Every finding on record at Cfhc No 13 Inc

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 1 of 14 (7%) clinical record reviewed revealed that the agency did not ensure an initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 11: The patient’s election of hospice care was dated 04/16/2025. A review of the clinical record for benefit period dated 04/16/2025-06/02/2025 identified that the initial nursing comprehensive assessment was dated 04/16/2025. The MSW initial psychosocial assessment was dated 04/22/2025, 6 days after the election of hospice care. During an interview with the Administrator/Director of Nurses (Personnel Record 5) on 12/31/2025 she stated she did not know why the comprehensive was not done by day five, but that additional education would be provided to the clinical staff on the importance of completing the comprehensive assessment by day five.

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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed of patient's who elected hospice aide services revealed that the agency did not ensure a registered nurse makes an on-site visit to supervise the hospice aide no less frequently than every 14 days. CLINICAL RECORD 1: The patient elected hospice care 06/03/2025. A review of the plan of care dated 06/03/2025-08/31/2025 included an order for the hospice aide one time a week (1xw). The hospice aide provided visits as ordered. The registered nurse (RN) documented aide supervisory visits on 06/17/2025, 07/02/2025 (15 days) and then on 07/18/2025 (16 days). There was no documented evidence that the RN supervised the hospice aide no less frequently than every 14 days. CLINICAL RECORD 5: The patient elected hospice care 05/17/2024. The plan of care dated 05/17/2025 -08/14/2025 included an order for the hospice aide. The RN supervisory visits were dated 06/04/2024, 06/19/2024 (15 days) and 07/10/2024 (21 days). There was no documented evidence that the RN supervised the hospice aide no less frequently than every 14 days. During an interview with the Administrator/Director of Nurses (Personnel Record 5) on 12/31/2025, she stated that an audit is done frequently for supervisory visit, but they will continue to monitor and educate on importance of completing supervisory visits at least every 14 days.

It is required that each patient’s individualized written Plan of Care (POC) that 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. 3 of 5 (60%) records reviewed revealed the agency did not ensure that the POC included planned interventions and goals for problems identified on the comprehensive assessment. Record 1: The hospice election of benefit became effective on 01/26/2023. The 01/26/2023 initial, 02/08/2023 and the 02/22/2023 updated assessments indicated patient is Diabetic. The patient was noted to be taking Metformin 200mg twice daily and Jardiance 10mg daily and had an implanted disc for blood glucose monitoring with no documented readings on file to date. The correlating POCs included the secondary diagnosis of Diabetes Mellitus (DM) and the associated medications, however, did not include inuring interventions and goals related to DM management and monitoring. Record 2: The hospice election of benefit became effective on 01/17/2023. The 01/17/2023 initial and the 01/25/2023, 02/08/2023 and the 02/22/2023 updated assessments indicated patient is Diabetic. Of note, on the 01/17/2023 thru 02/24/2023 visit notes the RN documented education on diabetic diet. The patient was also noted to be taking Januvia 50mg daily and Lantus 100units/ml 100 Units subcutaneously daily. The correlating POCs included the secondary diagnosis of Diabetes Mellitus (DM) and the associated medications, however, did not include inuring interventions and goals related to DM management and monitoring. Record 4: The hospice election of benefit became effective on 01/17/2023. The 01/17/2023 initial, 02/08/2023 and the 02/22/2023 updated assessments indicated need for Chaplain (SC) for spiritual and emotional support. The correlating POCs read SC 1xmonth however, did not include interventions and goals for the Chaplain to date. During an interview and review of records on 03/01/2023 with Administrator, it was stated that associated records with the RN and POCs did not include required goals and interventions.