Every finding on record at Divine Mercy Health Services LLC

It is required that each patient’s individualized written plan of care 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 3 of 14 (21%) clinical records reviewed, the patient’s individualized written plan of care did not identify planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 8: This patient elected the hospice benefit on 05/29/2023 with a terminal diagnosis of cerebral infarction. In a review of the clinical record, the clinical assessment documented a new wound on the patient's right shoulder on 10/20/2023. A physician order received 10/20/2023 was to cleanse the wound with wound cleanser, pat dry, apply Medi honey, and cover with border gauze. The plan of care was reviewed for the dates of 10/20/2023-03/11/2024 and did not include planned interventions for the care of the right shoulder wound. CLINICAL RECORD 12: This patient elected the hospice benefit on 07/11/2024 with a terminal diagnosis of heart disease. The nursing note dated 07/18/2024 documented the patient was transitioning and exhibited somnolence and was as free as pain as possible nearing the end of life. The nurse documented that the hospice would continue to follow up and provide comfort and reassurance. Daily nursing visits were documented 07/18/2024, 07/19/2024, 07/20/2024, and 07/21/2025, and a death visit was conducted on 07/22/2024. The plan of care was reviewed for the dates of 07/11/2024-07/22/2024 and was not updated to provide interventions for imminence of death. CLINICAL RECORD 14: This patient elected the hospice benefit 09/24/2024 with a terminal diagnosis of Alzheimer's Disease. The nursing note dated 11/01/2024 documented the patient was exhibiting a significant decline in overall condition and the physician was notified. The nurse documented visits on 11/01/2024, 11/02/2024, /11/03/2024, 11/04/2024, and 11/05/2024. The patient expired 11/05/2024. The plan of care was reviewed for the dates of 09/24/2024-11/05/2024 and was not updated to provide interventions for imminence of death. An interview was conducted with the Director of Patient Care Services on 02/20/2025. It was confirmed that the patient’s individualized written plan of care did not identify planned interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that each patient’s individualized written plan of care includes 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 1 of 14 (7%) clinical records reviewed, the agency did not ensure the patient's individualized written plan of care included measurable outcomes anticipated from implementation and coordination of the plan of care. CLINICAL RECORD 6: This patient elected the hospice benefit 06/03/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. The initial comprehensive assessment documented the patient was diagnosed with heart failure and diabetes. The patient's plan of care was reviewed from dates of 06/03/2024 to 02/19/2025. The goal for hypertensive heart disease with heart failure was the patient would have optimal circulation status as permitted by disease process. This patient had a diagnosis of diabetes. The patient's family was testing the patient's blood sugar levels and administering diabetes medications. The goal was the patient would have stable blood glucose levels within a safe range. The goals of the plan of care did not include measurable outcomes that would be anticipated from implementing and coordinating the plan of care. The plan of care did not define "optimal" or "stable." In an interview conducted with the Director of Patient Care Services on 02/20/2025, it was confirmed the patient's individualized written plan of care did not include measurable outcomes anticipated from implementation and coordination of the plan of care.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed in which the patient revoked the election of hospice care or was discharged from hospice per hospice regulation, the agency did not ensure that the hospice forwarded the hospice discharge summary to the attending physician. CLINICAL RECORD 8: This patient elected the hospice benefit 05/29/2023 with a terminal diagnosis of cerebral infarction and was discharged on 03/11/2024 for extended prognosis with improvement. There was no documentation present in the clinical record that the hospice forwarded a copy of the discharge summary to the attending physician. CLINICAL RECORD 10: This patient elected the hospice benefit 02/01/2023 with a terminal diagnosis of congestive heart failure and was discharged 02/20/2024 for extended prognosis with improvement. There was no documentation present in the clinical record that the hospice forwarded a copy of the discharge summary to the attending physician. In an interview conducted with the Director of Patient Care Services on 02/20/2025, it was confirmed that the agency sent the discharge summary to the receiving facilities, but there was no documentation that it was sent to the attending physician.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice 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. This standard was not met as evidenced by joint clinical record review and staff interview. 3 of 11 (27%) records were missing documented evidence that the staff completed the COVID-19 screening tool that was ordered to be completed prior to making home visits. Record #35311: The hospice benefit was elected on 3/29/2022. The hospice chaplain failed to document completion of the COVID-19 screening prior to completing the home visit on 3/30/2022. Record #93961: The hospice benefit was elected on 3/25/2022. The hospice chaplain failed to document completion of the COVID-19 screening prior to completing the home visit on 3/25/2022. Record #11490: The hospice benefit was elected on 2/9/2022. The hospice chaplain failed to document completion of the COVID-19 screening prior to completing the home visit on 2/13/2022. An interview with the RN Supervisor (Staff ID: 90599) on 4/6/2022 acknowledged that the documented screening prior to the visits did not follow the plan of care orders and was unable to provide documentation of the screening.

