review of the Hospice policy titled, "Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation," dated February 2021, indicated, ". . . The Administrator will ensure that all alleged violations involving mistreatment, neglect or verbal, mental, sexual and physical abuse including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of Hospice, are reported immediately by Hospice employees and contracted staff to the Hospice Administrator . . . Immediately investigate all alleged violations involving anyone furnishing services on behalf of Hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations will be conducted in accordance with established procedures . . ." During an interview on 04/30/25 at 11:30 AM, the COO/ Acting ED stated he/she had not heard anything from the SW regarding an allegation made by F9. The COO/Acting ED stated the SW should have reported it to his/her supervisor, who would then have reported it to his/her supervisor or the Hospice Director. The COO/Acting ED stated the Hospice policy is to report as soon as possible but no later than 24 hrs.During an interview on 04/30/25 at 1:04 PM, the SW stated F9 reported that after the HHA’s visit, he/she saw bruises on P9’s forearms bilaterally, that were reddish- purple in color. The SW stated F9 stated that he/she thought the bruises looked like fingerprints. The SW stated he/she reported this to Case Manager (CM) 2 on 04/29/25 at 11:49 AM (right after the visit to P9). The SW stated he/she was asked to file an incident report today (04/30/25). The SW stated the policy is to report to your direct manager as soon as possible but within 24 hrs. During an additional interview on 04/30/25 at 12:25 PM, the COO/Acting ED stated the SW reported the allegation to CM1 and CM2 on 04/29/25. CM2 stated he/she told the SW to do an incident report, and the COO/Acting ED stated he/she was not sure if the Incident report was completed yet. During an interview on 04/30/25 at 3:03 PM, CM2 stated that the SW notified CM1 and him/her of the allegation at approximately 12:00 PM to 1:00 PM on 04/29/25. CM2 stated they notified the Hospice Director so they could start the process. The SW did an incident report on 04/30/25 around noon. CM2 stated he/she reached out to the facility, and he/she went to the facility and talked with F9 who voiced concern about the time that the HHA comes in the mornings.During an interview on 04/30/25 at 3:29 PM, the Hospice Director (HD) stated he/she spoke with F9 to ask about his/her concerns. The HD stated F9 stated he/she was upset about the time that the aide gets P9 up in the morning more than the bruises. The HD stated he/she observed the bruises which were in various stages of healing and stated that the HHA has been removed from P9’s care. The HD stated he/she was not told of the incident until today (04/30/25).

