Every finding on record at Advisacare Hospice, LLC

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 4 of 14 (29%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The initial nursing assessment narrative dated 04/28/2025 stated "The patient has bladder incontinence". The interdisciplinary group (IDG) POC dated 04/28/2025 lacked evidence of goal(s) and intervention(s) for bladder incontinence. CLINICAL RECORD 2: The nursing visit note narrative dated 07/02/2025 stated, "Patient reports increased struggle to walk and decreased balance". The IDG POC dated 07/03/2025 lacked evidence of goal(s) and intervention(s) for increased fall risk. CLINICAL RECORD 3: The initial nursing assessment narrative dated 06/17/2025 stated "Patient is now bedbound when she was able to ambulate to the bathroom with her walker one month ago". The IDG POC dated 06/17/2025 lacked evidence of goal(s) and intervention(s) for skin integrity. CLINICAL RECORD 8: The initial nursing assessment narrative dated 09/30/2024 stated "The patient has dysphasia". The IDG POC dated 09/30/2024 lacked evidence of goal(s) and intervention(s) for dysphasia. The Vice President of Operations/Director of Clinical Services (DCS) designee, DCS, and Director of Hospice Operations stated in an interview on 07/17/20265 that the agency did not ensure that the POC reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.

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 and interview. In 1 of 12 (8%) clinical records reviewed for patients that elected hospice aide services revealed that the agency did not ensure that the aide provided services included on the aide care plan. CLINICAL RECORD 7: The aide care plan dated 06/10/2025 ordered the task "Shower" at every visit. The aide frequency ordered was two (2) times per week. The aide visit note dated 06/18/2025 reported the task "Shower" was "Acknowledged" and "Completed". The comments stated, "There was no hot water available so did a bed bath". The aide did not provide services included in the aide care plan. The Vice President of Operations/Director of Clinical Services (DCS) designee, DCS, and Director of Hospice Operations stated in an interview on 07/17/20265 that the agency did not ensure that the aide provided services included on the aide care plan.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed for patients that elected hospice aide services that required the aide to report changes in the patient medical needs to the registered nurse (RN) revealed the agency did not ensure the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. CLINICAL RECORD 3: The aide care plan dated 06/18/2025 ordered the task "Oral care" at every visit. The aide frequency ordered was two (2) times per week. The aide visit note dated 06/25/2025 reported the task "Oral care" was "Acknowledged" and "Not completed". The record lacked evidence as to why "Oral care" was "Not completed". The record also lacked evidence that the aide reported to the RN the change in the patient's medical condition as it related to the above ordered task "Oral care" being "Not completed". CLINICAL RECORD 7: The aide care plan dated 06/10/2025 ordered the task "Shower" at every visit. The aide frequency ordered was two (2) times per week. The aide visit note dated 06/18/2025 reported the task "Shower" was "Acknowledged" and "Completed". The comments stated, "There was no hot water available so did a bed bath". The record lacked evidence that the aide reported to the RN the change in the patient's medical condition as it related to the above ordered task "Shower" being changed to a "Bed bath". The Vice President of Operations/Director of Clinical Services (DCS) designee, DCS, and Director of Hospice Operations stated in an interview on 07/17/20265 that the agency did not ensure the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan.

It is required that hospice aides are supervised by a registered nurse (RN) 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 and 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 and interview. In 1 of 12 (8%) clinical records reviewed for patient's that elected aide services revealed the agency did not ensure hospice aides were supervised by a RN who made 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 and ensure that services ordered by the hospice IDG meet the patient’s need. CLINICAL RECORD 2: The aide care plan dated 06/07/2025 (certification dates 06/07/2025 - 08/05/2025) ordered an aide frequency of two (2) times per week. There was evidence of aide visits completed on 06/09/2025, 06/13/2025, 06/16/2025, 06/19/2025, 06/23/2025, 06/26/2025, 06/30/2025, 07/03/2025, 07/07/2025, 07/10/2025, and 07/14/2025. There was evidence of an RN supervisory visit completed on 06/11/2025, 06/25/2025 and 07/16/2025 (21 days). The record lacked evidence of the RN supervisory visits having been completed no less frequently than every 14 days. The Vice President of Operations/Director of Clinical Services (DCS) designee, DCS, and Director of Hospice Operations stated in an interview on 07/17/20265 that the agency did not ensure that hospice aides were supervised by a RN who made 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 and ensure that services ordered by the hospice IDG meet the patient’s need.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation, 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 1 of 1 (100%) clinical records reviewed for patients that revoked the hospice benefit revealed the agency did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient revoked the hospice benefit on 03/17/2025 to pursue aggressive treatment. The patient remained at the current place of residence. The record lacked evidence that the agency forwarded a copy of the discharge summary to the patient's attending physician. The Vice President of Operations/Director of Clinical Services (DCS) designee, DCS, and Director of Hospice Operations stated in an interview on 07/17/20265 that the agency did not ensure that a copy of the discharge summary was forwarded to the patient's attending physician.

