Every finding on record at Ardent Care Hospice Inc.

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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 2: The aide care plan dated 02/14/2024 assigned the aide the task of "Oral Hygiene." Review of the aide visit notes dated 04/29/2024 and 05/06/2024 revealed the aide documented "Oral Hygiene" done "No." The clinical record contained no documented evidence that the aide documented the reason the oral hygiene was not provided. Clinical Record 3: The aide care plan dated 04/19/2024 assigned the aide the task of "Oral Hygiene." Review of the aide visit notes dated 04/24/2024 and 05/01/2024 revealed the aide documented "Oral Hygiene" done "No." The clinical record contained no documented evidence that the aide documented the reason the oral hygiene was not provided. During an interview on 05/08/2024, the Administrator, Alternate Administrator/Alternate Director of Patient Care Services, and the Compliance Officer agreed the aide did not document the reason the task of oral hygiene was not completed as assigned.

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 2 (100%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide reported changes in the patient's medical needs to the Registered Nurse (RN) as the changes related to the plan of care. Clinical Record 2: The aide care plan dated 02/14/2024 assigned the aide the task of "Oral Hygiene." Review of the aide visit notes dated 04/29/2024 and 05/06/2024 revealed the aide documented "Oral Hygiene" done "No." The clinical record contained no documented evidence that the aide notified the RN of the change in the patient's medical needs. Clinical Record 3: The aide care plan dated 04/19/2024 assigned the aide the task of "Oral Hygiene." Review of the aide visit notes dated 04/24/2024 and 05/01/2024 revealed the aide documented "Oral Hygiene" done "No." The clinical record contained no documented evidence that the aide notified the RN of the change in the patient's medical needs. During an interview and joint review of records on 05/08/2024, the Administrator, the Alternate Administrator/Alternate Director of Patient Care Services, and the Compliance Officer agreed the records did not include documentation that the Aide reported the change in the patient’s medical needs to the RN.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient's record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the hospice election statement was completed as required by agency policy. Agency policy 1-031 The Hospice Election Statement, dated 11/2020, stated in part, "The date on the hospice election statement will be the official service start date. The patient/representative will be asked to identify the name of the attending physician." Clinical Record 1: The patient elected the hospice benefit on 02/20/2024. Review of the "Election of Hospice" benefit form revealed no documented evidence that the "Right to choose an attending physician" section and the "Effective Date of Election" were completed, these sections were not filled out. During an interview and joint clinical record review on 05/07/2024, the Alternate Administrator /Alternate Director of Patient Care Services (DPCS) confirmed the "Election of Hospice Benefit" form had two sections not completed, as required, the "Effective Date of Election" and the "Right to choose an attending physician." The Administrator, Alternate Administrator/Alternate DPCS, and the Compliance Officer stated in an interview on 05/08/2024 that the "Election of Hospice Benefit" form had not been completed as required by agency policy.

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 1 of 2 (50%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 4: The patient elected the hospice benefit on 12/01/2023 and revoked the hospice benefit on 12/06/2023 to pursue aggressive treatment. The clinical record contained no documented evidence that the patient’s discharge summary was forwarded to the patient's attending physician. During an interview and joint clinical record review on 05/08/2024, the Administrator, Alternate Administrator/Alternate Director of Patient Care Services, and the Compliance Officer agreed the clinical record contained no evidence that the discharge summary was sent to the attending physician.