Based on record review and interview, the Hospice failed to ensure that the Plan of Care (POC) for 10 of nineteen sampled patients (Patient (P) 1, P2, P3, P7, P9, P10, P11, P12, P13, and P14) contained measurable goals. Failure to include measurable goals on the patients' care plans has the potential to result in the inability to correctly monitor progress for all 86 patients receiving Hospice services. --- Findings include:1. Review of P1’s POC, located in P1’s electronic medical record (EMR) under the "Plan of Care" tab, indicated P1’s care plan goals included but were not limited to: "Patient will maintain optimal personal hygiene" and "Patient will maintain optimal mobility through benefit period." These goals were part of P1’s musculoskeletal/activities care plan. P1's care plans did not contain measurable goals to facilitate assessing P1's progress toward the goals.2. Review of P2’s POC, located in P2’s EMR under the "Plan of Care" tab, indicated P2’s care plan goals included but were not limited to: "Patient's desired nutrition/hydration needs will be met throughout benefit period (Nutritional goals)" and "Caregiver will demonstrate behavioral outburst management throughout benefit period (Psych/Mental/Emotional/Behavioral Goals.)." P2's care plans did not contain measurable goals to facilitate assessing P2's progress toward the goals.3. Review of P3’s POC, located in P3’s EMR under the "Plan of Care" tab, indicated P3’s care plan goals included but were not limited to: "Patient will maintain optimal mobility (Musculoskeletal/Activities care plan)" and "Patient's bowel/bladder incontinence will be managed (GI/GU/Nutritional/Endocrine Goals)." P3's care plans did not contain measurable goals to facilitate assessing P3's progress toward the goals.4. Review of P7’s POC, located in P7’s EMR under the "Plan of Care" tab, indicated P7’s care plan goals included but were not limited to: "Patient's desired nutrition/hydration needs will be met throughout benefit period (GI/GU/Nutritional/Endocrine Goals)" and "[P7] will maintain optimal mobility throughout benefit period (Musculoskeletal/Activities Goals)." P7's care plans did not contain measurable goals to facilitate assessing 7's progress toward the goals.5. Review of P9's POC, located in P9’s EMR under the "Plan of Care" tab, indicated P9’s care plan goals included but were not limited to: "Patient's personal care/ADL needs will be met throughout benefit period (Musculoskeletal/Activities Goals)" and "Patient/Caregiver will demonstrate safe use and maintenance of respiratory equipment throughout benefit period (Respiratory Goals)." P9's care plans did not contain measurable goals to facilitate assessing P9s progress toward the goals.6. Review of P10's POC, located in P10’s EMR under the "Plan of Care" tab, indicated P10’s care plan goals included but were not limited to: "Changes in respiratory status will be identified and managed (Respiratory Goals)" and"Patient/Caregiver will demonstrate safe use and maintenance of respiratory equipment (Respiratory Goals)." P10's care plans did not contain measurable goals to facilitate assessing P10’s progress toward the goals.7. Review of P11's POC, located in P11’s EMR under the "Plan of Care" tab, indicated P11’s care plan goals included but were not limited to: "Patient will maintain optimal mobility throughout the benefit period," and "Patient's personal care/ADL needs will be met throughout the benefit period ((Musculoskeletal/Activities Goals)."  P11's care plans did not contain measurable goals to facilitate assessing P11’s progress toward the goals. 8. Review of P12's POC, located in P12’s EMR under the "Plan of Care" tab, indicated P12’s care plan goals included but were not limited to: "Patient's bowel/bladder incontinence will be managed throughout benefit period "and "Patient's desired nutrition/hydration needs will be met throughout benefit period (GI/GU/Nutritional/Endocrine Goals)." P12's care plans did not contain measurable goals to facilitate assessing P12’s progress toward the goals. 9. Review of P13's POC, located in P13’s EMR under the "Plan of Care" tab, indicated P13’s care plan goals included but were not limited to: "Patient's personal care/ADL needs will be met throughout benefit period" and "Patient will maintain optimal mobility throughout benefit period (Musculoskeletal/Activities Goals)." P13's care plans did not contain measurable goals to facilitate assessing P13’s progress toward the goals.10. Review of P14's POC, located in P14’s EMR under the "Plan of Care" tab, indicated P14’s care plan goals included but were not limited to: "Patient will remain safe in environment throughout benefit period" and "Patient's personal care/ADL needs will be met throughout benefit period (Musculoskeletal/Activities Goals.)." P14's care plans did not contain measurable goals to facilitate assessing P14’s progress toward the goals.During an interview on 04/30/25, the Chief Operating Officer and Acting Executive Director (COO/Acting ED) confirmed the presence of care plan goals that are not measurable. This was also discussed during the exit conference on 05/01/25 at 6:00 PM, and it was again confirmed that care plan goals are required to be measurable.Review of the facility policy titled, "IDG Care Planning Process," revised February 2024, indicated, ". . . An individualized written plan of care is developed for each patient . . . Based on the problems identified in the initial, comprehensive and updated comprehensive assessments . . . The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including . . . Measurable outcomes anticipated from implementing and coordinating the plan of care . . ."

