Every finding on record at Care Alternatives of Northern VA, 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 7 of 14 (50%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the patient elected hospice care. Clinical Record 4: The patient elected the hospice benefit on 01/03/2024. The Chaplain attempted to complete the spiritual assessment, with the family, on 01/04/2024, 01/05/2024, and 01/09/2024. The spiritual care assessment was not performed and documented until 01/11/2024, eight days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 08/29/2023. The initial nursing and psychosocial assessments were completed on 08/29/2023 and 09/01/2023 respectively. A missed visit order dated 09/01/2023 included documentation that chaplain services were declined upon admission. The clinical record contained no evidence that a comprehensive assessment, including a spiritual assessment, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. Clinical Record 8: The patient elected the hospice benefit on 07/21/2023. The initial nursing and psychosocial assessments were completed on 07/21/2023 and 07/24/2023 respectively. A missed visit order dated 07/24/2023 included documentation that chaplain services were declined upon admission. The clinical record contained no evidence that a comprehensive assessment, including a spiritual assessment, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. Clinical Record 10: The patient elected the hospice benefit on 09/01/2023. The initial nursing assessment was performed and documented on 09/01/2023. Missed visit orders dated 09/04/2023 and 09/05/2023 included documentation that the chaplain and medical social worker services were declined after contacting the family to schedule their respective assessments. The clinical record contained no evidence that a comprehensive assessment, including spiritual, psychosocial, and emotional assessments, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. Clinical Record 11: The patient elected the hospice benefit on 08/09/2023. The initial nursing assessment dated 08/09/2023 included documentation that chaplain services were declined by the patient and family. The psychosocial assessment was performed and documented on 08/10/2023. The clinical record contained no evidence that a comprehensive assessment, including a spiritual assessment, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. Clinical Record 13: The patient elected the hospice benefit on 09/07/2023. The initial nursing and psychosocial assessments were completed on 09/07/2023 and 09/08/2023 respectively. The clinical record contained no evidence that a comprehensive assessment, including a spiritual assessment, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. Clinical Record 14: The patient elected the hospice benefit on 06/17/2023. The initial nursing assessment was performed and documented on 06/17/2023. The clinical record contained no evidence that a comprehensive assessment, including spiritual, psychosocial, and emotional assessments, was performed and documented within five calendar days of the election of hospice care. There was no additional documentation that a spiritual assessment was completed. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the clinical records identified contained no evidence of a completed comprehensive assessment within five calendar days of the election of hospice care.

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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of duplicate drug therapy. 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 clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the medication review process included the identification of duplicate drug therapy. Clinical Record 1: The patient elected the hospice benefit on 08/31/2023. The plan of care dated 06/26/2024 and the medication profile dated 07/16/2024 contained duplicate drug therapy for osteoporosis with two orders for Denosumab 60MG/1ML every six months. The clinical record contained no documented evidence that the medication review identified the duplicate drug therapy orders for Denosumab. Clinical Record 2: The patient elected the hospice benefit on 05/18/2024. The plan of care and medication profile, current 07/16/2024, contained duplicate oxygen opioid drug therapy for the treatment of pain and shortness of breath, Oxygen three liters per minute via nasal cannula as needed, Morphine 20MG/1ML, five milligrams every three hours as needed, and Hydromorphone 1MG/1ML, 0.5MG every four hours as needed. The clinical record contained no documented evidence that the medication review identified duplicate oxygen and opioid drug therapy orders for acute management of pain and shortness of breath. Clinical Record 6: The patient elected the hospice benefit on 08/10/2023. The patient was discharged from hospice services on 12/21/2023. The plan of care and medication profile effective 08/10/2023 through 11/21/2023 contained duplicate orders for Metoprolol tartrate 25MG oral tablet each day. The clinical record contained no documented evidence of a medication review that identified the Metoprolol tartrate duplicate drug therapy at each comprehensive assessment until 11/21/2023, 103 days after the plan of care and medication profile was established. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the clinical records contained no evidence that the medication reviews completed identified the duplicate drug therapies on the drug profiles.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records review and interviews which revealed the hospice: Failed to ensure the bereavement care and services provided to the identified bereaved followed the individualized plan of care established by the Interdisciplinary Group (IDG) {HCPC.19. I/L543}; Failed to ensure that each patient's individualized written Plan of Care included identified problems and planned interventions based upon assessment data from the comprehensive and updated comprehensive assessments {HCPC.21. I/L545; Failed to ensure he individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21. I/L548} and Failed to ensure the written plan of care included all drugs and treatments necessary to meet the patient’s needs {HCPC.21. I/L549}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the bereavement care and services provided to the identified bereaved followed the individualized plan of care established by the Interdisciplinary Group (IDG). Clinical Record 10: The patient elected the hospice benefit on 09/01/2023 and died at home on 09/10/2023. The bereavement plan of care dated 09/10/2023 included instructions for the Bereavement Coordinator to provide a phone call and bereavement letter to the bereaved at three and five months respectively. The clinical record contained no evidence that the Bereavement Coordinator provided the bereaved a phone call and letter per the established bereavement plan of care. Clinical Record 11: The patient elected the hospice benefit on 08/09/2023 and died in the assisted living facility on 11/19/2023. The bereavement plan of care dated 11/19/2023 included instructions for the Bereavement Coordinator to provide a bereavement phone call initially upon death and at two months and a bereavement letter at five months to the bereaved. The clinical record contained no evidence that the Bereavement Coordinator provided the bereaved phone calls and letters per the established bereavement plan of care. Clinical Record 12: The patient elected the hospice benefit on 01/17/2024 and died in the assisted living facility (ALF) on 05/09/2024. The bereavement plan of care dated 05/09/2024 included instructions for a psychosocial phone call to be performed within one week of the patient’s death and then ten days after the call, a bereavement phone call at three months, a condolence card at two weeks, and a bereavement letter at five months. The Bereavement Coordinator's documentation included participation in the patient’s funeral on 05/15/2024 and a memorial event at the ALF on 05/28/2024 as requested by the bereaved. The clinical record contained no evidence that the psychosocial phone calls, bereavement phone calls, and mailings were provided per the established bereavement plan of care and no evidence that the bereavement plan of care was updated to include the funeral and memorial service. Clinical Record 13: The patient elected the hospice benefit on 09/07/2023 and died at home on 09/17/2023. The bereavement plan of care dated 09/17/2023 included instructions for the Bereavement Coordinator to provide a phone call and bereavement letter to the bereaved at three and five months respectively. The clinical record contained no evidence that the Bereavement Coordinator provided the bereaved a phone call and letter per the established bereavement plan of care. Clinical Record 14: The patient elected the hospice benefit on 06/17/2023 and died at home on 08/25/2023. The bereavement plan of care dated 08/25/2023 included instructions for the Bereavement Coordinator to provide a phone call initially after the patient’s death and at three months, a condolence card at two weeks, and a letter at five months to the bereaved. The clinical record contained no evidence that the Bereavement Coordinator provided phone calls, cards, and letters per the established bereavement plan of care. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the clinical records identified contained no evidence that the bereavement coordinator followed the established bereavement plan of care.