Every finding on record at Aura Hospice LLC

It is required that each patient’s individualized written plan of care 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%) of clinical records reviewed revealed the organization did not ensure that each patient's plan of care identified planned interventions based on problems identified in initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient was admitted to hospice services on 11/15/2024 with benefit period 1 effective through 02/12/2025 and primary and pertinent secondary diagnoses that included Alzheimer’s Disease, Parkinson’s Disease, and a seizure disorder for which the patient was taking prescribed medication Levetiracetam covered by the hospice. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the plan of care effective 11/15/2024-02/15/2025 did not identify planned interventions such as seizure precautions for the patient's seizure diagnosis. The alternate DPCS stated, "We should have opened a care plan for seizures. We were watching her in case she had seizures because of her history." CLINICAL RECORD 7: The patient was admitted to hospice services on 11/20/2024 in benefit period 1 effective through 02/17/2025 with primary and pertinent secondary diagnoses that included senile degeneration of the brain, Alzheimer’s Disease, peripheral vascular disease, hypertension, depression, and a history of bladder cancer with urostomy, and lung cancer. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the patient's plan of care (POC) 11/20/2024-02/17/2025 and POC updates did not include a problem or identify planned interventions for shortness of breath/respiratory status to correspond with the patient's daily use of inhalers and albuterol inhalation therapy. The alternate DPCS stated, "We should have opened a plan of care for altered respiratory status that included the inhalers and albuterol as interventions among other things we were doing." CLINICAL RECORD 9: The patient was admitted to hospice services on 10/10/2024 into Benefit Period 1 effective through 01/10/2025 with primary terminal and pertinent secondary diagnoses that included traumatic subdural hemorrhage, chronic diastolic (congestive) heart failure, chronic kidney disease, Type 2 Diabetes Mellitus, and a right heal blister/wound. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, it was revealed that the patient had physician orders for insulin doses to be administered every morning, at bedtime, and with every meal. The alternate DPCS confirmed that comprehensive assessments performed by the RN case manager after the start of care included documentation that the patient’s blood sugar was “uncontrolled” as the patient “often forgot to check her blood sugar level.” The alternate DPCS confirmed that the POC 10/13/2024-01/10/2025 or POC updates did not include a problem or identify planned interventions for blood glucose monitoring and management. The alternate DPCS stated, “We needed to open a care plan for blood sugars that included how and how often the patient is supposed to check her blood sugar.” CLINICAL RECORD 12: The patient was admitted to hospice services on 07/29/2023 with Benefit Period 11 effective 11/20/2024-01/18/2025 that included primary terminal and pertinent secondary diagnoses of heart failure, dementia, Type 2 Diabetes Mellitus with diabetic neuropathy and atherosclerotic heart disease. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, it was revealed that a physician order was written for Cefuroxime Axetil 50mg twice daily for 7 days to treat a cellulitis infection of the patient's "red and tender" bilateral lower extremities with "worsening edema". The alternate DPCS confirmed that the POC or POC updates did not include a problem or identify planned interventions (other than the antibiotics) for the patient's new lower extremity infection. The alternate DPCS stated, “We didn't open a care plan with interventions documented by the nurses for the patient's lower extremity cellulitis."

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: 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 14 (7%) of clinical records reviewed revealed the organization did not ensure that each patient's individualized written plan of care included all wound care treatments necessary to meet the needs of each patient. CLINICAL RECORD 1: The patient was admitted to hospice services on 06/20/2024 with primary diagnoses and pertinent secondary diagnoses that included late effect CVA, a history of blood clots, bilateral lower extremity contractures, and the presence of a left hip pressure ulcer and left anterior foot, left lateral foot, and left lower leg venous stasis ulcers. The patient resided in an assisted living facility (ALF). During a concurrent clinical record review and interview with the DPCS and Alternate DPCS on 01/10/2025, it was discovered that the patient had three left lower extremity venous stasis ulcers identified at the start of care dated 06/20/2024 that were receiving wound care treatments documented as performed by the hospice RNs and LVNs along with wound characteristics and measurements. The DPCS and alternate DPCS confirmed that the plan of care (POC) 06/2024-0//27/2024 and POC updates did not include the wound treatment instructions for the treatment being performed (Cleanse with normal saline, apply Iodosorb to the wound bed, and cover with Foam dressing, twice weekly) for the three venous stasis ulcers and the POC and POC updates only contained wound treatment instructions for the patient's left hip pressure ulcer that was also documented as performed each skilled nursing visit with characteristics and measurements. Before the end of the site visit on 1/10/2025, the alternate DPCS provided a paper copy of wound care treatment instructions from the patient's primary physician dated and signed 06/20/2024 (the hospice SOC date) for the specific wound care treatments documented as performed by skilled nurses to the three venous stasis ulcers. "We should have added the written instructions for these three wounds to the patient's POC along with the wound care treatment instructions that we did include in the POC for the patient's left hip pressure ulcer. It was a busy time for us, and it was overlooked."