Based on record review, documentation review, policy review, and staff interviews, it was determined the Hospice failed to maintain current and accurate written agreements and did not provide required documentation to the Skilled Nursing Facility (SNF) and Nursing Facility (NF). This had the potential to affect 88 of 88 patients served by the Hospice. --- Findings include:The Hospice failed to ensure that fourteen of twenty written agreements with SNF and NF contained the required documentation that the Hospice Bereavement Counselor will provide bereavement counseling to the staff of the SNF or NF. Cross Reference: L771.The Hospice failed to ensure that fourteen of twenty written agreements with SNF’s and NFs contained the required documentation that the Hospice staff will report any allegation, done by a person not employed by the Hospice, to the Facility Administrator of the SNF or NF, within 24 hours. Cross Reference L772.The Hospice failed to ensure that the required documents were supplied to the SNF’s and NF’s such as copies of: the most recent “Plan of Care (POC),)” the “Hospice election” form, information on the Patient’s “Advance directives,” the “Physician certification and recertification of terminal illness,” names and contact information for Hospice personnel involved in a patient’s care, instructions on how to access the Hospice’s 24 hour on-call system, Hospice medication information specific to each patient, and Hospice physician and attending physician orders specific to each patient. Cross Reference L781.

Based on record review and interview, the Hospice failed to ensure 14 of 20 contracts/written agreements between the Hospice, SNF/NF (Skilled Nursing Facility/Nursing Facility) and ICF/MR (Intermediate Care Facilities for Individuals with Mental Retardation) facilities providing general inpatient care, routine, or respite care to hospice patients, contained provisions to indicate that the Hospice would report allegations of any type of abuse, neglect, mistreatment or misappropriation by anyone unrelated to the Hospice to the facility Administrator within 24 hours of becoming aware of the alleged violation. --- Findings Include:A review of the Hospice's contracts/written agreements on 04/28/25 indicated the Hospice maintained contracts/written agreements with 20 facilities to provide various levels of care to hospice patients. The levels of care included general inpatient, routine (inpatient), and respite care. Fourteen of the twenty contracts/written agreements reviewed did not contain a provision indicating the responsibility of the Hospice to report allegations of abuse, neglect, mistreatment, or misappropriation by anyone unrelated to the Hospice to the Administrator of the facility the specific patient resided in, within 24 hours of learning of the allegation. During an interview on 04/28/25 at 5:00 PM, the Chief Operating Officer (COO)/ Acting Executive Director (ED) stated that the Hospice maintained the 20 contracts/written agreements with other facilities to provide various levels of care such as general inpatient, routine, or respite. The COO/ED confirmed that the required information related to reporting allegations was not present in 14 of the 20 contracts/written agreements.

Based on record review and interview, the Hospice failed to ensure 14 of 20 contracts/written agreements between the Hospice, SNF/NF (Skilled Nursing Facility/Nursing Facility) and ICF/MR (Intermediate Care Facilities for Individuals with Mental Retardation) facilities providing general inpatient care, routine, or respite care to hospice patients, contained a provision to indicate that the Hospice would provide bereavement services to SNF/NF or ICF/MR staff. --- Findings Include:A review of the Hospice's contracts/written agreements on 04/28/25 indicated the Hospice maintained contracts/written agreements with 20 facilities to provide various levels of care to hospice patients. The levels of care included general inpatient, routine (inpatient), and respite care. Fourteen of the twenty contracts/written agreements reviewed did not contain a provision indicating the responsibility of the Hospice to provide bereavement services to the staff of the SNF/NF or ICF/MR. During an interview on 04/28/25 at 5:00 PM, the Chief Operating Officer (COO)/Acting Executive Director (ED) stated that the Hospice maintained the 20 contracts/written agreements with other facilities to provide various levels of care such as general inpatient, routine, or respite. The COO/ED confirmed that the required information related to the Hospice providing Bereavement services to the staff of the SNF/NF or ICF/MR was not present in the fourteen contracts/written agreements.

