Every finding on record at Crown Hospice, Inc.

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, interviews, and document review which revealed the hospice: Failed to ensure that the hospice care and services provided to patients and families 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; and Failed to ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individual plan of care no less frequently than every 15 calendar days {HCPC.22. I/L553}. 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 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 19 (26%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the Interdisciplinary Group (IDG). Clinical Record 2: The patient elected the hospice benefit on 08/29/2022. The initial plan of care dated 08/29/2022 included a visit frequency order for the hospice aide to visit twice a week. The clinical record contained no documented evidence that the aide provided visits from 08/29/2022 to 01/05/2023 and no documentation of why the visits were missed. Clinical Record 3: The patient elected the hospice benefit on 09/23/2022. The plan of care effective for the benefit periods starting 01/15/2024 and 03/16/2024 included a visit frequency order for the hospice aide to provide two visits per week. The clinical record contained documentation of one visit completed by the aide per week from 01/15/2024 to 04/11/2024. The clinical record contained no documented evidence that the aide completed the second visit of the week from 01/15/2024 to 04/11/2024 and no documentation of why the visits were missed. Clinical Record 7: The patient elected the hospice benefit on 11/29/2023. The chaplain’s spiritual assessment dated 11/30/2023 included documentation that the facility had declined spiritual care services for the patient. The plans of care dated 11/29/2023 and 02/27/2024 included a visit frequency order for the chaplain to provide one visit per month. The clinical record contained no documented evidence to support that the chaplain provided visits from 12/1/2023 to 04/11/2024 and no documentation of why the visits were missed. Clinical Record 16: The patient elected the hospice benefit on 05/19/2023. The plan of care effective 05/19/2023 included a visit frequency order for the hospice aide to provide two visits per week. The clinical record contained no documented evidence that the aide provided visits from 05/19/2023 to 08/09/2023 and no documentation of why the visits were missed. Clinical Record 17: The patient elected the hospice benefit on 02/29/2024. The patient died at home on 03/30/3034. The plan of care effective 02/29/2024 included a visit frequency order for the hospice aide to provide two visits per week. The clinical record contained no documented evidence that the aide provided visits from 02/29/2024 to 03/30/2024 and no documentation of why the visits were missed. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the clinical records identified contained no documented evidence that the hospice aide and chaplain followed the plan of care visit frequency established by the Interdisciplinary Group and no documentation of why the visits were missed.

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 13 of 19 (68%) 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 02/12/2024 with a terminal diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The initial nursing assessment dated 02/12/2024 included documentation that the patient had dyspnea with minimal exertion, anxiety rated six out of ten, and was at risk for falls with a fall risk score of six out of ten. The written plan of care dated 02/12/2024 did not reflect patient and family goals and planned interventions associated with the patient's dyspnea, anxiety, and fall risk identified in the initial comprehensive assessment. Clinical Record 3: The patient elected hospice services on 09/23/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 09/23/2022 included documentation that the patient had dyspnea with moderate exertion, two plus edema to bilateral lower extremities, occasional constipation, was at risk for falls with a fall risk score of nine out of ten, was unwilling to stop smoking, and required continuous oxygen at six liters per minute. The medication profile dated 09/23/2022 included opioids as needed and scheduled laxatives twice a day. The written plan of care dated 09/23/2022 did not reflect patient and family goals and planned interventions associated with the patient's dyspnea, edema, constipation, fall risk, and oxygen safety needs identified in the initial comprehensive assessment. Clinical Record 4: The patient elected hospice services on 05/09/2024 with a terminal diagnosis of Alzheimer’s disease. The initial nursing assessment dated 05/09/2024 included documentation that the patient had an increase in anxiety and restlessness. The written plan of care dated 05/09/2024 did not reflect patient and family goals and planned interventions associated with the patient's anxiety and restlessness identified in the initial comprehensive assessment. Clinical Record 5: The patient elected hospice services on 01/31/2024 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The initial nursing assessment dated 01/31/2024 included documentation that the patient was chair-bound, incontinent of bowel and bladder, and required daily wound care to pressure wounds on bilateral feet. The written plan of care dated 01/31/2024 did not reflect patient and family goals and planned interventions associated with the patient's skin integrity issues and