Every finding on record at Cardinal Hospice North, LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, of patients that accepted the hospice aide, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 10: The aide plan of care was documented on 09/24/2024 and reviewed but not updated as of 07/16/2025. One of the assigned tasks was to shower twice a week, on the 1st and 3rd days of the week. The hospice aide frequency was for benefit period 27 dated 05/09/2025 - 07/07/2025. The updated nursing assessment dated 06/21/2025 documented a wound on the left Iliac crest with a required foam dressing changed 3 times a week by the facility. Additionally, a splint and Ace wrap on the right lower leg were documented as intact. The aide plan of care provided no direction on what to do during the shower with the splint and Ace wrap on the right lower leg or the dressing on the left iliac crest, if it was off or saturated during the shower. During the interview, the Regional Director of Clinical Services reviewed the record and stated the direction was not documented.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed in which the hospice aide was accepted and provided care for greater than 14 days, it was revealed that the agency did not ensure that RN supervision was provided every 14 days. CLINICAL RECORD 10: The benefit period 26 was dated 03/10/2025 - 05/08/2025, benefit period 27 was dated 05/29/2025 - 07/07/2025, and benefit period 28 was dated 07/08/2025 - 09/05/2025. There was supervision of the hospice aide documented on 04/29/2025, with the next documented supervisory visit dated 05/21/2025, which was 22 days, or 8 days late. Then supervision was documented weekly until 06/27/2025. Supervision was not documented again until 07/14/2025, which was 18 days and 4 days late. CLINICAL RECORD 13: The benefit period 3 was dated 05/29/2025 - 07/27/2025. The hospice aide's first visit was dated 05/30/2025, with biweekly visits noted. A supervisory visit was due to be completed on 06/13/2025. No supervisory RN visit was documented as completed until 06/30/2025, which was 31 days - 17 days overdue. The next supervisory visit was due 07/11/2025 - overdue by 4 days and had not been completed as of 07/15/2025. No further RN supervisory visits were completed as of 07/15/2025, During the interview the Director of Clinical Services, who reviewed the records, stated that supervision was not documented every 14 days.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer. The work time spent by volunteers occupying those positions. Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. The review of the volunteer program documentation for the calendar year 2024, revealed, the agency did not ensure that a cost saving of 5% or over was accomplished for the agency. The documentation contained cost savings of 0.36% in the first quarter of 2024, 0.66% the second quarter of 2024, and 0% the third and fourth quarters, with an annual savings of 0.51%. For 2025 the first quarter was 0.6% and the second quarter was 1.6% with a savings of 1.1% so far this year. The process improvement plan is in place, as well as documentation of recruitment and retention efforts, which continue from the team. During the review of the volunteer program binder, the agency did not ensure that a cost saving of 5% or over was accomplished for the agency. The binder contained cost savings of 0.36% in the first quarter of 2024, 0.66% the second quarter of 2024, and 0% the third and fourth quarters, with an annual savings of 0.51%. For 2025 the first quarter was 0.6% and the second quarter was 1.6% with a savings of 1.1% so far this year. The process improvement plan is in place, as well as documentation of recruitment and retention efforts, which continue from the team.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed, it was revealed that the agency did not ensure the comprehensive assessment included an updated drug profile. Clinical Record 6 - The SOC was dated 6/7/2022. The patient was admitted with a diagnosis of heart disease. The Plan of care dated 6/7/2022 included an order for oxygen 2-4 liters per nasal cannula. Oxygen was not listed on the drug profile. During interview and joint record review with the Clinical Director on 9/5/2022, she confirmed that oxygen was not listed on the drug profile.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed; it was revealed that the agency did not ensure that all orders for patient care were obtained and documented. Clinical Record 2 - The patient was admitted to service on 7/22/2022 with a diagnosis of Neoplasm of the Breast. During the home visit on 10/4/2022 an oxygen concentrator was observed in the patient's room. The Plan of Care dated 7/22/2022 did not include an order for oxygen, and no additional orders for oxygen could be found. Clinical Director During interview and review of the clinical record with the Clinical Director on 10/4/2022, she was not able to locate the order for oxygen.