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 8 of 14 (57%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice services on 08/31/2023. The initial nursing assessment dated 08/31/2023 included documentation that the patient was tachypneic, short of breath at rest, rating shortness of breath eight out of ten, and dependent on continuous oxygen. The written plan of care dated 08/31/2023 included interventions that included an assessment of the patient’s respiratory status and use of oxygen along with goals that the patient and caregiver would understand and use the oxygen safely. The plan of care did not reflect patient and family goals associated with the tachypnea and shortness of breath identified in the comprehensive assessment. Clinical Record 2: The patient elected hospice services on 05/18/2024 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 05/18/2024 included documentation that the patient was readmitted to hospice services after sustaining and surgically treating a femur fracture, agitated, and combative with increased stimuli such as turning and positioning. The written plan of care dated 05/18/2024 included interventions associated with the end-of-life and self-care issues identified during the comprehensive assessment. The plan of care did not reflect patient and family goals associated with the patient’s care at the end of life and self-care deficits. Clinical Record 3: The patient elected hospice services on 04/18/2024 with a terminal diagnosis of chronic kidney disease, stage 5. The initial nursing assessment dated 04/18/2024 included documentation that the patient had an active internal cardiac defibrillator (ICD) in place. The plan of care dated 04/18/2024 did not reflect patient and family goals and planned interventions associated with the ICD identified in the comprehensive assessment. Clinical Record 5: The patient elected hospice services on 08/29/2023 with a terminal diagnosis of unspecified Parkinsonism. The initial nursing assessment dated 08/29/2023 included documentation that the patient was non-ambulatory, bedbound, paralyzed, and suffered from muscle contractions that required an opioid as needed to manage pain. The plan of care dated 08/29/2023 did not reflect patient and family goals and planned interventions associated with the risk for constipation identified in the comprehensive assessment. Clinical Record 7: The patient elected hospice services on 12/15/2023 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The patient was discharged from hospice services on 03/03/2024. The initial plan of care dated 12/15/2023 included a durable medical equipment order for an oxygen concentrator. The plan of care did not reflect patient and family goals and planned interventions associated with the use and safety measures required with oxygen therapy. The initial psychosocial, emotional, and spiritual assessments dated 12/19/2023 included documentation that the patient and caregiver requested additional support from the medical social worker (MSW) and spiritual counselor (SC). The plan of care effective 12/15/2023 included a visit frequency order for the MSW and SC to visit once a week. The plan of care dated 12/15/2023 through 02/01/2024 did not reflect patient and family goals and planned interventions associated with psychosocial, emotional, and spiritual concerns identified in the comprehensive assessment. Clinical Record 8: The patient elected hospice services on 07/21/2023 with a terminal diagnosis of unspecified Parkinsonism. The patient was discharged from hospice services on 05/20/2024. The initial plan of care dated 07/21/2023 included durable medical equipment orders for an oxygen concentrator, portable E-tank oxygen, and portable M6 tank oxygen. The plan of care did not reflect patient and family goals and planned interventions associated with the use and safety measures required with oxygen therapy. The initial psychosocial and emotional assessment dated 07/24/2023 included documentation that the patient and caregiver requested additional support from the medical social worker (MSW). The plan of care effective 07/21/2023 included a visit frequency order for the MSW to visit once a month. The plan of care dated 07/21/2023 through 08/17/2023 did not reflect patient and family goals and planned interventions associated with psychosocial and emotional concerns identified in the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 09/01/2023 with a terminal diagnosis of unspecified cerebral infarction. The initial nursing assessment dated 09/01/2023 included documentation that the patient was unable to swallow, at risk for aspiration, and had adventitious lung sounds throughout lung fields. The plan of care dated 09/01/2023 did not reflect patient and family goals and planned interventions associated with aspiration risks identified in the comprehensive assessment. Clinical Record 13: The patient elected hospice services on 09/07/2023 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The patient died at home on 09/17/2023. The initial psychosocial and emotional assessment dated 09/08/2023 included documentation that the patient and caregiver requested additional support from the medical social worker (MSW). The plan of care effective 09/07/2023 included a visit frequency order for the MSW to visit once a month. The plan of care dated 09/07/2023 through 09/17/2023 did not reflect patient and family goals and planned interventions associated with psychosocial and emotional concerns identified in the comprehensive assessment. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the written plans of care identified did not reflect patient and family goals and planned interventions associated with issues identified during the comprehensive assessments including shortness of breath, oxygen use and safety, constipation, psychosocial, emotional, and spiritual issues.