risks identified in the initial comprehensive assessment. Clinical Record 7: The patient elected hospice services on 11/29/2023 with a terminal diagnosis of Alzheimer’s disease. The initial nursing assessment dated 11/29/2023 included documentation that the patient was at risk for falls with a fall risk score of ten out of ten. The written plan of care dated 11/29/2023 did not reflect patient and family goals and planned interventions associated with the patient's fall risk identified in the initial comprehensive assessment. Clinical Record 8: The patient elected hospice services on 03/15/2024 with a terminal diagnosis of unspecified heart failure. The initial nursing assessment dated 03/15/2024 included documentation that the patient was dyspneic with minimal exertion, required continuous oxygen and scheduled nebulizer treatments, required topical treatment of a yeast infection, and was at risk for falls with a risk score of nine out of ten. The written plan of care dated 03/15/2024 did not reflect patient and family goals and planned interventions associated with the patient's dyspnea, oxygen safety needs, skin integrity, and fall risk identified in the initial comprehensive assessment. Clinical Record 10: The patient elected hospice services on 12/20/2023 with a terminal diagnosis of Alzheimer’s disease. The initial nursing assessment dated 12/20/2023 included documentation that the patient was dyspneic with moderate exertion, agitated with an anxiety score of two out of ten, had two plus edema in both hands and bilateral upper extremities and had constipation issues. The written plan of care dated 12/20/2023 did not reflect patient and family goals and planned interventions associated with the patient's dyspnea, agitation, anxiety, edema, and constipation identified in the initial comprehensive assessment. Clinical Record 11: The patient elected hospice services on 08/22/2023 with a terminal diagnosis of Alzheimer’s disease. The initial nursing assessment dated 08/22/2023 included documentation that the patient had three plus pitting edema in bilateral lower extremities and was at risk for falls with a risk score of eight out of ten. The written plan of care dated 08/22/2023 did not reflect patient and family goals and planned interventions associated with the patient's edema and fall risk identified in the initial comprehensive assessment. Clinical Record 12: The patient elected hospice services on 09/07/2023 with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lungs. The initial nursing assessment dated 09/07/2023 included documentation that the patient was at risk for falls with a risk score of ten out of ten. The written plan of care effective 09/07/2023 did not reflect patient and family goals and planned interventions associated with the patient's fall risk identified in the initial comprehensive assessment. Clinical Record 13: The patient elected hospice services on 06/20/2024 with a terminal diagnosis of alcoholic cirrhosis of the liver without ascites. The initial nursing assessment dated 06/20/2024 included documentation that the patient was unable to swallow, had Edmonton anxiety and depression scores of four and had two to three plus pitting edema in bilateral lower extremities. The written plan of care dated 06/20/2024 did not reflect patient and family goals and planned interventions associated with the patient's dysphagia, anxiety, depression, and edema identified in the initial comprehensive assessment. Clinical Record 14: The patient elected hospice services on 05/22/2024 with a terminal diagnosis of malignant neoplasm of unspecified ovary. The initial nursing assessment dated 05/22/2024 included documentation that the patient was dyspneic at night and with exertion and had an indwelling urinary catheter with hematuria assessed in the drainage bag. The written plan of care dated 12/20/2023 did not reflect patient and family goals and planned interventions associated with the patient's dyspnea, indwelling urinary catheter, and urinary symptoms identified in the initial comprehensive assessment. Clinical Record 15: The patient elected hospice services on 01/08/2024 with a terminal diagnosis of unspecified degenerative disease of the nervous system. The patient was transferred to another hospice on 03/19/20254. The initial nursing assessment dated 01/08/2024 included documentation that the patient was bed-bound, incontinent of bowel and bladder, and was at risk for falls with a risk score of nine out of ten. The written plan of care dated 01/08/2024 did not reflect patient and family goals and planned interventions associated with the patient's risks for skin breakdown and falls identified in the initial comprehensive assessment. Clinical Record 18: The patient elected hospice services on 12/01/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient died in the assisted living facility on 12/24/2023. The initial nursing assessment dated 12/01/2023 included documentation that the patient had constipation issues that required multiple laxatives and was at risk for falls with a risk score of nine out of ten. The written plan of care dated 12/01/2023 did not reflect patient and family goals and planned interventions associated with the patient's constipation and fall risk identified in the initial comprehensive assessment. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the written plans of care identified did not reflect patient and family goals and planned interventions associated with problems identified during the comprehensive assessment.