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 joint clinical record review and staff interview. 5 of 9 (55%) applicable records, in which the hospice aide was accepted, revealed evidence that hospice aide visits were not completed as ordered on the hospice plan of care orders. Record #35311: The election of hospice benefit was dated 3/29/2022, and the hospice aide plan of care order, effective 3/29/2022, was for five visits per week. During the week of 3/29/2022 there were only three (3) visits documented as made. Record #93961: The election of hospice benefit was dated 2/24/2022, and the hospice aide plan of care order, effective 2/24/2022, was for five visits per week. During the week of 2/24/2022 there were only two (2) visits documented as made. Record #11490: The election of hospice benefit was dated 2/9/2022, and the hospice aide plan of care order, effective 2/9/2022, was for three visits per week. During the week of 2/9/2022 only one (1) visit was documented as made. Record #58024: The election of hospice benefit was dated 12/13/2021, and the hospice aide plan of care order, effective 12/13/2022, was for three visits per week. During the week of 12/13/2022 there were only two (2) visits documented as made. Record #57958: The election of hospice benefit was dated 7/21/2021, and the hospice aide plan of care order, effective 7/21/2022, was for 3 times per week. During the week of 7/21/2022 there was only one (1) visit documented as made. An interview with the RN Supervisor (Staff ID: 90599) on 4/6/2022 acknowledged that the documented aide visits did not follow the plan of care orders and was unable to provide documentation for missed visits or changes to the aide plan of care orders.

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 team. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and staff interview. 7 of 11 (63%) clinical records contained hospice election statements that were not fully completed. Record 93961: The hospice election of care statement dated 3/24/2022 was missing the date the patient signed the form. The area designated for documenting choice of attending physician, physician NPI, and address were not completed. Also, the acknowledgement of non-covered items, services and drugs not related to terminal illness and related conditions was not completed. Record 92859: The hospice election of care statement dated 2/25/2022 was missing documentation of the patient's choice of attending physician, physician NPI and address. Acknowledgement of non-covered items, services and drugs not related to terminal illness and related conditions was also not completed. Record 11490: The hospice election of care statement dated 2/9/2022 was missing complete documentation of the acknowledgement of non-covered items, services and drugs not related to terminal illness and related conditions. Record 58024: The hospice election of care statement dated 12/13/2021 was missing documentation of the physician identified as attending physician, the physician NPI, and address. The statement was also missing documentation of the name of the hospice agency and date of election. Record 16943: The hospice election of care statement dated 11/10/2021 was missing documentation in the designated areas of the name of the hospice agency and attending physician, and entry of any non-covered items, services and drugs not related to terminal illness and related conditions. Record 98004: The hospice election of care statement dated 10/2/2021 was missing documentation of start of care date, the chosen attending physician's name, NPI, and office address. Also, any non-covered items, services and drugs not related to terminal illness and related conditions was not completed. Record 11614: The hospice election of care statement dated 9/27/2021 was missing documentation of the start of care date, the name of the chosen attending physician, their NPI, and office address. Also, any non-covered items, services and drugs not related to terminal illness and related conditions was not completed. An interview with the Administrator (Staff ID: 68543) and RN Supervisor (Staff ID: 90599) on 4/6/2022 acknowledged that the clinical documentation initiated at the time of admission was not fully completed.