Every finding on record at Boerne Hospice Partners, LLC

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 clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the bereavement and spiritual assessment, was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 1: The date of the hospice election was 08/07/2024 with a primary diagnosis of Other specified degenerative diseases of basal ganglia. There was no documented evidence that an initial bereavement assessment occurred in the first five days of the election of hospice or at any point throughout the course of care. CLINICAL RECORD 4: The date of the election was 05/29/2024 with a diagnosis of Cerebral infarction, Alzheimer's disease, hypertension, type 2 diabetes mellitus without complications, chronic kidney disease. There was no documented evidence that an initial bereavement assessment occurred in the first five days of the election of hospice or at any point throughout the course of care. CLINICAL RECORD 16: The date of the election was 05/29/2024. The clinical record lacked evidence that a spiritual assessment occurred in the first five days or at any point throughout the course of care. The Admission (RN [Registered Nurse]) Clinical Note dated 05/29/2024 documented, " Spiritual - A spiritual assessment could not be completed. I was unable to assess [patient's name] because the chaplain will perform this assessment." The CH [Chaplain]) Clinical Note dated 05/29/2024, documented, "Initial Assessment - I was unable to assess the patient because the patient declined to discuss when asked. Patient declined Chaplain upon initial assessment by RN." During a joint record review and an interview on 01/24/2025, the Director of Clinical Services/Registered Nurse agreed there was no documented evidence that the initial bereavement and spiritual assessments were completed no later than five calendar days after the election of hospice care.

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 clinical record review and interview. In 2 of 14 (14%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 1: The Hospice Aide Clinical Note dated 08/28/2024 documented, "Missed Visit Reason: Pt was at appointments at time of visit. Other comment: Pt was at a dentist appointment upon arrival wife refused visit and wanted to resume visit on Friday." The Hospice Aide Clinical Note dated 09/04/2024 documented, "Missed Visit Reason: Pt is out with friends." The Hospice Aide Clinical Note dated 10/29/2024 documented, "Missed Visit Reason: Wife cancel visit." The Hospice Aide Clinical Note dated 11/29/2024 documented, "Missed Visit Reason: Pt wife refused visit." The Hospice Aide Clinical Note dated 01/21/2025 documented, "Missed Visit Reason: Missed visit due to weather." There was no documented evidence that the aide notified the registered nurse of changes to the plan of care. CLINICAL RECORD 5: The Hospice Aide Clinical Note dated 11/29/2024 documented, "Missed Visit Reason: Pt refused visit. Other comments: Wife refused visit will resume next visit." The Hospice Aide Clinical Note dated 01/04/2025 documented, "Missed Visit Reason: Patient refuses visit." There was no documented evidence that the aide notified the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 01/24/2025, the Director of Clinical Services/Registered Nurse confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.

It is required that the plan of care specifies the hospice care and services necessary to meet the specific needs of the patient identified in the comprehensive assessment. This standard was not met as evidenced by review of clinical records and interview. 3 of 13 (23%) clinical record plans of care did not specify the hospice care and services necessary to meet the specific needs of the patient identified in the comprehensive assessment. Clinical Record #97001 was reviewed and identified the patient elected hospice care on 1/9/22 with a diagnosis of dementia. SN communication note on 4/18/22 documents "reported open area on buttocks. Appears to be another boil which is a recurring issue. Will have treatment nurse assess.” On 4/20/22 this surveyor participated in 2 independent interviews. The RNCM, prior to an observation visit stated, “the boil is a recurring issue.” The director of clinical services also confirmed the boil as a recurring issue during an interview on 4/20/22 while reviewing clinical record documentation. There is no evidence of documentation of wound care orders or treatments for boils since patient admission to hospice on to 1/9/22. Review of the POCs dated 1/13, 1/27, 2/10, 2/24, 3/10, 3/24, and 4/7 revealed there is no evidence of wound care or problems related to skin integrity. Clinical Record #51148 was reviewed and identified the patient elected hospice care on 10/18/21 with a diagnosis of colon cancer. Skilled Nursing Assessment of 3/8/22 documents “Pt with abscessed area to mid-back. Pt has history of these types of issues. SN called Dr. and he ordered doxycycline 100 mg 1 PO x 7 days; mupirocin ointment apply daily to area.” There is no evidence of documentation on the plans of care for the Staph infection with abscessed area to the mid-back. Review of the plans of care dated 3/17/22, 3/31/22, and 4/13/22 revealed there is no evidence of a problem, interventions and goals related to staph infection or abscessed area to the mid-back. Clinical Record #25284 was reviewed and identified the patient elected hospice care on 9/24/21 with a diagnosis of heart disease. Skilled Nursing Assessment on 3/2/22, 3/8/22, 3/11/22, 3/18/22, 3/21/22, 3/25/22, 3/28/22, 4/5/22, 4/13/22, 4/15/22 and 4/20/22 documents "wound wrapping to right ankle applied per LTCF staff. Dressing to left lower dorsal of calf, clean/dry intact." Review of the plans of care dated 3/10/22, 3/24/22 and 4/7/22 revealed there is no evidence of a problem, interventions and goals related to a wound wrapping to the right ankle or wound dressing on the left lower dorsal of calf. During an interview with the director of clinical services on 4/22/22 the director agreed the assessment findings with treatments identified on the comprehensive assessments were not documented in the plans of care.