It is required that the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 8 of 19 (42%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individual plan of care no less frequently than every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 09/23/2022. The individualized plan of care (POC) was established on 09/23/2022 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 11/30/2022, 69 days after the initial POC was established. The plan of care effective 05/21/2023 was reviewed, revised, and documented by the IDG on 06/28/2023 and not again until 08/09/2023, 42 days after 06/28/2023. The plan of care was reviewed, revised, and documented by the IDG on 01/15/2024 and not again until 04/11/2024, 86 days after 01/15/2024. Clinical Record 7: The patient elected the hospice benefit on 11/29/2023. During the benefit period (BP) 02/27/2024 through 05/26/2024, the IDG reviewed, revised and documented the plan of care on 02/28/2024, 03/13/2024, and 04/11/2023, 29 days after 03/13/2024. Clinical Record 8: The patient elected the hospice benefit on 03/15/2024. The individualized plan of care (POC) was established on 03/15/2024 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 04/11/2024, 27 days after the POC was established. Clinical Record 9: The patient elected the hospice benefit on 05/02/2024. The individualized plan of care (POC) was established on 05/02/2024 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 06/12/2024, 41 days after the initial POC was established and 26 days outstanding. The IDG reviewed, revised, and documented patient updates to the POC on 07/10/2024, 28 days after 06/12/2024 and 13 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 12/20/2023. The established plans of care for the benefit periods starting 03/18/2024 and 06/17/2024 were reviewed, revised, and documented to include changes in the patient’s condition and needs by the IDG on 06/12/2024 and not again for 28 days on 07/10/2024. Clinical Record 12: The patient elected the hospice benefit on 09/07/2023. The individualized plan of care (POC) was established on 09/07/2023 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 09/27/2023, 20 days after the initial POC was established. The IDG reviewed, revised, and documented patient updates to the POC on 10/04/2023 and not again for 21 days on 10/25/2023. Clinical Record 16: The patient elected the hospice benefit on 05/19/2023. The individualized plan of care (POC) was established on 05/19/2023 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 06/14/2023, 26 days after the initial POC was established. The IDG reviewed, revised, and documented patient updates to the POC on 08/30/2023 and not again for 28 days on 09/27/2023. Clinical Record 19: The patient elected the hospice benefit on 05/10/2023. The individualized plan of care (POC) was established on 05/10/2023 by the Interdisciplinary Group (IDG). The IDG reviewed, revised, and documented patient updates to the POC on 07/05/2023, 56 days after the initial POC was established. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the individualized plans of care identified were not reviewed, revised, and documented by the IDG no less frequently than every 15 calendar days. Leaders stated there had been and were ongoing issues transitioning to a new electronic medical record affecting the development and notification of required elements.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that nursing care provided by the Licensed Practical Nurse (LPN) was supervised by a Registered Nurse per state regulations. Document 1: Department of Health and Senior Services, Division 30—Division of Regulation and Licensure, Chapter 35—Hospices, 02/28/2023, stated in part, "The registered nurse shall make on-site supervisory visits at least monthly to assess and document that the licensed practical nurse is routinely providing nursing services in accordance with the plan of care." Clinical Record 16: The patient elected the hospice benefit on 05/19/2023. The Licensed Practical Nurse (LPN) documented visits performed on 06/05/2023, 06/15/2023, 06/26/2023, 07/17/2023, 07/20/2023, and 08/14/2023. The clinical record contained no documented evidence that the Registered Nurse (RN) performed a supervisory visit on the nursing care provided by the LPN in June 2023 and July 2023. Clinical Record 19: The patient elected the hospice benefit on 05/10/2023. The plan of care dated 05/10/2023 included a visit frequency order for the skilled nurse (SN) to visit twice a week. The Licensed Practical Nurse (LPN) performed one of the two scheduled nursing visits each week starting the week of 05/14/2023. The clinical record contained no documented evidence that the Registered Nurse (RN) performed a supervisory visit on the nursing care provided by the LPN in May 2023, June 2023, and July 2023. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the clinical records identified contained no evidence that the Registered Nurse had performed supervisory visits on the nursing care provided by the LPN.