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 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 7 of 14 (50%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/31/2023 with a terminal diagnosis of other non-specific abnormal findings of the lung. The plan of care dated 08/31/2023 included goals and interventions associated with the patient’s potential for pain and skin breakdown. The plan of care included goals that the patient would achieve and maintain “optimal” physical comfort and skin integrity. The goals did not include the measurability of optimal for the patient. Clinical Record 2: The patient elected the hospice benefit on 05/18/2024 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The plan of care dated 05/18/2024 included goals and interventions associated with the patient’s risk for pain and grief issues. The plan of care included goals that the patient would achieve an “optimal” level of pain, symptom management, and grief reaction. The goals did not include the measurability of optimal for the patient. Clinical Record 5: The patient elected the hospice benefit on 08/29/2024 with a terminal diagnosis of unspecified Parkinsonism. The plan of care dated 06/24/2024 included scheduled medications to manage pain, anxiety, agitation, and hallucinations including Fentanyl, Lorazepam, and Haloperidol. The plan included goals that the patient would verbalize “adequate” relief of pain, “optimal” orientation, and social/emotional distress, suffering, and depression would be at a “manageable” level. The goals did not include how adequate, optimal, and manageable would be measured for the patient. Clinical Record 10: The patient elected the hospice benefit on 09/01/2023. The patient died at home on 09/10/2023. The initial nursing assessment dated 09/01/2023 included documentation that the patient required continuous oxygen at two liters per minute, had dysphagia, and had a history of bowel obstruction. The plan of care dated 09/01/2023 included goals that “optimal” physical comfort, breathing patterns, and airway patency would be maintained. The goals did not include the measurability of optimal for the patient. Clinical Record 11: The patient elected the hospice benefit on 08/09/2023. The patient died at the assisted living facility on 11/19/2023. The initial nursing assessment dated 08/09/2023 included documentation that the patient had mild pain, confusion, agitation, and was combative. The plan of care dated 08/09/2023 included goals that the patient’s pain would “remain at a comfortable level during care/within… period of time” and agitation would be controlled at a “manageable” level. The goals did not include the measurability of optimal and manageable for the patient and family and did not define the period of time. Clinical Record 12: The patient elected the hospice benefit on 01/17/2024. The patient died at the assisted living facility on 05/09/2024. The initial nursing assessment dated 01/17/2024 included documentation that the patient had three plus pitting edema to bilateral lower extremities. The plan of care dated 01/17/2024 included the goal that the patient would maintain “adequate cardiac/circulatory function and fluid volume as long as possible.” The goal did not include the measurability of adequate for the patient and define a realistic time frame to achieve the goal. Clinical Record 13: The patient elected the hospice benefit on 09/07/2023. The patient died at home on 09/17/2023. The initial nursing assessment dated 09/07/2023 included documentation that the patient had mild pain for which the nurse administered Advil. The plan of care dated 09/07/2023 included a goal that “optimal” physical comfort would be achieved. The goal did not include the measurability of optimal for the patient. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the written plans of care identified did not include measurable outcomes anticipated from implementing and coordinating interventions for pain, dyspnea, edema, agitation, skin integrity, and grief.

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 drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the written plan of care included all drugs and treatments necessary to meet the patient’s needs. Clinical Record 5: The patient elected the hospice benefit on 08/29/2023 with a terminal diagnosis of unspecified Parkinsonism. The initial nursing assessment dated 08/29/2023 included documentation that the patient suffered mild pain from muscle contractions and was taking Baclofen 5MG twice a day and Morphine 5mg every four hours as needed to manage the pain. The plan of care dated 08/29/2023 did not include drugs used by the patient at the time the patient elected the hospice benefit, including Baclofen and Morphine. Clinical Record 7: The patient elected hospice services on 12/15/2023 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The patient was discharged from hospice services on 03/03/2024. The initial plan of care dated 12/15/2023 included a durable medical equipment order for an oxygen concentrator. The plan did not include the specific oxygen treatment necessary to meet the patient’s needs, including liter flow, administration route, and frequency. Clinical Record 8: The patient elected hospice services on 07/21/2023 with a terminal diagnosis of unspecified Parkinsonism. The patient was discharged from hospice services on 05/20/2024. The initial plan of care dated 07/21/2023 included durable medical equipment orders for an oxygen concentrator, portable E-tank oxygen, and portable M6 tank oxygen. The plan did not include the specific oxygen treatment necessary to meet the patient’s needs, including liter flow, administration route, and frequency. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the written plans of care identified did not include all the necessary drugs and treatments to meet the patient’s needs.

