Every finding on record at Athc - Hospice, LLC

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 the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the written plan of care included individualized goals with measurable outcomes. CLINICAL RECORD 1: This patient elected the hospice benefit on 08/21/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The initial Registered Nurse (RN) comprehensive assessment documented that the patient was receiving tramadol 50 mg every six hours as needed for pain, gabapentin 100 mg, two (2) tablets at night for neuropathy, and lidocaine 4% topical patch, apply one patch to the back of neck at bedtime and remove in the am. The patient was alert and oriented to person, place, and time. The plan of care dated 08/21/2024 through 07/30/2025 documented the patient's goal: pain will be managed for a patient who is unable to report or articulate pain. The patient's goal for pain did not include a measurable outcome. CLINICAL RECORD 6: This patient elected the hospice benefit on 05/30/2025 with a terminal diagnosis of fracture of the right pubis. The initial Registered Nurse (RN) comprehensive assessment dated 05/30/2025 documented the patient stated experiencing pain at "3-8/10." The RN nursing visit on 07/30/2025 documented that the patient had pain in both wrists. The plan of care was reviewed for the dates of 05/30/2025-07/30/2025, documenting the patient's goal: pain is managed for a patient who is unable to verbally report or articulate pain as evidenced by patient/caregiver report or visual observation. The patient's goal for pain did not include a measurable outcome. In an interview on 07/30/2025, the Regional Compliance Officer stated that the goals were not individualized and did not include measurable outcomes.

It is required that each patient’s individualized written plan of care: includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the written plan of care included drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 1: This patient elected the hospice benefit on 08/21/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The initial Registered Nurse (RN) comprehensive assessment dated 08/21/2024 documented that the patient had a Foley catheter. The plan of care for the dates of 08/21/2024 through 11/05/2024 did not document orders for the care and maintenance of the Foley catheter. The plan of care, updated on 11/06/2024, ordered the assessment and management of the catheter but did not address the size of the catheter or how often it should be changed. During an interview on 07/30/2025, the Regional Compliance Officer stated that the care of the Foley catheter was not present in the plan of care.

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 clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit on 07/27/2024 with a terminal diagnosis of diastolic congestive heart failure and revoked the hospice benefit on 08/14/2024. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient's attending physician. In an interview and a joint record review on 07/30/2025, the Regional Compliance Officer (RCO) stated that there was no documentation that the hospice forwarded the patient’s attending physician a copy of the hospice discharge summary.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits observed of a patient who resided in a skilled nursing facility (SNF), the agency did not ensure that the SNF was provided with the physician certification and recertification of the terminal illness. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 06/30/2025 with a terminal diagnosis of end-stage heart failure. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 07/29/2025, a review of the patient's SNF hospice chart revealed no evidence of the physician certification of terminal illness.. During an interview on 07/30/2025, the SNF Director of Nursing (DON) stated that this information was not included in the SNF hospice chart and that they had contacted the agency two weeks ago to request this missing documentation, with no response. The Regional Compliance Director was interviewed on 07/30/2025 and stated that the hospice agency did not have evidence that the physician certification of terminal illness was provided. The hospice agency emailed the physician certification of terminal illness to the SNF during the site visit.

