Every finding on record at Aseracare Hospice-Monroeville, L.L.C.

Upon patient record review 1 of 19 (Patient #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 11:The patient was admitted to services on 6/7/24. The spiritual care comprehensive assessment was completed on 6/21/24, greater 5 days after admission.

Upon patient record review, 2 of 19 (Patient #3,#10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3:The medical record indicates that a stage II coccyx wound was reported to the facility nurse on 9/12/24. From 9/12 through 9/25/24 and 9/27/24 through 10/10, there is no evidence that weekly wound assessments were completed per agency policy. Patient 10:The medical record includes documentation of a Stage II coccyx wound with onset noted as 3/1/24. There is no evidence that weekly assessments were completed per agency policy from 9/26/24 through 10/11/24.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 6: The medication profile includes entries for Wellbutrin, Bentyl, Doxepin, Vit D, morphine, Miralax, Effexor, Vitamin D3 and Zofran. There is no evidence that education was provided on purpose, directions for use and side effects.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5:The plan of care includes an order for oxygen to be delivered at 3 liters per minute via nasal cannula continuous. There is nursing documentation on 10/1/24 and 10/3/24 that the patient was on room air, the patient was wearing oxygen as needed, not continuous.

Upon patient record review, 4 of 19 (Patient #1,#10,#11,#12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1 :The medical record includes documentation of recent infections requiring antibiotic therapy on 9/24/24. There is no evidence that the plan of care was updated with problems, goals and interventions for an active infection. Patient 10:The medical record includes documentation on admission that the patient required an indwelling foley catheter and that the catheter was discontinued on 7/31/24. There is no evidence that the plan of care was updated to reflect the discontinuation of the indwelling foley catheter. Patient 11:The medical record includes documentation on 7/16/24 that the wound was inactivated and on 8/7/24 that chaplain visits were discontinued per patient request. There is no evidence that the plan of care was updated to reflect the discontinuation of wound care and chaplain visits. Patient 12: The medical record includes documentation of recent infections requiring antibiotic therapy on 9/16/24. There is no evidence that the plan of care was update with problems, goals and interventions for an active infection.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 11:The aide plan of care included 2 bath options, the task of sponge bath and assist with shower assigned every visit.

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 agency policy review, clinical record review, and interview. 2 of 13 (15%) records reviewed, the agency failed to ensure that the initial comprehensive assessments were completed within five days of the start of care. Record #28289: The patient elected the hospice benefit on 9/10/2021. On 9/17/2021 (6 days post start of care), a social worker note was entered that stated, "Evaluation scheduled after five days - Technical difficulty with IT and admission." The initial social worker visit was performed on 9/17/2021. On 9/21/2021 (11 days post start of care), a Chaplain note was entered that stated, "Evaluation scheduled after five days no answer to phone." The Spiritual Care visit note, documented on 9/21/2021, included a completed COVID screening. All other entries state, "patient declined SCC (Spiritual Care Coordinator) visit." Record #47071: The patient elected the hospice benefit on 8/2/2021. On 8/16/2021 (14 days post start of care), the chaplain documented a visit note that stated, "SCC visit declined." There was no documentation regarding contact with the patient by the chaplain within the initial five days. Agency policy "AA-005 Hospice Plan of Care" (revised 10/29/2021) states in relevant parts, "The comprehensive assessment and plan of care will be completed by the IDT within five days of the election of benefits." The policy further states, "The hospice plan of care is comprised of but is not limited to the following forms: the initial plan of treatment and certification, the initial assessment/Plan of Care, the Comprehensive Assessment, IDT Plan of Care Update, Medication Profile, the Social Work Assessment, Spiritual Care Assessment, Bereavement Assessment, Hospice Aide Plan of Care." In an interview with the Director of Operations, it was confirmed that the agency did not document attempts to complete the social worker and/or spiritual care assessments within the required five days from the hospice benefit election date.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by agency policy review, clinical record review, and interview. 6 of 13 (46%) records reviewed, the RN member(s) of the IDG (Interdisciplinary Group) failed to ensure that care was provided in accordance with the ordered visit frequencies. Record #75690: The patient's SOC (start of care) was 7/23/2021. An order dated 7/23/2021 included a social worker (SW) visit frequency of 3m1, 1 m3. One social worker visit was documented on 7/27/2021, rather than the 3 visits ordered for that month. There were no documented missed visits. Record #23055: The patient's SOC was 9/10/2021. A bereavement coordinator visit was performed on 9/20/2021. There was no order for the visit. Record #51065: The patient's SOC was 3/30/2021. The record included an order, dated 10/1/2021, for an SW visit frequency of 3mo1. One visit was performed on 10/12/2021 rather than the 3 visits ordered. The record did not include documentation of the 2 missed visits. Record #30369: The patient's SOC was 9/17/2021. The record included an order dated 9/17/2021 for Spiritual Care 2mo2. One Spiritual Care visit was performed on 9/21/2021, rather than the 2 visits ordered. The record did not include documentation of the missed visit. Record #28289: The patient's SOC was 9/10/2021 (a Friday). SN (skilled nursing) was ordered at a visit frequency of 4w1. One SN visit was performed on 9/10/2021, rather than 4 visits that week as ordered. There were no documented missed visits and the ordered visit frequency exceeded the number of days remaining in the order week. The full visit frequency ordered on 9/10/2021, was 4w1, 1 every 2 weeks x 2. The week of 9/12/2021 (2nd week of the episode), no SN visits were performed. The week of 9/19/2021 (3rd week of the episode), 2 SN visits were performed (on 9/21 and 9/23/2021). The visits performed exceeded the ordered visit frequency of 1 every 2 weeks x 2. Record #48941: The patient's SOC was 6/3/2021. An order dated 10/24/2021 increased the SN visit frequency to 2x/week. The week of 10/24/2021, 4 SN visits were performed. There was no order for the 2 extra visits. Agency policy "AA-005 Hospice Plan of Care" states in relevant parts, "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 caregiver in accordance with the patient's needs if any of them so desire." The policy further states, "The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including but not limited to scope and frequency of all services necessary to meet the needs of the patient." In an interview with the Director of Operations, it was confirmed that the visit frequencies were not followed in accordance with what was ordered.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by agency policy review, clinical record review, and interview. 1 of 10 (10%) applicable records of patients with hospice aide services, the agency failed to ensure that the hospice aide was in compliance with the ordered visit frequencies in the Plan of Care. Record #52869: The Plan of Care starting 7/14/2021 included an order for an aide visit frequency of 3w8 and 1w1. The week of 8/8/2021 (week 5 of the episode), one aide visit was performed on 8/13/2021, rather than the three visits ordered. There were no documented missed visits. Agency policy, "AA-005 Hospice Plan of Care," states in part, "The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including but not limited to scope and frequency of all services necessary to meet the needs of the patient." In an interview with the Director of Operations, it was confirmed that the aide did not provide services in accordance with the ordered visit frequency.