Every finding on record at Crown Capital Strategies, LLC

It is required that the comprehensive assessment include an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's comprehensive assessment included an initial bereavement assessment. Clinical Record 7: The patient elected the hospice benefit on 07/26/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The Registered Nurse (RN) completed the initial comprehensive assessment on 07/26/2024. The initial social work psychosocial comprehensive assessment was completed on 07/31/2024. The patient declined spiritual counseling services. The initial bereavement assessment was documented on 09/12/2024 by the Social Worker, with 48 days outstanding. The late Initial bereavement risk assessment was confirmed during a joint clinical record review and interview with the Vice President of Quality on 04/30/2025.

It is required that the hospice designates a registered nurse member of the IDG to ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Nursing Services" (06/21/2013) stated in part, "Hospice nursing services are accountable to...identify the patient's nursing needs...identify the patient's response to intervention and treatment...assess the ability of the family or other caregivers to meet the patient's immediate needs...Nursing services are available 24 hours per day..." In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the Registered Nurse provided continuous assessment of the patient's needs when ongoing symptom management was identified that required medication changes and instructions to the caregivers. Clinical Record 11: The patient elected the hospice benefit on 10/18/2024 with a diagnosis of malignant neoplasm of the rectum. The patient resided in a group home (GP). The Registered Nurse (RN) visit note dated 11/22/2024 at 0802 documented that the patient did not report any pain. The Licensed Practical Nurse (LPN) as-needed (PRN) visit dated 11/22/2024 at 2020 because the patient's colostomy bag was leaking, documented that the patient reported increased pain in the chest and stomach. On 11/22/2024 at 2338, the RN made another PRN visit because the patient told the GH staff they wished to go to the hospital. When the RN arrived for the PRN visit, the patient reported their pain was a 2/10 and they no longer wished to be transported to the hospital. The patient's documented pain goal was 3/10. On 11/23/2024 at 0444, the GH staff called to report that the patient was in pain. The agency’s on-call Licensed Practical Nurse (OCLPN) care coordination note dated 11/23/2024, at 0445, documented that the GH staff reported that the patient continued to have increased pain. The OCLPN documented that the GH staff were provided instructions to alternate the patient's dosing with Tylenol and ibuprofen. The OCLPN care coordination note dated 11/23/2024, at 0628, documented that the GH staff called and reported the patient continued to have increased pain. The OCLPN documented that they asked the GH staff when the last time was that the patient had received anything for pain, and that the GH staff reported they had given everything they could. Additionally, the OCLPN documented that they advised the GH staff to try repositioning and a warm towel or blanket, that the RN manager was aware and had put in an order for Morphine, and that the GH staff should start the Morphine per order as soon as it arrived. On 11/23/2024 at 0653, the physician ordered Morphine Sulfate (20mg/ml) - 0.25ml by mouth every three hours as needed for pain or shortness of breath. On 11/23/2024 at 0805, the OCLPN documented that the GH staff called, reporting that the patient was in pain and that the physician had ordered Morphine to be dispensed and delivered. On 11/23/2024 at 1105, the GH staff called, reporting that the patient was still in pain and the Morphine had not arrived. On 11/23/2024 at 1109, the OCLPN returned the call, and the GH staff reported the patient's pain level as 3/10, but the Morphine had not arrived yet. At 1115 on 11/23/2024, the GH nurse called the hospice agency to report that the GH staff had just informed them about the patient's pain. On 11/23/2024, at 1242, the LPN visited the patient. The LPN picked up the morphine and delivered it to the GH, where the GH staff administered it. The patient then complained of muscle spasms. On 11/23/2024, at 1350, the physician ordered Lorazepam (2mg/ml)- 0.5 ml by mouth every 3 hours as needed and Cyclobenzaprine HCL 10mg by mouth three times daily. The OCLPN documented another call from the GH staff at 1605, reporting that the patient's pain was still not controlled. At 1617, the RN returned the call to the GH. The RN documented that after consulting with the hospice physician, the morphine dose and frequency had been adjusted. Morphine (20mg/ml) 0.5ml by mouth every three hours, scheduled, and Morphine (20mg/ml) 0.5ml by mouth every hour as needed was ordered by the hospice physician at 1628, and an updated medication list was faxed to the GH. The General Manager [Personal Record 2] (non-clinical) documented in a coordination note at 1612 that the GH staff reported that after the LPN visit, the patient was comfortable for a short time but now reported pain at 12/10. The General Manager [Personal Record 2] (non-clinical) documented a call at 2005 from the GH staff requesting to speak to the nurse. The OCLPN returned the call at 2007, and the staff reported that the patient was drowsier and more confused. The LPN documented that the GH staff was told this was likely one of the medication's side effects. On 11/24/2024 at 0646, the hospice received a phone call from the GH staff reporting that the patient was not moving or breathing. The patient was pronounced by the hospice RN at 11/24/2024 AT 0722. After a joint clinical record review and interview on 04/30/2025, the Vice President of Quality and the General Manager confirmed that there was no additional documentation outside the evidence in clinical record 11. The Vice President of Quality contacted the Director of Health Care Services by phone for further clarification. The DHCS relayed that she reviewed this event at the time and did not believe it to be a crisis care situation, but rather a poor handling of the patient and interventions by the unlicensed Group Home staff.