It is required that a hospice aide provides services 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. In 2 of 7 (29%) clinical records reviewed, the hospice did not ensure the hospice aide was compliant with the visit frequency ordered by the Interdisciplinary Group and included in the plan of care. . THIS IS A CONTINUING PRIOR REQUIRED ACTION Clinical Record 7 was reviewed and the IDG Comprehensive Assessment Plan of Care Update dated 9/6/22 identified the Hospice Aide visit frequency of two times a week. Review of the clinical record revealed one missing Hospice Aide visit the week of 9/6/22. A physician's order was obtained 9/5/22 to decrease the Hospice Aide visit frequency to one time a week, however, the change in frequency was not included on the IDG Plan of Care Update dated 9/6/22. During interview and joint clinical record review 9/28/22, the Clinical Director confirmed the missing hospice aide visit note and stated "The order to change the Hospice Aide frequency did not get transferred over onto the IDG plan of care on 9/6/22". Clinical Record 6 was reviewed and the IDG Comprehensive Assessment Plan of Care Update dated 9/6/22 and 9/20/22 identified the Hospice Aide visit frequency of two times a week. Review of the clinical record revealed one extra Hospice Aide visit the weeks of 9/6/22, 9/11/22 and 9/22/22. A physician's order was obtained 8/30/22 to increase the Hospice Aide visit frequency to three times a week, however, the change in frequency was not included on the IDG Plan of Care Update dated 9/6/22 or 9/20/22. During interview and joint clinical record review 9/28/22, the Clinical Director confirmed the extra hospice aide visit notes and stated "The order to change the Hospice Aide frequency did not get transferred over onto the IDG plan of care on 9/6/22 and 9/20/22". THIS IS A CONTINUING PRIOR REQUIRED ACTION

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 a review of clinical records and interviews. 2 of 11 (18%) records reviewed revealed the agency did not ensure the comprehensive assessments were completed no later than five (5) calendar days after the election of hospice care. Record #7 was reviewed and identified the patient elected hospice care on 5/5/2022. The initial Medical Social Worker (MSW) assessment visit was completed on 5/11/2022, 6 days outstanding. The RN, former Director of Clinical Services (DCS) as of 6/2022, stated during interview and a joint review of the record, the visit was one day late. Record #2 SOC: was reviewed and identified the patient elected hospice care on 5/12/2022. The initial MSW assessment visit was completed on 5/31/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record, the visit was missed. See description below

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; 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 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. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the drug profile was complete and accurate. Record #0 was reviewed and identified the patient elected hospice care on 5/18/2022. The assessment completed by the Registered Nurse (RN) documented the patient was on oxygen at 2 liters per minute (LPM). The medication profile and the plan of care did not include the oxygen. The RN, former Director of Clinical Services (DCS) as of 6/2022, stated during an interview and a joint review of the record on 8/17/2022, the oxygen order was not documented. Record #3 was reviewed and identified the patient elected hospice care on 1/24/2022. The assessment completed by the RN documented the patient was dependent on oxygen at 2-5 LPM. The medication profile and the plan of care did not include the oxygen. The RN, former DCS stated during an interview and a joint review of the record on 8/17/2022, the oxygen order was not documented. See description below