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 Hospice aides reported changes in the patient's care needs to the Registered Nurse {HCDT.18. I/L628}; and Failed to ensure the Registered Nurse performed an on-site visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days {HSRM.25. I/L629}. 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 (RN) 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 14 of 15 (93%) 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 02/12/2024 with a terminal diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The hospice aide care plan dated 06/22/2024 included instructions for the aide to perform two bath types, a bed bath and a shower two times a week. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 2: The patient elected the hospice benefit on 08/29/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. The hospice aide care plan updated 05/24/2024 included instructions for the aide to perform two bath types, a bed bath and a partial bed bath at each visit. The care plan did not specify when one bath type would be performed instead of the other, forcing the aide to make decisions outside the aide’s scope of practice. Clinical Record 4: The patient elected the hospice benefit on 05/12/2024 with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan dated 05/13/2024 included instructions for the aide to perform three bath types, a bed bath, partial bed bath, and shower two times a week. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 5: The patient elected the hospice benefit on 01/31/2024 with a terminal diagnosis of unspecified severe protein-calorie malnutrition. The initial nursing assessment dated 01/31/2024 included documentation that the patient had contractures of the hands and feet, Thromboembolic Deterrent (TED) hose applied to bilateral lower extremities daily, dressings applied to both feet daily, and barrier cream applied after incontinence. The hospice aide care plan dated 01/31/2024 did not alert the aide to the patient’s contractures, the need for TED hose, measures to take if dressings were soiled or became wet, and the need for barrier cream application. The care plan included instructions for the aide to perform two bath types, a complete bed bath and a complete shower, every visit. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 6: The patient elected the hospice benefit on 04/11/2024 with a terminal diagnosis of Atherosclerotic heart disease of the native coronary artery without angina pectoris. The hospice aide care plan dated 04/12/2024 included instructions for the aide to perform three bath types, a bed bath, partial bed bath, and shower every visit. The care plan instructed the aide to remove the patient’s oxygen during patient care as needed. The care plan did not specify when one bath type would be performed instead of the other and did not provide a specific reason for removing oxygen during patient care. Clinical Record 7: The patient elected the hospice benefit on 11/29/2023 with a terminal diagnosis of Alzheimer’s disease. The nursing visit note dated 06/04/2024 included documentation that an indwelling urinary catheter had been inserted for long-term use. The hospice aide care plan dated 06/12/2024 did not alert the aide to the indwelling urinary catheter and any care needed. The hospice aide care plan dated 06/12/2024 included instructions for the aide to apply barrier cream to the patient’s buttocks and coccyx. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 8: The patient elected the hospice benefit on 03/15/2024 with a terminal diagnosis of unspecified heart failure. The initial nursing assessment dated 03/15/2024 included documentation that the patient was at risk for falls with a fall risk score of nine out of ten. The hospice aide care plan dated 03/15/2024 included instructions for the aide to perform a complete shower, assist with ambulation, and transfer every visit. The care plan did not alert the aide to the patient’s fall risk. Clinical Record 9: The patient elected the hospice benefit on 05/02/2024 with a terminal diagnosis of chronic kidney disease, stage four (severe). The hospice aide care plan dated 05/02/2024 included instructions for the aide to perform two bath types, a bed bath and a shower at each visit. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 10: The patient elected the hospice benefit on 12/20/2023 with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan dated 07/10/2024 included instructions for the aide to perform a bed bath or a shower “per aide discretion due to frequent agitated behavior” at each visit. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 11: The patient elected the hospice benefit on 08/22/2023 with a terminal diagnosis of Alzheimer’s disease. The hospice aide care plan dated 08/22/2023 included instructions for the aide to perform three bath types, a bed bath, partial bed bath, and shower every visit. The care plan instructed the aide to shave the patient as needed. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 12: The patient elected the hospice benefit on 09/07/2023 with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. The initial nursing assessment dated 09/07/2023 included documentation that the patient was at risk for falls with a fall risk score of ten out of ten. The hospice aide care plan dated 09/07/2023 included instructions for the aide to perform a complete shower and to assist with ambulation. The care plan did not alert the aide to the patient’s fall risk. The care plan dated 07/03/2024 included instructions for the aide to remove the patient’s oxygen during the shower and provide bathroom assistance as needed. The care plan did not include a specific reason for removing the patient’s oxygen or when to provide bathroom assistance. . Clinical Record 14: The patient elected the hospice benefit on 05/22/2024 with a terminal diagnosis of malignant neoplasm of unspecified ovary. The hospice aide care plan dated 05/24/2024 included instructions for the aide to remove the patient’s oxygen during patient care as needed. The care plan did not specify when one bath type would be performed instead of the other. Clinical Record 15: The patient elected the hospice benefit on 01/08/2024 with a terminal diagnosis of unspecified degenerative disease of the nervous system. The initial nursing assessment dated 01/08/2024 included documentation that the patient was at risk for falls. The hospice aide care plan dated 01/08/2024 included instructions for the aide to assist with transfers and to perform two bath types, a bed bath and shower every visit. The care plan did not alert the aide to the patient’s fall risk, and the care plan did not specify when one bath type would be performed instead of the other. Clinical Record 18: The patient elected the hospice benefit on 12/01/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 12/01/2023 included documentation that the patient had a history of seizures requiring scheduled medication to manage and was at risk for falls with a fall risk score of nine out of ten. The hospice aide care plan dated 12/01/2023 included instructions for the aide to assist with transfers. The care plan did not alert the aide to the patient’s seizure and fall risks. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the hospice aide care plans included non-specific instructions that forced the aide to make decisions outside the aide’s scope of practice, and care plans did not alert the aide to seizure and fall risks.

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 3 of 15 (20%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes in the patient's care needs to the Registered Nurse. Clinical Record 1: The patient, an assisted living facility resident, elected the hospice benefit on 02/12/2024. The hospice aide visits, dated 06/20/2024 and 07/03/2024, included documentation that the aide had not completed personal care as instructed because the facility staff had performed the care. The clinical record contained no documented evidence that the hospice aide reported a change in the patient’s care needs to the Registered Nurse. Clinical Record 2: The patient elected the hospice benefit on 08/29/2022. The hospice aide care plan, effective 05/24/2024, provided instructions for the aide to perform scheduled repositioning, range of motion (ROM), bed bath and a partial bed bath, and to document the patient’s last bowel movement and output. The aide’s visit dated 05/24/2024 did not include documentation that the aide performed scheduled repositioning, ROM, bed bath, date of last bowel movement, and output. The clinical record contained no documented evidence that the hospice aide reported changes in the patient’s care needs and assigned tasks not completed during the visit. Clinical Record 6: The patient elected the hospice benefit on 04/11/2024. The hospice aide care plan dated 06/24/2024 included instructions for the aide to perform personal care including a shower and nail cleaning. The hospice aide’s visit dated 07/03/2024 included documentation that the patient refused a shower or a “wash up.” The clinical record contained no documented evidence that the hospice aide reported a change in the patient’s care needs to the Registered Nurse. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the clinical records identified contained no documented evidence that the hospice aide reported changes in the patient’s care needs to the Registered Nurse.