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: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) of clinical records reviewed, the organization did not ensure that each patient's individualized written plan of care included all medical supplies necessary to meet the needs of each patient. CLINICAL RECORD 14: The patient was admitted to hospice services on 04/27/2024 with Benefit Period 4 effective 12/23/2024-02/20/2025 with primary Diagnosis and pertinent secondary diagnoses that included Alzheimer’s Disease, edema, chronic pain, and dependence on supplemental oxygen. The patient resided in an assisted living facility (ALF). During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the face-to-face certifying document signed 12/02/2024 by the Nurse Practitioner (NP) (Personnel Record 9) for the patient entering into the 4th Benefit Period effective 12/23/2024 indicated that the patient's status had declined, required 2-person transfers, and that a Hoyer lift had been provided to the facility for patient and staff safety. The DPCS and Alternate DPCS confirmed that the Hoyer Lift was not included in the plan of care (POC) or POC updates after 12/02/2024.

It is required that a revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) of clinical records reviewed revealed the organization did not ensure that a revised plan of care based on information from the patient's updated comprehensive assessment included a record of the patient's progress toward outcomes and goals as specified in the plan of care. CLINICAL RECORD 5: The patient was admitted to hospice services on 11/15/2024 with benefit period 1 effective through 02/12/2025 and primary and pertinent secondary diagnoses that included Alzheimer’s Disease, Parkinson’s Disease, and a seizure disorder. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the plan of care effective 11/15/2024 included a problem with interventions for "imbalanced nutrition". The DPCS and Alternate DPCS confirmed that POC updates documented on 11/19, 11/27, 12/11, and 12/24/2024 following Interdisciplinary Group (IDG) meetings did not include documented progress toward goals related to imbalanced nutrition specified in the original plan of care. The Quality Coordinator also present for the clinical record review confirmed that none of the goals identified at the patient's start of care included documented progress toward outcomes, and stated, "We asked our clinicians not to touch the plans of care when documenting their assessments because the EMR was making duplicate plans rather than plan of care updates. I had to delete all new duplicate care plans being created so we told the clinicians not to touch the care plans." CLINICAL RECORD 12: The patient was admitted to hospice services on 07/29/2023 with Benefit Period 11 effective 11/20/2024-01/18/2025 that included primary terminal and pertinent secondary diagnoses of heart failure, dementia, Type 2 Diabetes Mellitus with diabetic neuropathy and atherosclerotic heart disease. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, it was revealed that the RN recertification summary note dated 11/12/20w4 indicated that the patient had experienced "increased confusion and forgetfulness", "nighttime hallucinations" and "sleeplessness" which was treated with an "increase in Haloperidol from 0.25ml to 0.5ml" administered at bedtime. The DPCS and alternate DPCS confirmed that the patient's POC for altered mental status/confusion had not been updated since the start of care on 07/29/2023 to include the patient's increased confusion and agitation and that the patient's clinical record did not include a documented outcome related to the patient's confusion and agitation after the increase in medication. CLINICAL RECORD 14: The patient was admitted to hospice services on 04/27/2024 with Benefit Period 4 effective 12/23/2024-02/20/2025 with primary Diagnosis and pertinent secondary diagnoses that included Alzheimer’s Disease, edema, chronic pain, and dependence on supplemental oxygen. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, it was revealed that the face-to-face certifying document signed on 12/02/2024 by PRR 9 Nurse Practitioner (NP) indicated that the patient had experienced "increased episodes of agitation and restlessness" during Benefit Period 3 and "routine Haloperidol dosing was increased for symptom management". The DPCS and alternate DPCS confirmed that the patient's POC for altered mental status/confusion had not been updated since the start of care on 04/27/2024 to include the patient's increased agitation and restlessness and that the patient's clinical record did not include a documented outcome related to the patient's agitation and restlessness after the increase in Haloperidol.