It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure the Registered Nurse prepared specific written patient care instructions for the aide to follow. HCDT.15. I/L625}; Failed to ensure the aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care {HCDT.16. I/L626}; and Failed to ensure the aide reported and documented changes in the patient’s care needs to the Registered Nurse {HCDT.16. I/L628}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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 an 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 10 of 14 (71%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 1: The patient elected the hospice benefit on 08/31/2023. The initial plan of care dated 08/31/2023 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 08/31/2023 included instructions for the aide to “apply barrier cream to…” every visit. The plan did not include specific instructions on where to apply the barrier cream. Clinical Record 3: The patient elected hospice services on 04/18/2024 with a terminal diagnosis of End-stage renal disease, stage 5. The initial nursing assessment dated 04/18/2024 included documentation that the patient had an active internal cardiac defibrillator (ICD) in place. The hospice aide care plan dated 04/18/2024 did not alert the aide to the ICD and the potential risks associated. Clinical Record 4: The patient elected the hospice benefit on 01/03/2024. The initial plan of care dated 01/03/2024 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 01/03/2024 included instructions for the aide to “apply barrier cream to…” every visit and to apply deodorant and lotion to all extremities, assist to the bathroom, make bed, provide perineal care, and perform shower “as directed. The plan did not include specific instructions on where to apply the barrier cream and specific instructions on when to use deodorant, apply lotion, assist to the bathroom, make bed, provide perineal care, and perform shower. Clinical Record 6: The patient elected the hospice benefit on 08/10/2023. The initial plan of care dated 08/10/2023 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 08/10/2023 included instructions for the aide to “apply barrier cream to…” every visit. The plan did not include specific instructions on where to apply the barrier cream. Clinical Record 7: The patient elected the hospice benefit on 12/15/2023. The initial plan of care dated 12/15/2023 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 12/15/2023 and updated on 12/20/2023, 01/29/2023, and 02/02/2024 included instructions for the aide to “apply barrier cream to…” every visit and to perform a shower “per the facility schedule” for showers. The plan did not include specific instructions on where to apply the barrier cream and specific instructions for when the hospice aide was to perform a shower. Clinical Record 8: The patient elected the hospice benefit on 07/21/2023. The plan of care dated 03/17/2024 included a visit frequency order for the hospice aide to visit once a week. The hospice aide care plan dated 04/25/2024 included instructions for the aide to “…remove oxygen to perform the following tasks…” every visit. The plan did not include specific instructions on when the hospice aide could remove the patient’s oxygen. Clinical Record 9: The patient elected the hospice benefit on 11/30/2023. The initial plan of care dated 11/30/2023 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 11/30/2023 included instructions for the aide to “apply barrier cream to…”, to perform two bath types, bed bath and partial bed bath, and to assist with feeding every visit. The plan did not include specific instructions on where to apply the barrier cream, and when one type of bath would be performed over the other, forcing the aide to make decisions outside the aide’s scope of practice. The care plan did not alert the aide to the pureed dietary requirements. Clinical Record 11: The patient elected the hospice benefit on 08/09/2023. The initial plan of care dated 08/09/2023 included a visit frequency order for the hospice aide to visit five times a week. The hospice aide care plan dated 11/30/2023 included instructions for the aide to “apply barrier cream to…” and to perform two bath types, a partial bed bath, and a shower every visit. The plan did not include specific instructions on where to apply the barrier cream and when one type of bath would be performed over the other. Clinical Record 12: The patient elected the hospice benefit on 01/17/2024. The hospice aide care plan dated 04/02/2024 included instructions for the aide to perform two bath types every visit, a bed bath and a partial bed bath. The plan did not include specific instructions on when one bath type would be performed over the other. Clinical Record 13: The patient elected the hospice benefit on 09/07/2023. The hospice aide care plan dated 09/07/2023 included instructions for the aide to “apply barrier cream to…” every visit. The plan did not include specific instructions on where to apply the barrier cream. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the hospice aide care plans identified did not include specific instructions on where to apply barrier cream, type of bath to be performed, when to replace oxygen after removal, and did not alert the aide to dietary needs.