It is required that each patient’s individualized written plan of care reflects patient and family goals, measurable outcomes anticipated from implementing and coordinating the plan of care, and documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by a review of clinical records and interviews. 13 of 13 (100%) clinical records reviewed revealed the agency did not ensure that individualized plans of care included measurable patient outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 5: The Patient was admitted on 09/23/2022 with a diagnosis of malignant neoplasm. The plan of care identified "Altered Neurological Status." The outcome documented included " patient tolerates neurological assessment." Clinical Record 11: The Patient was admitted on 09/02/2022 with a diagnosis of Senile Degeneration Of The Brain. The plan of care identified "Altered Genitourinary Status." The outcome documented included "patient will be free from exacerbation of genitourinary disease since the last visit." Clinical Record 13: The Patient was admitted on 09/18/2022 with a diagnosis of Senile Degeneration Of The Brain. The plan of care identified an "Altered gastrointestinal system" The outcome documented included " patient/caregiver will demonstrate proper hygiene measures after each episode of Bowel movement." Clinical Record 8: The Patient was admitted on 10/22/2022 with a diagnosis of COPD. The plan of care identified a "caregiver knowledge deficit of the patient's pain management." The outcome included " patient caregiver will understand pain scale." Clinical Record 9: The Patient was admitted on 10/19/2022 with a diagnosis of COPD. The plan of care identified "Altered home safety." The outcome documented included " patient's safety needs to be met." Clinical Record 3: This Patient was admitted on 08/19/2022 with a diagnosis of Prostate CA. The plan of care identified a "caregiver knowledge deficit of the patient's safety." The outcome documented included " patient has safety needs met." Clinical Record 10: The patient was admitted on 04/30/2021 with a diagnosis of Senile Degeneration Of The Brain. The plan of care identified a "caregiver knowledge deficit of the patient's pain management." The outcome documented included " patient caregiver will understand pain scale." Clinical Record 7: The Patient was admitted on 09/22/2022 with a diagnosis of Alzheimer's. The plan of care identified " Altered Neurological Status.". The outcome documented included " patient caregiver will verbalize understanding of seizure precautions." Clinical Record 12: The Patient was admitted on 10/22/2022 with a diagnosis of Senile Degeneration Of The Brain. The plan of care identified a "Selfcare deficit." The outcome documented included " patient's personal care needs will be met." Clinical Record 4: The Patient was admitted on 09/09/2022 with a diagnosis of Heart Disease. The plan of care identified a "caregiver knowledge deficit of the patient's care of an indwelling catheter." The outcome documented included " indwelling catheter remains patent" Clinical Record 1: The Patient was admitted on 08/19/2022 with a diagnosis of Prostate CA. The plan of care identified a "self-care deficit' The outcome documented included " The patient's needs will be met." Clinical Record 6: The Patient was admitted on 10/06/2022. with a diagnosis of CHF. The plan of care identified "safety issues.". The outcome documented included "Safety needs will be met." Clinical Record 2: The Patient was admitted on 07/21/2022 with a diagnosis of Malignant Neoplasm Of The Liver. The plan of care identified a "caregiver knowledge deficit of the patient's pain management." The outcome documented included " patient caregiver will understand pain scale." During an interview with the Executive Director on 11/02/2022, she confirmed that the patient's outcomes were not measurable.

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records, documents, and interview. The agency policy, NO.9-020.1 HOSPICE AIDE SERVICES states in part, "Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to registered nurse as changes relate to the plan of care and any quality assessment and improvement activities." 2 of 11 (18%) clinical records reviewed for patients receiving services of a Hospice Aide, revealed no documented evidence that the hospice aide reported changes to the RN that may impact the plans of care. Clinical Record 2: The patient elected the hospice benefit on 07/21//2022. The aide plan of care initiated on admission assigned the aide to shampoo the patient's hair every visit. On 08/26/2022 the aide documented that the patient refused shampoo. However, there was no documentation that the RN was notified. Clinical Record 6: The patient elected the hospice benefit on 10/06/2022. The aide plan of care initiated on admission assigned the aide to shampoo the patient's hair every visit. On 10/15/2022 the aide documented that the patient refused shampoo. However, there was no documentation that the RN was notified. During an interview with the Executive Director on 11/02/2022, she confirmed that the Aide(s) did not report changes to the RN.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40. I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. The agency policy, NO.1-025.1 titled Discharge from Hospice Program states in part, "When a patient is discharged, transferred, or referred to another organization, relevant information will include a discharge summary, current plan of care, medication profile, physician order and reason for the transfer or discharge. The hospice will make all arrangements necessary to assure continuing care and services including a discharge summary for the receiving hospice provider." 2 of 3 (67%) applicable clinical records of patients with care transferred to another Medicare Certified facility lacked documentation that the transfer/discharge summary had been forwarded to the Medicare Certified receiving facility. Clinical Record 3: The patient was admitted for Hospice services on 8/19/2022 with a diagnosis of Prostate CA. Then transferred and was admitted to the hospital at which time revoked Hospice services were on 10/07/2022. There was a discharge summary completed. There was no documented evidence that the patient's discharge summary, medication list, plan of care, and history, and physical were forwarded to the receiving Medicare Certified Hospital for continuity of care. Clinical Record 1: The patient was admitted for Hospice services on 08/19/2022 with a diagnosis of Prostate CA. On 10/26/2022 transferred to the hospital and moved out of the service area. The patient revoked hospice services and was admitted to a Medicare certified facility. There was a discharge summary completed. There was no documented evidence the patient's discharge summary, medication list, plan of care, history, and physical were forwarded to the receiving Medicare certified facility for continuity of care. During an interview with the Executive Director on 11/02/2022, she confirmed that the transfer/discharge summaries were not forwarded to the receiving Medicare certified facility.