It is required that Hospice aides 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 this section. This standard was not met as evidenced by clinical record review and interview. In 6 of 13 (46%) of clinical records reviewed that included aide services, the organization did not ensure that the aide plan of care included all written instructions and guidance necessary for safe and effective care. CLINICAL RECORD 1: The patient was admitted to hospice services on 06/20/2024 with pertinent secondary diagnoses that included bilateral lower extremity contractures and the presence of a left hip pressure ulcer and left anterior foot, left lateral foot, and left lower leg venous stasis ulcers that were covered with wound care dressings. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 06/20/2024 did not include information that the patient had left lower extremity wounds, wound dressings, or how to cover/protect them during personal cares/showering. The alternate DPCS stated, “Our aides are instructed to report if a dressing has come off and aides are trained to cover dressings. I didn’t think it needed to be included in the aide plan of care instructions.” CLINICAL RECORD 4: The patient was admitted to hospice services on 01/16/2024 in the third benefit period with a pertinent secondary diagnosis of a sacral pressure ulcer that was covered with a wound care dressing. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 01/16/2024 did not include information that the patient had a sacral wound that was covered with a dressing or how to cover/protect it during a bed bath. CLINICAL RECORD 5: The patient was admitted to hospice services on 11/15/2024 with benefit period 1 effective through 02/12/2025 and primary and pertinent secondary diagnoses that included Alzheimer’s Disease, Parkinson’s Disease, and a seizure disorder for which the patient was taking medication. The plan of care effective 11/15/2024 indicated that the patient used a walker for mobility. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 11/15/2024 was blank in the sections titled mobility and activities permitted and did not indicate that the patient used a walker for mobility or that the patient had a history of seizures/required seizure precautions. CLINICAL RECORD 6: The patient was admitted to hospice services on 11/20/2024 in benefit period 1 effective through 02/17/2025 with pertinent secondary diagnoses that included the presence of an ileostomy. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 11/20/2024 did not include the patient’s ileostomy or any instructions for protecting the appliance or assisting the patient if the appliance needed to be emptied or changed. CLINICAL RECORD 7: The patient was admitted to hospice services on 11/20/2024 in benefit period 1 effective through 02/17/2025 with pertinent secondary diagnoses that included the presence of a urostomy. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 11/20/2024 did not include the patient’s urostomy or any instructions for protecting the appliance or assisting the patient if the appliance needed to be emptied or changed. CLINICAL RECORD 14: The patient was admitted to hospice services on 04/27/2024 with Benefit Period 4 effective 12/23/2024-02/20/2025 with primary Diagnosis and pertinent secondary diagnoses that included Alzheimer’s Disease, edema, chronic pain, and dependence on supplemental oxygen. The Nurse Practitioner's face-to-face certifying document dated 12/02/2024 indicated that the patient required continuous oxygen, and a Hoyer Lift/2-person transfer due to a decline in status. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the aide plan of care effective 12/23/2024 did not include the patient's dependence on continuous oxygen and that the patient required the use of a Hoyer Lift with 2-persons for a safe transfer.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) of clinical records reviewed with F2F certifying documents completed by the Nurse Practitioner (NP), the organization did not ensure that the signed F2F certifying documents were authenticated with the NP's credentials. CLINICAL RECORD 8: The patient was admitted to hospice services on 05/03/2024 with Benefit Period 4 effective 12/29/2024-02/26/2025 with primary Diagnosis and pertinent secondary diagnoses that included chronic obstructive pulmonary disease, pulmonary hypertension, congestive heart failure, dementia, hypertension, and dependence on supplemental oxygen. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the face-to-face certifying document signed 12/09/2024 by Nurse Practitioner (NP)(Personnel Record 9) for the patient entering into the 4th Benefit Period effective 12/29/2024 did not include the NP's credentials, only her electronic signature/name. The alternate DPCS stated, "I don't know why they [NP credentials] are not showing up next to her name in the electronic medical record. We'll have to check into that." CLINICAL RECORD 10: The patient was admitted to hospice services on 04/19/2024 with Benefit Period 4 effective 12/15/2024-01/10/2025 with primary terminal and pertinent secondary diagnoses that included Parkinson’s Disease, Lewy Body Dementia, hypertension, bipolar disorder, and mild cognitive impairment. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the face-to-face certifying document signed 12/05/2024 by Nurse Practitioner (NP) (Personnel Record 9) for the patient entering into the 4th Benefit Period effective 12/15/2024 did not include the NP's credentials, only her electronic signature/name. CLINICAL RECORD 12: The patient was admitted to hospice services on 07/29/2023 with Benefit Period 11 effective 11/20/2024-01/18/2025 that included primary terminal and pertinent secondary diagnoses of heart failure, dementia, Type 2 Diabetes Mellitus with diabetic neuropathy and atherosclerotic heart disease. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the face-to-face certifying document signed 11/04/2024 by the Nurse Practitioner (NP) (Personnel Record 9) for the patient entering into the 11th Benefit Period effective 11/20/2024 did not include the NP's credentials, only her electronic signature/name. CLINICAL RECORD 14: The patient was admitted to hospice services on 04/27/2024 with Benefit Period 4 effective 12/23/2024-02/20/2025 with primary Diagnosis and pertinent secondary diagnoses that included Alzheimer’s Disease, edema, chronic pain, and dependence on supplemental oxygen. During a concurrent review of the clinical record and interview with the DPCS and Alternate DPCS on 01/10/2025, both confirmed that the face-to-face certifying document signed 12/02/2024 by the Nurse Practitioner (NP) (Personnel Record 9) for the patient entering into the 4th Benefit Period effective 12/23/2024 did not include the NP's credentials, only her electronic signature/name.