Every finding on record at Cs Mi Opco LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide care plan included all written patient care instructions. Clinical Record 8: The patient elected the hospice benefit on 12/12/2024. On 05/11/2025, the physician ordered wound care with a dressing for a wound on the patient's left leg. The plan of care dated 04/11/2025 through 06/09/2025 ordered "HA 2x/week." The Hospice Aide care plan dated 05/12/2025 assigned the Hospice Aide the relevant task of "Bed bath every visit." The Hospice Aide care plan did not document instructions for the Hospice Aide related to the wound dressing on the patient's left leg, should it become wet or dislodged during the bed bath. During a joint record review on 05/29/2025, the Manager of Accreditation and Regional Director of Clinical Operations confirmed that wound dressing instructions were not included in the Hospice Aide care plan.

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 4 of 16 (25%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that Hospice Aide supervisory visits were completed by a Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 08/29/2024. The plan of care dated 02/25/2025 through 04/25/2025 ordered "HA 1x/week." The first Hospice Aide visit was dated 02/26/2025. Hospice Aide supervisory visits were documented on 02/27/2025 and 03/14/2025, with 15 days outstanding. Clinical Record 4: The patient elected the hospice benefit on 11/26/2024. The plans of care dated 02/13/2025 through 04/13/2025 and 04/14/2025 through 06/11/2025 ordered "HA 2x/week." The first Hospice Aide visit was dated 02/18/2025. Hospice Aide supervisory visits were documented on 03/03/2025 and 04/17/2025, 45 days outstanding. Clinical Record 8: The patient elected the hospice benefit on 12/12/2024. The plans of care dated 12/12/2024 through 02/09/2025, 02/10/2025 through 04/10/2025, and 04/11/2025 through 06/09/2025 ordered "HA 2x/week." The first Hospice Aide visit was dated 12/16/2024. Hospice Aide supervisory visits were documented on 02/03/2025 and 04/21/2025, with 77 days outstanding. Clinical Record 11: The patient elected the hospice benefit on 10/25/2024. The plans of care dated 10/25/2024 through 01/22/2025 and 01/23/2025 through 04/22/2025 ordered "HA 2x/week." The first Hospice Aide visit was dated 10/31/2024. Hospice Aide supervisory visits were documented on 01/13/2025 and 03/14/2025, with 60 days outstanding. During joint record reviews on 05/28/2025 and 05/29/2025, the Regional Director of Clinical Operations and the Manager of Accreditation confirmed that Hospice Aide supervisory visits were completed less frequently than every 14 days. The Regional Director of Clinical Operations stated, "The late aide supervisory visits involved two new nurses who were re-educated about a month ago on documenting aide supervision every 14 days."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency's "Volunteer Cost Savings Report" for 2024 (01/01/2024 through 12/31/2024) revealed that the total percentage of hours worked by volunteers for the year 2024 was 0.08%. Documentation of a performance improvement plan (PIP) initiated in January 2025 to increase the percentage of volunteer hours to 5% was reviewed. The agency's Volunteer Cost Savings Report for 2025 revealed that the total percentage of hours worked by volunteers for 01/01/2025-04/30/2025 was 0.5%. During an interview on 05/30/2025, the Regional Director of Clinical Operations confirmed the finding, stating, "Our volunteer hours have not been 5%, but we are onboarding additional volunteers." The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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 a review of clinical records and interviews. 1 of 13 (8%) clinical records reviewed revealed that the initial comprehensive assessment was not completed within 5 days of the election of the hospice benefit. Clinical Record 12: The patient elected the hospice benefit on 10/8/2021. The initial psychosocial assessment was completed on 10/16/2021 (8 calendar days from election of the benefit). There was no documentation provided to explain why the assessment was not completed within 5 days. The Manager of Clinical Services was interviewed on 8/11/2022 and agreed the initial psychosocial assessment was not completed timely. He had no additional information to provide. revealed that the initial comprehensive assessment was not completed within 5 days.