##### It is required that each patient’s individualized written plan of care identify planned interventions based on problems identified in comprehensive assessments. This standard was not met as evidenced by review of clinical records and interview. 6 of 6 (100%) plans of care in clinical records of patients receiving aide services did not have aide services identified as a planned intervention based on problems identified in the comprehensive assessment. Clinical Record #51148 was reviewed and identified the patient elected hospice care on 10/18/21 with a diagnosis of colon cancer. The aide plan of care dated 4/16/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #17411 was reviewed and identified the patient elected hospice care on 10/7/21 with a diagnosis of hypertension. The aide plan of care dated 4/5/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #67985 was reviewed and identified the patient elected hospice care on 12/3/21 with a diagnosis of unspecified severe protein mal nutrition. The aide plan of care dated 4/15/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #97001 was reviewed and identified the patient elected hospice care on 1/9/22 with a diagnosis of dementia. The aide plan of care dated 3/10/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #99894 was reviewed and identified the patient elected hospice care on 6/30/21 with a diagnosis of neoplasm cancer. The aide plan of care dated 2/25/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #60357 was reviewed and identified the patient elected hospice care on 7/7/21 with a diagnosis of heart disease. The aide plan of care dated 3/4/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. Clinical Record #25284 was reviewed and identified the patient elected hospice care on 9/24/21 with a diagnosis of heart disease The aide plan of care dated 3/10/22 states aide provides services 3/week. The plan of care does not include any problems, interventions or goals related to the aide services. During an interview with the DCS on 4/20/22 the DCS confirmed this finding.

It is required that if a patient revokes the election of hospice care the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by review of clinical records and interview. 1 of 4 (25%) clinical records reviewed with live discharges did not contain documentation of a discharge summary. Clinical Record #14907 was reviewed and identified the patient elected hospice care on 1/10/2022 with a diagnosis of heart disease. Documentation in the clinical record dated 4/7/22 includes a signed revocation statement and a signed order from the medical director stating “DC from hospice services. Patient hospitalized for aggressive treatment.” Review of the clinical record revealed of a hospice discharge summary was not in the record. Hospice policy “Criteria for Patient Admission and Discharge/Discharge Planning” states, in part, “If a patient revokes the election of hospice or is discharged from hospice, a copy of the hospice discharge summary and a copy of the hospice clinical record (if requested) is sent to the attending physician.” On interview of 4/21/22 with the director of clinical services she confirmed this finding.

It is required that the hospice discharge summary includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care, latest physician orders; and any other documentation that will assist in the post-discharge continuity of care. This standard was not met as evidenced by review of clinical records and interview. 2 of 4 (50%) clinical records reviewed with live discharges a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care, latest physician orders; and any other documentation that will assist in the post-discharge continuity of care. Clinical Record #88838 was reviewed and identified the patient elected hospice care on 12/4/21 with a diagnosis of heart disease. Documentation in the clinical record contains an order signed by the medical director on 1/18/22. The order states, in part, “discharge from services, patient transferring to another hospice effective 1/18/2022.” Review of the clinical record revealed the discharge details/summary note did not contain a summary of the patient’s care (pain management, symptoms, and treatments), the patients current plan of care, including the current medication profile, or the latest physician orders that may assist with the patient’s post-discharge continuity of care. Clinical Record #12007 was reviewed and identified the patient elected hospice care on 11/25/21 with a diagnosis of heart disease. Documentation in the clinical record contains an order signed by the medical director on 1/17/22. The order states, in part, “discharge from hospice services effective 1/20/22 due to prolonged prognosis. Pt/caregiver in agreement with change in POC.” Review of the clinical record revealed the discharge details/summary note did not contain a summary of the patient’s care (pain management, symptoms, and treatments), the patients current plan of care, including the current medication profile, or the latest physician orders that may assist with the patient’s post-discharge continuity of care. Hospice policy “Patient Discharge” states, in part, “The hospice will forward copies on the following in the patient’s Attending Physician upon discharge from the hospice’s services. The hospice discharge summary which includes but is not limited to a summary of the patient’s care (pain management, symptoms, and treatments), the patients current plan of care, including the current medication profile, the latest physician orders and any other documentation requested or that may assist with the patient’s post-discharge continuity of care.” On interview of 4/21/22 with the director of clinical services she stated she wasn’t aware of all the required elements of a discharge summary.