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 5 of 14 (36%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care. Clinical Record 1: The patient, an assisted living facility (ALF) resident, elected the hospice benefit on 08/31/2023. The plan of care dated 08/31/23 included an order frequency for the hospice aide of five visits per week. The hospice aide care plan dated 08/31/2023 included instructions for the aide to perform a bed bath every visit. During Home Visit 1 with the hospice aide (Personnel Record 2), the ALF staff reported, and the hospice aide (Personnel Record 2) confirmed that only two baths were performed by hospice staff each week. Clinical Record 2: The patient elected the hospice benefit on 05/18/2024. The hospice aide care plan dated 05/18/2024 included instructions for the aide to perform a shower on every visit. The hospice aide visit dated 05/20/2024 included documentation that the aide had provided the patient with a bed bath and performed an “activity” with the patient. The aide’s care plan did not include instructions for the aide to perform any companionship or activities with the patient. Clinical Record 3: The patient elected the hospice benefit on 04/18/2024. The hospice aide care plan dated 06/19/2024 included instructions for the aide to perform a shower every visit and notify the Registered Nurse if the patient refused a shower. The hospice aide’s visit dated 07/09/2024 included documentation that the patient refused a shower but allowed the aide to assist with a sponge bath. Clinical Record 8: The patient elected the hospice benefit on 07/21/2023. The plan of care dated 03/17/2024 included a frequency order for the hospice aide once a week. The hospice aide visit dated 04/04/2024 included documentation that the aide had provided the patient with peanut butter, honey, chips, grapes, and water. The aide’s care plan did not include instructions for the aide to prepare, provide, and assist with feeding and offering fluids to the patient. Clinical Record 12: The patient elected the hospice benefit on 01/17/2024. The hospice aide care plan dated 04/02/2024 included aspiration precautions and instructions for the aide to assist with feeding the patient a puree diet. The hospice aide’s visit dated 04/18/2024 included documentation that the aide provided and fed the patient scrambled eggs, oatmeal, and sausage. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the aide did not provide the services as ordered and included in the plan of 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. HC This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide reported and documented changes in the patient’s care needs to the Registered Nurse. Clinical Record 1: The patient, an assisted living facility (ALF) resident, elected the hospice benefit on 08/31/2023. The plan of care dated 08/31/23 included an order frequency for the hospice aide of five visits per week. The hospice aide care plan dated 08/31/2023 included instructions for the aide to perform a bed bath every visit. During Home Visit 1 with the hospice aide (Personnel Record 2), the ALF staff reported, and the hospice aide (Personnel Record 2) confirmed that only two baths were performed by hospice staff each week. The clinical record contained no evidence that the hospice aide reported to the Registered Nurse that three baths a week were not being done. Clinical Record 2: The patient elected the hospice benefit on 05/18/2024. The hospice aide care plan dated 05/18/2024 included instructions for the aide to perform a shower on every visit. The hospice aide visit dated 05/20/2024 included documentation that the aide had provided the patient with a bed bath and performed an “activity” with the patient. The aide’s care plan did not include instructions for the aide to perform any companionship or activities with the patient. The clinical record contained no documented evidence that the hospice aide reported to the Registered Nurse that a bed bath and companionship/activity was done with the patient. Clinical Record 3: The patient elected the hospice benefit on 04/18/2024. The hospice aide care plan dated 06/19/2024 included instructions for the aide to perform a shower every visit and notify the Registered Nurse if the patient refused a shower. The hospice aide’s visit dated 07/09/2024 included documentation that the patient refused a shower but allowed the aide to assist with a sponge bath. The clinical record contained no documented evidence that the hospice aide reported to the Registered Nurse that the patient refused a shower. Clinical Record 8: The patient elected the hospice benefit on 07/21/2023. The plan of care dated 03/17/2024 included a frequency order for the hospice aide once a week. The hospice aide visit dated 04/04/2024 included documentation that the aide had provided the patient with peanut butter, honey, chips, grapes, and water. The aide’s care plan did not include instructions for the aide to prepare, provide, and assist with feeding and offering fluids to the patient. or documentation that the Registered Nurse was notified that the hospice aide prepared, provided and assisted with the feeding and offered fluid to the patient. Clinical Record 11: The patient elected hospice benefit on 08/09/2023. The plan of care dated 08/09/2023 included a frequency visit order for the hospice aide twice a week. The aide’s visit dated 10/27/2023 included documentation that the patient was “very agitated” during the visit. The clinical record contained no documented evidence that the hospice aide reported the patient’s agitation to the Registered Nurse. Clinical Record 12: The patient elected the hospice benefit on 01/17/2024. The hospice aide care plan dated 04/02/2024 included aspiration precautions and instructions for the aide to assist with feeding the patient a puree diet. The hospice aide’s visit dated 04/18/2024 included documentation that the aide provided and fed the patient scrambled eggs, oatmeal, and sausage. The clinical record contained no documented evidence that the hospice aide reported to the Registered Nurse that the hospice aide provided and fed the patient scrambled eggs, oatmeal and sausage. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the clinical records identified contained no documented evidence that the aide notified the Registered Nurse of the changes in the patient’s condition and care needs.

