Every finding on record at Antelope Hospice Corparation

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; the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed of patients who revoked the hospice benefit revealed the agency did not ensure a copy of the hospice discharge summary had been forwarded to the patient's attending physician. CLINICAL RECORD 7: The patient's family revoked the hospice benefit on 12/15/2025 because the patient's family was moving the patient beyond the geographical service area of the hospice. The record lacked evidence that the agency forwarded the discharge summary to the patient's attending physician. The Director of Patient Care Services designee and Case Manager Licensed Vocation Nurse stated in an interview while performing joint clinical record reviews on 01/07/2026 that they both agreed the clinical record for the patient who revoked the hospice benefit was missing evidence demonstrating that the discharge summary had been forwarded to the patient's attending physician.

Based on interview and record review, the Hospice Agency (HA) failed to ensure all members of the interdisciplinary group were involved in the completion of the comprehensive assessment for two of ten sampled patients (Patient 8 and Patient 9). This deficient practice had the potential to result in lack of care and services and patients needs not being identified. --- a. A review of Patient 8s (P8) ";Patient Information", indicated a start of care date of 5/12/22, with diagnoses including uterine cancer (a type of cancer that begins in the uterus [a hollow pear-shaped pelvic organs where fetal development occurs]). During an interview on 12/12/22, at 1:50 p.m. the Administrator (ADM) stated, the Spiritual Counselor (SC) was responsible in conducting the spiritual assessment. The ADM stated it was important for the SC to do the spiritual assessment to assess the patients needs and offer resources for their spiritual preferences. The ADM stated there was no evidence the SC assessed the patient. b. A review of Patient 9s (P9) ";Patient Information", indicated a start of care date of 6/7/22, with diagnoses including end-stage renal disease (kidneys unable to get rid of body waste). During an interview on 12/12/22. At 1:35 p.m., the administrator (ADM) stated it was important for the Medical Social Worker (MSW) to do the psychosocial assessment because they are able to spot for emotional support and other things they need to do for the patient; to deal with all of the legal issues such as power of attorney and so forth. During an interview on 12/12/22, at 1:40 p.m., the ADM stated the psychosocial assessment had to be completed within 5 days of the start of care. The ADM stated the reason the psychosocial assessment was not done was because the patient passed away on 6/10/22. The ADM stated there was no documentation to show the MSW contributed to the comprehensive assessment or attempted to see the patient or talk to the patient. During an interview on 12/12/22, at 1:50 p.m. the ADM stated the Spiritual Counselor (SC) was responsible in conducting the spiritual assessment. The ADM stated it was important for the SC to do the spiritual assessment to assess the patients needs and offer resources for their spiritual preferences. The ADM stated there was no evidence the SC assessed the patient. A review of the HAs policy and procedure titled, ";Initial Assessment/Comprehensive Assessment", dated 11/2017, indicated ";Procedure:...2.Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for Hospice care and identify the patients need for:...psychosocial and emotional care...All areas of Hospice care related to the palliation and management of the terminal illness and related conditions." A review of the HAs policy and procedure titled, ";Spiritual Care Services", revised 11/2022, indicated, ";Procedure...2.The Hospice Spiritual Counselor will conduct the depth assessment."

Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director participated in the interdisciplinary group (IDG, a group of healthcare professionals with various areas of expertise who works together towards the goals of their clients) meeting for one of ten sampled patients (Patient 1). This deficient practice had potential for lack of care and services to meet the patients care goals. --- A review of Patient 1s (P1) ";Patient Information" indicated P1's Start of Care (SOC) date of 4/5/2022 with the primary diagnosis of cerebral ischemia (low blood flow to the brain). A review of P1s ";Hospice IDG Meeting Care Plan Update" dated 12/1/2022 indicted the Medical Director signature section has been left blank. During a concurrent interview and record review on 12/13/2022 at 11 a.m., the Administrator (ADM) stated, ";Sometimes they dont sign them", she also stated that they notice the missing signatures on their next IDG meeting and that she has them sign them there. ADM confirm P1s IDG meeting on 12/1/2022, the Medical Director signature section was left blank. A review of the HAs policy and procedure titled, ";IDG Care Planning Process", dated 11/2017, indicated ";Procedure: 7. Written evidence of care coordination ... will involve the hospice patients attending physician. 10. The IDG (in collaboration with the patients attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patients conditions requires, but no less frequently than every 15 calendar days." A review of facilitys policy and procedure titled, ";Physician Orders" dated September 2011, indicated ";The IDG (interdisciplinary group) plan of care is established in consultation with the physician, Medical Director..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure counseling services were available to the family following the death of their family member for five of ten (Patient 2, Patient 4, Patient 5, Patient 7 and Patient 8) sampled patients. This deficient practice had the potential to result in the patient's families not receiving supportive services for the bereavement process. --- a. A review of Patient 2s (P2) ";Patient Information" indicated P2's Start of Care (SOC) dated 9/30/2022 and an End of Care (EOC) date of 11/6/2022 with the primary diagnosis of malignant neoplasm (cancerous tumor) of unsp site of right breast (breast cancer). During an interview on 12/12/22, at 3 p.m., the ADM stated P2s record did not reflect counseling services were offered to the family after P2s passed away. b. A review of Patient 4s (P4) ";Patient Information" indicated P4's Start of Care (SOC) dated 1/14/2022 and an End of Care (EOC) date of 1/14/2022 with the primary diagnosis of congestive heart failure (CHF, the heart does not pump enough blood to meet the body's need). During an interview on 12/13/22, at 12 p.m., the ADM stated P4s record did not reflect counseling services were offered to the family after P4 passed away. c. A review of Patient 5s (P5) ";Patient Information" indicated P5's Start of Care (SOC) dated 5/23/2022. A review of P5s Discharge indicated an End of Care (EOC) date of 5/26/2022. A review of P5s Plan of Treatment indicated P5 had a primary diagnosis of chronic obstructive pulmonary disease (COPD, a group of disease that causes airflow blockage and breathing related problems). During an interview on 12/12/22, at 250 p.m., the ADM stated P5s record did not reflect counseling services were offered to the family after P5s passing. d. A review of Patient 7s (P7) ";Patient Information", indicated a start of care date of 7/12/22, with diagnoses including severe calorie protein malnutrition. During an interview on 12/12/22, at 2:22 p.m., the ADM stated P7s record did not reflect counseling services were offered to the family after P7 passed away. e. A review of Patient 9s (P9) ";Patient Information", indicated a start of care date of 6/7/22, with diagnoses including end-stage renal disease (kidneys unable to get rid of body waste). During an interview on 12/12/22, at 2:05 p.m., the ADM stated P9s record did not reflect counseling services were offered to the family after P9 passed away. A review of the HAs policy and procedure titled, ";Bereavement Services", dated 9/2011, indicated, ";Procedure 1. Alden Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patients death. The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions which may interfere with the eventual resolution and integration of their losses..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure a bereavement (a process that includes going through several stages of grief) care plan was formulated for eight of ten sampled patients, (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This deficient practice had the potential to result in lack of emotional support and resources for the bereaved family. --- a. A review of Patient 2s (P2) ";Patient Information" indicated P2 was an 87- year- old female with a Start of Care (SOC) date of 9/30/2022 and an End of Care (EOC) date of 11/6/2022 with the primary diagnosis of Malignant neoplasm of right breast (breast cancer). During an interview on 12/12/2022, at 3 p.m., the Administrator (ADM) stated P2s record did not reflect a bereavement care plan for the bereaved. b. A review of Patient 3s (P3) ";Patient Information", indicated P3 was an 83 year old male with a start of care date of 12/13/2021, with diagnoses of Alzheimers Disease (progressive decrease in memory). During an interview on 12/13/2022, at 10 a.m., the ADM stated P3s record did not have a bereavement care plan for the bereaved. c. A review of Patient 4s (P4) ";Patient Information" indicated P4 was an 97 year old female with an Start of Care (SOC) date of 1/14/2022 and an End of Care (EOC) date of 1/14/2022 with the primary diagnosis of Congestive Heart Failure (Heart failure). During an interview on 12/13/2022, at 12 p.m., the ADM stated P4s record did not reflect a bereavement care plan for the bereaved. d. A review of Patient 5s (P5) ";Patient Information" indicated P5 was an 88 year old male with an Start of Care (SOC) date of 5/23/2022. A review of P5s Discharge indicated an End of Care (EOC) date of 5/26/2022. A review of P5s Plan of Treatment indicated P5 had a primary diagnosis of chronic obstructive pulmonary disease (COPD, a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). During an interview on 12/12/2022, at 250 p.m., the ADM stated P5s record did not reflect a bereavement care plan for the bereaved. e. A review of Patient 6s (P6) ";Patient Information", indicated a start of care date of 3/23/22, with diagnoses including alcohol induced dementia (memory problems). During an interview on 12/12/2022, at 2:15 p.m., the ADM stated P6s record did not have a bereavement care plan for the bereaved. f. A review of Patient 7s (P7) ";Patient Information", indicated a start of care date of 7/12/22, with diagnoses including severe calorie protein malnutrition. During an interview on 12/12/2022, at 2:22 p.m., the ADM stated P7s record did not have a bereavement care plan for the bereaved. g. A review of Patient 8s (P8) ";Patient Information", indicated a start of care date of 5/12/22, with diagnoses including uterine cancer. During an interview on 12/12/2022, at 2:20 p.m., the ADM stated P8s record did not have a bereavement care plan for the bereaved. h. A review of Patient 9s (P9) ";Patient Information", indicated a start of care date of 6/7/22, with diagnoses including end-stage renal disease (kidney failure). During an interview on 12/12/2022, at 2:00 p.m., the ADM stated it was important to have a bereavement care plan so the staff know what the needs are for the patients and family; and what the agency needs to do for them. During an interview on 12/12/2022, at 2:05 p.m., the ADM stated P9s record did not have a bereavement care plan for the bereaved. During an interview on 12/12/2022, at 2:00 p.m., the ADM stated it was important to have a bereavement care plan so the staff know what the needs are for the patients and family; and what the agency needs to do for them. A review of the HAs policy and procedure titled, ";Bereavement Services", dated 9/2011, indicated, ";a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated...The plan of care will note the kind of bereavement services to be offered and frequency of service delivery."