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 4 of 14 (29%) clinical records reviewed, the agency did not ensure that the patient’s durable medical equipment and supplies were included on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 09/03/2024. The plans of care for the benefit periods dated 03/02/2025 to 04/30/2025 and 01/01/2025 to 03/01/2025 did not document the patient’s adult briefs, disposable chux pads, and wipes at the time of record review. Clinical Record 2: The patient elected the hospice benefit on 10/25/2024. The plans of care for the benefit periods dated 04/23/2025 to 06/21/2025 and 01/23/2025 to 04/22/2025 did not document the patient’s reclining high-back wheelchair, adult briefs, disposable chux pads, and wipes at the time of record review. Clinical Record 4: The patient elected the hospice benefit on 02/13/2025. The plan of care for the benefit period dated 02/13/2025 to 05/13/2025 did not document the patient’s over-the-bed table, adult briefs, disposable chux pads, and incontinent wipes at the time of clinical record review. Clinical Record 13: The patient elected the hospice benefit on 01/17/2025 and revoked hospice services on 02/21/2025. The plan of care for the benefit period dated 01/17/2025 to 04/16/2025 did not document the patient’s wheelchair at the time of clinical record review. The findings were confirmed during a joint clinical record review and interview with the Vice President of Quality on 04/29/2025. After the error was pointed out, the hospice staff began to work to bring the clinical records into compliance during the site visit.

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 review of clinical records, and interview. 2 of 11 (18%) records in which a hospice aide was accepted revealed the hospice did not provide clear and specific written instructions for the hospice aide assignment, thus leaving the aide to potentially make decisions, outside of the aide's scope of practice, on what tasks to perform. Record #72619: the patient elected the hospice benefit on 2/11/2022 with diagnoses of Parkinson’s Disease and confusion. The hospice aide care plan, for benefit periods 2/11/2022 to 5/10/2022 and 5/11/2022 to current, did not evidence specific bath type instructions for the hospice aide; instead, multiple bath types were assigned which included: bath, bath complete, bath partial, bath shower, bath tub. The hospice aide documented “done” for all bath types in the following visit notes dated 2/23/2022; 3/22/2022; 3/23/2022; 3/29/2022; 3/30/2022; 4/1/2022; 4/5/2022; 4/7/2022; and 5/13/2022. Record #14034: the patient elected the hospice benefit on 5/7/2022 with a diagnosis of chronic obstructive pulmonary disease (COPD). The hospice aide care plan, effective on 5/7/2022 to 5/11/2022 (date of death), did not evidence a specific bath type instruction for the hospice aide; instead, a general instruction for bath type of “bath complete”. Aide visits were documented as conducted on 5/9/2022 and 5/10/2022. Interview, conducted on 6/21/2022, with the Hospice Manager (#52080) and Registered Nurse (#38241) confirmed that hospice aide care plans lacked detail and instructions of the bath type and the instruction of “bath complete” did not provide specificity of bed or shower.

It is required that a hospice aide provides services that are 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 standard was not met as evidenced by review of clinical records and interview. 2 of 11 (18%) records of patients who accepted hospice aide services revealed the hospice did not ensure the aide provided the services in accordance with the documented plans of care. Record #82714 (election of benefit 5/12/22): The hospice aide plan of care, effective date 5/12/22, revealed a list of assigned interventions which included in part: shower, wash hair, make patient bed, incontinent care, clean bathroom after patient care, oral care, assist patient with dressing, and transfer bed/chair with assistance with Hoyer lift. In the visit note from 5/16/22 the hospice aide documented a narrative note that stated in part, "Pt (patient) had shower this morning with hair washed. No skin issues that aide knows of. Pt in wheelchair when aide left." All the specific tasks listed in the plan of care were not addressed or documented against. Record #14303 (election of benefit 5/7/22): Documentation for a hospice aide visit on 5/10/22 revealed the aide completed a seventy-five (75) minute visit and a narrative note that stated in relevant part, “...pt (patient) opened eyes during cares.” The aide did not document what specific cares were provided and there was no documentation addressing the specific tasks in the plan of care. In an interview with the Hospice Manager (#52080), conducted on 6/21/22, he stated that the hospice aide care plans were in place, but the aide visit documentation did not contain which care plan interventions were completed. The hospice was unable to produce any paper, or other, documentation indicating what tasks had been completed by the hospice aide.

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. This standard was not met as evidenced by review of clinical records and interview. 2 of 11 (18%) records in which aide services were accepted, the hospice did not ensure that the reporting of changes in the patient needs, or condition, occurred and was documented. Record #72619 (election of benefit 2/10/22): revealed a hospice aide visit note, dated 03/14/2022, that stated patient "was feeling dizzy upon standing"; there was no documented communication made to the nurse. A routine nursing visit was conducted on 3/15/22; there was no documentation regarding dizziness being reported by aide. Record #82714 (election of benefit 5/12/22): revealed a hospice aide visit note, dated 5/24/22, where the aide documented "pain to leg" and "redness under the left abdominal fold” with no documented report to the nurse. The next nursing visit was documented on 5/26/22 and did not have any documented communication from the hospice aide. In an interview with the Hospice Manager (#52080), conducted on 6/21/22, he agreed that the records did not have documentation that the nurse had been notified and said the aides are expected to document the communication to the nurse regarding any changes.