Based on record review and interview, the Hospice failed to provide the Skilled Nursing Facility (SNF) or Nursing Facility (NF) with the required information on each Hospice patient in their SNF or NF for two of two patients (Patient (P) 9 and P12) reviewed during visits to residential facilities out of a total sample of 19. The SNF or NF not having the required information has the potential to result in Hospice patients not receiving the care they need. --- Findings include:1. During a visit to an Assisted Living facility on 04/29/25 at 11:00 AM, to assess the care provided to P9, the Surveyor requested to view P9’s Hospice information. During an interview with the Health Manager (in charge of the facility), the Health Manager stated they did not have any binder, folder, or chart. The Health Manager said the facility did not have the most recent plan of care (POC), the Hospice election form, any advanced directives, the Physician certification and recertification of terminal illness, Hospice medication lists, or Hospice Physician and/or attending Physician orders for P9.2. During a visit to a Skilled Nursing Facility (SNF) on 04/29/25 at 2:00 PM, to assess the care provided to P12, the Surveyor requested to view P12’s Hospice information. During an interview with the Director of Nursing (DON) she said the facility did not have the required Hospice information for P12 such as the current Hospice POC, Hospice Election form, Advance Directive, Physician Certification of Terminal illness, medication orders and a coordinated POC. She said the expectation was that each Hospice patient would have their own Hospice Binder to keep the Hospice information in. The DON and other nursing personnel on duty at the time on P12’s unit were unable to produce a Hospice binder for P12.During an interview on 04/30/25 at 11:30 AM, the surveyor informed the Chief Operating Officer/Acting Executive Director (COO/Acting ED) that neither facility was able to provide the documents that were required to be sent to their facilities by the Hospice, and they could not find the documents in any “Hospice Binder,” hard chart, or EMR at their facilities. The COO/Acting ED confirmed the documents should be at the facilities and stated he/she would remedy that right away.

Based on record review and interview, the hospice agency failed to complete the Initial Comprehensive Assessment for 6 Patient ((P)1, P3, P4, P5, P7, and P11) of 11 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10 and P11) within the required timeframe of 5 days in order to identify the patient/family's physical, psychosocial, emotional and spiritual needs and contribute to the development of the plan of care to address those needs. This deficient practice is likely to delay treatment and can cause harm to patients. Findings include: A. Review of the Electronic Medical Record (EMR) for P1, P3, P4, P5, P7 and P11 revealed that a complete Initial Comprehensive Assessment was not completed within five days of election of hospice care. 1. P1 Start of Care (SOC) 03/10/2021, Date Assessment was completed 03/17/2021 2. P3 (SOC) 05/06/2022, Date Assessment was completed 05/12/2022 3. P4 (SOC) 08/04/2020, Date Assessment was completed 08/14/2020 4. P5 (SOC) 01/11/2022, Date Assessment was completed 01/19/2022 5. P7 (SOC) 09/30/2020, Date Assessment was completed 10/13/2020 6. P11 (SOC) 09/28/2021, Date Assessment was completed 10/12/2021 B. During an interview on 05/20/22 at 4:15 PM, the Hospice Director confirmed that the Initial Comprehensive Assessment should have been completed within the mandatory five-day timeframe.

Based on record review and interview, the hospice agency failed to obtain the physician's signature and the physician's narrative statement on the Initial Certification of Terminal Illness (CTI) for 1 (Patient (P)7) of 11 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10 and P11). This deficient practice is likely to cause delay in treatment. Findings include: A. Review of the Electronic Medical Record (EMR) for P7 revealed the Initial CTI 09/30/2020 did not have the required imminence of death (terminal illness) narrative or the physician's signature that provide justification for admission to Hospice services. B. During an interview on 05/20/22 at 4:15 PM, with the Executive Director and Hospice Director, both confirmed all CTI's should contain physicians narratives and signatures.

Based on record review and interview, the hospice agency failed to obtain attending physician's signature on the Plan of Care (POC) for 7 Patients (P)3, P5, P6, P8, P9, P10, and P11) of 11 patients(Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10 and P11) . This deficient practice is likely to delay treatment and can cause harm to patient. Findings include: A. Review of the POC in the Electronic Medical Record (EMR) for P3, P5, P6, P8, P9, P10, and P11 revealed the POC was not signed by the attending physician. B. During an interview on 05/20/22 at 4:15 PM, the Executive Director confirmed the agency's POC should contain the attending physician's signature. She further stated that the signature is obtained at the Interdisciplinary Group (IDG) meeting.