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. This standard was not met as evidenced by interview and document review. In a review of the agency's volunteer program and services, the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care service hours equal to five percent (5%) of the total of all paid patient care hours. During a joint program review and interview on 07/17/2024, the Volunteer Coordinator (VC) reported that the agency had no volunteers to provide day-to-day administrative or direct patient care services from December 2023 through the current date. The VC provided documentation of volunteer recruitment efforts including participation in community events, social media outlets, the agency’s website, and mailings. The current volunteer hired on 06/03/2024 had not completed orientation. The agency did not provide documented evidence to support that hospice volunteers had provided day-to-day administrative or direct patient care services equal to five percent (5%) of the total of all paid patient care hours starting 01/01/2024. During joint clinical record reviews, volunteer program review, and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that volunteers had not provided, at a minimum, five percent (5%) of the total of all paid patient care hours. The Directors provided documented evidence to support a Performance Improvement Project, initiated 02/01/2024, to increase volunteer recruitment and hiring efforts and volunteer hours. In a review of the agency's volunteer program and services, the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care service hours equal to five percent (5%) of the total of all paid patient care hours.

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 physician orders. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the patient’s clinical record contained physician orders for all care and services provided. Clinical Record 1: The patient, an assisted living facility resident, elected the hospice benefit on 05/21/2024. The plan of care dated 05/21/2024 included durable medical equipment (DME) orders for an oxygen concentrator, a walker, and a wheelchair. During Home Visit 1 with the Hospice Aide (Personnel Record 2), it was observed that the patient received and used the following DME, and medical supplies provided by the hospice: hospital bed, fall mat, body wash, and incontinent briefs. The clinical record contained no evidence of physician orders for the hospital bed, fall mat, body wash, and incontinent briefs. Clinical Record 5: The patient elected the hospice benefit on 08/29/2023. The plan of care dated 06/24/2024 included an order to apply a condom catheter. The plan did not include who was to apply the condom catheter and how often care and change were to be provided. The clinical record contained a physician order dated 07/08/2024 for skin prep to be applied to the patient’s left heel twice a day, Calmoseptine applied to wounds on the left ear, spine, right leg, and mid-back rib, and cover with Mepilex three times a week and as needed if soiled and turn and reposition patient every two hours. The physician’s order did not include who was responsible for the wound care, applying the skin prep, and turning and positioning of the patient. The plan of care dated 07/18/2024 included orders to apply Calmoseptine and Mepilex to wounds on the patient’s spine and left outer leg and to use skin prep twice a day on the left heel. The wound care order for the patient’s spine and left outer leg did not include a frequency, and the order did not include who was responsible for the wound care and skin prep. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed that the clinical records identified did not include physician orders for all care and services provided, including durable medical equipment, medical supplies, and clarification on who was responsible for wound care.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care reflected the participation of the hospice and the SNF. Clinical Record 2: The patient, a skilled nursing facility (SNF) resident, elected the hospice benefit on 05/18/2024. The plan of care dated 05/18/2024 included orders for goals and interventions associated with pain, fall risks, and skin care. The plan did not reflect the participation and consultation between the hospice and the SNF in establishing and maintaining a written plan of care and services needed and the provider responsible for specific functions. During joint clinical record reviews and interviews on 07/18/2024, the Regional Executive Director and Executive Director confirmed the plan of care identified did not reflect the participation of the hospice and the skilled nursing facility in establishing and maintaining the written plan.