Based on interview and record review, the Hospice Agency (HA) failed to ensure correct information was documented in the clinical record for one of ten sampled patients, (Patient 2). This failure can result to poor communication process that can affect the quality of care and services provided to the patients under the agencys care. --- A review of Patient 2s (P2) ";Patient Information" indicated P2 was an 87-year-old female with a Start of Care (SOC) date of 9/30/2022 and an End of Care (EOC) date of 11/6/2022 with the primary diagnosis of Malignant neoplasm of right breast (breast cancer). A review of P2s ";Patient Visit Calendar" indicated P2 had her fist Certified Home Health Aide (CHHA) visit on October 6, 2022, from 10:30 am to 11:30 a.m. made by a Certified Home Health Aide (CHHA) 1. It also indicated P2 had a Skilled Nursing (SN) visit last October 1, 2022, from 1 p.m. to 2:15 p.m. made by Registered Nurse 1 (RN). A review of P2s ";Plan of Treatment" dated 9/30/2022, indicated an aide visit frequency of two times per week to assist with personal care/ADLs (activities of daily living) light housekeeping as needed within 90 days period. It also indicated Skilled Nursing (SN) service with a frequency of 2-3 times per week. A review of P2s Aide Supervisory Visit" dated 10/1/2022 indicated RN2 completed the form on 10/1/2022 at 1 p.m. which stated, ";Client/Family is satisfied with care provided. Services are performed properly. Infection control procedures used, and documentation is adequate and timely." A review of P2s ";Aide Visit Note" dated 10/6/2022 indicated, CHHA1 first visited P2 on 10/6/2022 from 10:30 a.m. to 11:30 a.m. During an interview and concurrent record review with ADM on 12/12/2022 at 3 p.m., the clinical record for P2 indicated first CHHA encounter date of 10/6/2022, however, RN1 indicated CHHA supervisory visit was completed on 10/1/2022. When asked, ADM stated that RN1 wrote the CHHA supervisory visit 10/1/2022, ";because I told her the CHHA was going to be there. I dont know why she did that." A review of facilitys policy and procedure titled, ";Hospice Aide Documentation" dated November 2011, indicated ";HA will ensure accurate documentation of Hospice Aide Services." A review of facilitys policy and procedure titled, ";Hospice Aide Supervision" dated September 2011, indicated ";At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationship and determine whether goals are being met. In addition, RNs must assess the adequacy of the aide services in relationship to the needs of the patient and family." A review of facilitys policy and procedure titled, ";Patient Record Content" dated September 2011, indicated ";The record must contain correct clinical information."

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure one of ten sampled patients (Patient 1) had current clinical notes documented. This failure had the potential to result in confusion among staff about patients current status, which could cause delays in treatments. --- A review of Patient 1s (P1) ";Patient Information" indicated P1 was an 85-year-old female with a Start of Care (SOC) date of 4/5/2022 with diagnosis that included cerebral ischemia (low blood flow to the brain). A review of P1s ";Plan of Treatment" dated 11/22/2022 indicated, P1 will have aide visit frequency of two times per week to assist with personal care/ADLs (activities of daily living) light housekeeping as needed within 90 days period. A review of P1s ";Patient Visit Calendar" indicated P1 had Certified Home Health Aide 2 (CHHA 2) scheduled visits on 11/25/2022, 11/29/2022, and 12/2/2022. During an interview and concurrent record review with the Administrator (ADM) on 12/13/2022 at 11 a.m. of P1s clinical record, the clinical record indicated the last CHHA visit note on file was dated 11/22/2022. No other notes that indicate the recent visits of CHHA. ADM stated that the visit notes must be in the patients clinical record the week following their visit. ADM also stated, ";It is important so that we can see what happened and what she has." A review of facilitys policy and procedure titled, ";Hospice Aide Documentation" dated November 2011, indicated, ";The Manager of Patient Services or designated RN is responsible for reviewing the Hospice Aides charting. The original documentation will be filed in the medical record within seven (7) days of the visit. (HA) will ensure accurate documentation of Hospice Aide Services." A review of facilitys policy and procedure titled, ";Timely Submission of Patient Documentation" dated September 2011, indicated ";Itineraries, with all visit reports attached, must be submitted the next schedule workday, not exceeding three (3) business days."