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This CONDITION was not met as evidenced by a review of patient records and interviews. The hospice failed as follows: to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care [HCPC.19.I/L543]; to ensure the plan of care includes drugs and treatment necessary to meet the needs of the patient [HCPC.21.I/L549]; to ensure that the hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care [HCDT.16.I/L626]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment. This is a CMS CONDITION level finding.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary care giver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and interviews. 9 of 11 (82%) records reviewed revealed the hospice did not ensure the individualized plan of care was followed. Record #7 was reviewed and identified the patient elected hospice care on 5/5/2022. The Registered Nurse (RN) visit frequency was ordered as "2 visits per week (W)." During the weeks of 5/22/2022 and 6/5/2022, the actual frequency was 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 1 week. The nursing visit frequency was decreased to "one visit per week" on 6/15/2022. The record was missing nursing visits documented as completed for the weeks of 6/26/2022, 7/3/2022, 7/24/2022, 7/31/2022, and 8/7/2022, the actual frequency was 1 time a week for 2 weeks, 0 time a week for 2 weeks, 1 time a week for 2 weeks, 0 time a week for 3 weeks. The RN, former Director of Clinical Services (DCS) as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed or the visits were not yet documented in the electronic medical record (EMR). Record #4 was reviewed and identified the patient elected hospice care on 2/16/2022. For the certification period beginning on 5/17/2022, the RN visit frequency was ordered as "2 visits per week." The week of 5/22/2022, one nursing visit was documented as completed. There were no nursing visits documented as completed the week of 5/29/2022. The week of 6/5/2022 one RN visit was completed on 6/10/2022. The week of 6/12/2022, no nursing visits were completed. The week of 6/19/2022 one visit was completed on 6/24/2022. In addition, six Licensed Practical Nurse (LPN) visits were completed the week of 6/26/2022. The record was missing nursing visits documented as completed for the weeks of 7/10/2022, 7/17/2022, 7/24/2022, 7/31/2022, 8/7/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the nurse frequency was not followed as ordered. Record #10 was reviewed and identified the patient elected hospice care on 1/27/2022. The RN visit frequency was ordered as "2 visits per week." There were no nursing visits documented as completed for the weeks of 7/10//2022, 7/31/2022, and 8/7/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN visits were likely completed and not yet documented in EMR. Record #9 was reviewed and identified the patient elected hospice care on 7/18/2022. The RN visit frequency was ordered as "daily visits." There were no RN visits documented as completed for 7/19/2022, 7/20/2022, 7/21/2022, 7/22/2022, 7/23/2022, 7/24/2022, 7/30/2022, 7/31/2022, 8/5/2022, 8/6/2022, and 8/7/2022. In addition, the Chaplain was ordered "1 time per week." There were no Chaplain visits documented as completed for the week of 7/31/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the visits did not follow the plan of care ordered. Record #2 was reviewed and identified the patient elected hospice care on 5/12/2022. The RN visit frequency was ordered as "2 visits per week." The week of 5/22/2022 one RN visit was documented as completed on 5/25/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed. Record #5 was reviewed and identified the patient elected hospice care on 6/24/2022. The RN visit frequency was ordered as "2 visits per week." The week of 6/24/2022, one RN visit was documented as completed on 6/24/2022 The nursing visit frequency was decreased to "1 time per week" on 7/5/2022. There were no RN visits documented as completed for the weeks of 6/26/2022, 7/10/2022, and 7/17/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed due to the visits not yet documented in the EMR. Record #8 was reviewed and identified the patient elected hospice care on 6/29/2022. The RN visit frequency was ordered as "2 visits per week." During the weeks of 6/29/2022, 7/3/2022, 7/10/2022, 7/31/2022, and 8/7/2022, one nursing visit was documented as completed for each week. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed due to the visits not yet documented in the EMR. Record #1 was reviewed and identified the patient elected hospice care on 9/20/2021. The RN visit frequency was ordered as "1 visit per week." There was no RN visit documented as completed the week of 6/26/2022. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed. Record #6 was reviewed and identified the patient elected hospice care on 6/15/2022. The RN visit frequency was ordered as "2 visits per week." During the weeks of of 6/26/2022 and 7/3/2022, one nursing visit was documented as completed for each week. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the record on 8/16/2022, the RN frequency was missed. See description below

It is required that each patient’s individualized written plan of care 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 a review of clinical records and interviews. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. Record #0 was reviewed and identified the patient elected hospice care on 5/18/2022. The assessment completed by the Registered Nurse (RN) documented the patient used oxygen at 2 liters per minute (LPM). The record was missing evidence of a physician's order for oxygen documented on the plan of care. The RN, former Director of Clinical Services (DCS) as of 6/2022, stated during an interview and a joint review of the clinical record on 8/17/2022, the oxygen order was not documented. Record #3 was reviewed and identified the patient elected hospice care on 1/24/2022. The assessment completed by the RN documented the patient was oxygen dependent, at 2-5LPM. The record was missing evidence of a physician's order for oxygen documented on the plan of care. The RN, former DCS as of 6/2022, stated during an interview and a joint review of the clinical record on 8/17/2022, the oxygen order was not documented.