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 8 of 15 (53%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse performed an on-site visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 02/12/2024. The plan of care order dated 04/18/2024 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 03/22/2024. The next on-site supervisory visit by the RN was completed on 04/15/2024, 24 days after the previous supervisory visit. Clinical Record 2: The patient elected the hospice benefit on 08/29/2022. The plan of care order dated 08/29/2022 through the current date included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 03/11/2024. The next on-site supervisory visit by the RN was completed on 04/08/2024, 28 days after the previous supervisory visit. Clinical Record 3: The patient elected the hospice benefit on 09/23/2022. The plan of care order for the benefit period 01/15/2024 through 03/15/2024 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was visiting once a week. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 03/07/2024. The next on-site supervisory visit by the RN was completed on 04/04/2024, 28 days after the previous supervisory visit. Clinical Record 5: The patient elected the hospice benefit on 01/31/2024. The plan of care order dated 01/31/2024 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide performed the first visit on 02/02/2024 and performed additional visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 02/19/2024, 17 days after the first hospice aide visit. The next on-site supervisory visit by the RN was completed on 03/07/2024, 17 days after the previous supervisory visit. The RN documented that an on-site supervisory visit was completed on 04/08/2024 and next on 04/29/2024, 21 days after the previous supervisory visit. The RN documented that an on-site supervisory visit was completed on 05/13/2024 and next on 05/30/2024, 17 days after the previous supervisory visit. The RN documented that an on-site supervisory visit was completed on 06/07/2024 and next on 06/27/2024, 20 days after the previous supervisory visit. Clinical Record 7: The patient elected the hospice benefit on 11/29/2023. The plan of care order dated 11/29/2023 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 12/28/2023. The next on-site supervisory visit by the RN was completed on 01/15/2024, 18 days after the previous supervisory visit. Clinical Record 8: The patient elected the hospice benefit on 03/15/2024. The plan of care order dated 08/29/2022 through the current date included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide performed the first visit on 03/19/2024 and performed additional visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 04/09/2024, 21 days after the first hospice aide visit. The next on-site supervisory visit by the RN was completed on 04/08/2024, 28 days after the previous supervisory visit. Clinical Record 11: The patient elected the hospice benefit on 08/22/2023. The plan of care order dated 08/22/2023 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 02/22/2024. The next on-site supervisory visit by the RN was completed on 04/02/2024, 39 days after the previous supervisory visit. The RN documented that an on-site supervisory visit was completed on 06/18/2024. The next on-site supervisory visit by the RN was completed on 07/09/2024, 21 days after the previous supervisory visit. Clinical Record 12: The patient elected the hospice benefit on 09/07/2023. The plan of care order dated 09/07/2023 included a frequency order for the hospice aide to visit twice a week. A clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 03/19/2024. The next on-site supervisory visit by the RN was completed on 04/08/2024, 20 days after the previous supervisory visit. The RN documented that an on-site supervisory visit was completed on 06/03/2024. The next on-site supervisory visit by the RN was completed on 06/18/2024, 15 days after the previous supervisory visit. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the clinical records identified contained no evidence that the Registered Nurse had performed on-site supervisory visits no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure the services ordered met the patient’s needs.

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 and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for all care and services provided. Clinical Record 1: The patient elected the hospice benefit on 02/12/2024. The clinical record review revealed volunteer visits were made on 02/22/2024, 03/07/2024, and 03/15/2024. The review also revealed that the hospice aide care plan updated 06/22/2024 included instructions for the aide to apply Calmoseptine after bathing or incontinence change. The clinical record contained no evidence of physician orders for volunteer visits and Calmoseptine. Clinical Record 2: The patient elected the hospice benefit on 08/29/2022. The Volunteer Coordinator documented weekly visits performed by the volunteer from 09/01/2022 to 02/09/2023 except the weeks of 09/11/2022 and 12/11/2022. The Volunteer Coordinator documented weekly visits performed by the volunteer on 04/14/2024, 04/21/2024, 05/07/2024, 05/29/2024, 06/07/2024, -6/11/2024, 06/19/2024, and 07/03/2024. The clinical record contained no evidence of physician orders for volunteer visits from 09/01/2022 to 02/09/2023 and 04/10/2024 to 07/07/2024. Clinical Record 5: The patient elected the hospice benefit on 01/31/2024. The Volunteer Coordinator documented visits performed by the volunteer on 03/22/2024 and 03/29/2024. The clinical record contained no evidence of physician orders for volunteer visits. During joint clinical record reviews and interviews on 07/12/2024, the Administrator, Director of Nursing, Compliance Officer, and Quality Assurance Performance Improvement Nurse confirmed that the clinical records identified contained no evidence of physician orders for volunteer visits.