It is required that a hospice aide provides services 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. 6 of 10 (60%) records reviewed revealed the hospice did not ensure the aide plan of care was followed. Record #4 was reviewed and identified the patient elected hospice care on 2/26/2022. The record revealed the patient declined aide services at the start of care. An aide was ordered "1 time per week" beginning the week of 5/24/2022. There were no aide visits documented as completed for the weeks of 6/5/2022, 7/17/2022, and 8/7/2022. The record was missing evidence of communication with the physician or documented missed visits. The RN, former DCS as of 6/2022, stated in an interview and a joint review of the clinical record on 8/16/2022, that the visits were not completed. Record #9 was reviewed and identified the patient elected hospice care on 7/18/2022. The record revealed an aide was ordered "3 visits per week", as of 7/18/2022. The first aide visit was documented as completed on 7/28/2022. In addition, two aide visits were documented as completed the week of 7/31/2022 and 8/7/2022, the actual frequency was 2 times a week for 2 weeks. The record was missing evidence of communication with the physician or documented missed visits. The RN, former DCS as of 6/2022, stated in an interview during a joint review of the clinical record on 8/16/2022 that the aide visits were missed. Record #2 was reviewed and identified the patient elected hospice care on 5/12/2022. The record revealed an aide was ordered "2 visits per week", as of 5/12/2022. The week of 5/12/2022, one aide visit was documented as completed, actual frequency was 1 time a week for 1 week. In addition, the week of 5/15/2022, the aide documented 3 visits as completed (5/16/2022, 5/17/2022, 5/19/2022), actual frequency was 3 times a week for 1 week. The record was missing evidence of communication with the physician or documented missed visits. The RN, former DCS as of 6/2022, stated in an interview during a joint review of the clinical record on 8/16/2022 that the aide visits were missed. Record #5 was reviewed and identified the patient elected hospice care on 6/24/2022. The record revealed an aide was ordered "2 visits per week", as of 6/24/2022. The week of 6/24/2022, no aide visits were documented as completed. The week of 6/26/2022, one aide visit was documented as completed on 6/29/2022, actual frequency was 1 time a week for 1 week. There were no aide visits documented as completed for July 2022, actual frequency was 0 time a week for 4 weeks. In addition, one aide visit was documented as completed the week of 8/7/2022, actual frequency was 1 time a week for 1 week. The record was missing evidence of communication with the physician or documented missed visits. The RN, former DCS as of 6/2022, stated in an interview during a joint review of the clinical record on 8/16/2022 that the aide visits were missed. Record #8 was reviewed and identified the patient elected hospice care on 6/29/2022. The record revealed an aide was ordered "2 visits per week", as of 6/29/2022. The week of 6/29/2022, no aide visits were documented as completed, actual frequency was 0 times a week for 1 week. The week of 7/3/2022, one aide visit was documented as completed, actual frequency was 1 time a week for 1 week. In addition, three aide visits were documented as completed the week of 8/1/2022 and 8/8/2022, actual frequency was 3 times a week for 2 weeks. The record was missing evidence of communication with the physician or documented missed visits. The RN, former DCS as of 6/2022, stated in an interview during a joint review of the clinical record on 8/16/2022 that the aide plan of care was not followed. Clinical Record 0 SOC: 5/18/2022, aide was ordered 5 visits per week, the first week of care, 2 visits were documented and the week of 5/22/2022 two visits documented, actual frequency was 2 times a week for 2 weeks. The RN, former DCS as of 6/2022, stated in an interview during a joint review of the clinical record on 8/16/2022 that the aide visits were missed. See description below

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 interviews. 1 of 1 (100%) records reviewed of patients discharged from hospice services revealed the hospice did not ensure a copy of the discharge summary was provided to the attending physician. Record #2 was reviewed and identified the patient elected hospice care on 5/18/2022. The patient's daughter moved the patient out of state with family on 5/26/2022. There was no evidence that a copy of the hospice discharge summary was sent to the attending physician who would be assuming care. The Registered Nurse ( RN) stated during interview, the hospice did not send a plan of care or a copy of the discharge information with the patient/family. The organization's policy, "111.13, Discharge Policy", states that, "The Hospice must forward a copy of the discharge summary and the patient record if requested. See description below