Every finding on record at Elysian Hospice, LLC

Based on interview and record review, the agency failed ensure the rights of the patient in 1 (Patient #2) of 20 patient records reviewed in that:  HHA B cut Patient #2’s hair without  consent from the  Patient #1 or Patient #1's family.This failure places agency staff and patients at risk of receiving inappropriate care or treatment and could lead to miscommunication between the agency’s patients and staff. --- Findings Include:  Record review of TULIP identified intake number 1013445 as a self-report made by the agency Admin with an incident report date as 5/28/2025. Review of the provider investigative report revealed no prior allegations of similar nature.  An interview with the Admin was conducted on 5/6/2026 at 12:00 p.m. regarding a self-re ported intake#1013445 . The Admin stated she was aware of the incident and had completed an internal investigation. Admin stated HHA B was caring for Patient #2, who resided in a long-term care facility and attempted to brush the Patient’s matted hair before shampooing it. Because the hair could not be brushed out, HHA B cut the matted portions with scissors. The Patient’s family member later saw that Patient #2’s hair had been cut and became upset that he had not been notified beforehand. He then requested that Patient #2be removed from hospice services immediately.  Surveyor attempted to reach Patient #2’s family via telephone and email 3 times between 5/1/2026 and 5/7/2026 but was unable to reach family for a statement. An interview with HHA B was conducted on 5/6/2026 at 12:45 PM. HHA B reiterated the details given by the Admin. HHA B stated that she never had any ill intentions when cutting Patient #2’s hair, but she was unable to get a brush through the matted portions of her hair and it needed to be washed. HHA B denied having obtained permission from the Patient #2 or family prior to cutting the patient’s hair. HHA B stated that she understood why it was important to obtain permission before cutting Patient #2’s hair. HHA B personal statement was attached as well as documented EMR/NAR checks completed on 1/9/2025. HHA B was deemed employable on 1/9/2025 with no deficiencies or unemployable convictions noted Review of Patient #2’s Plan of Care revealed a start of care date of 4/10/25 and a primary diagnosis of Alzheimer’s disease. The plan of care contained orders for skilled nursing visits 3 times per week for 1 week followed by 2 times per week for 12 weeks.  Home health aide visits were ordered 2 times per week for 1 week and then 3 times per week for 12 weeks.  Chaplain and social work services were ordered once. Per the plan of care, skilled nursing visits were ordered for wound care, observation, assessment, pain management and coordination of services with skilled nursing facility staff. It was noted in the plan of care that there were no family willing or able to provide for the hygiene needs of Patient #2. Patient’s plan of care revealed no orders to HHA B to cut Patient #2’s hair.  Review of agency policy titled “Patient’s Right and Responsibilities” dated 10/01/21 read in part… “Regarding patient’s rights, the patient has the right to… refuse care or treatment”.

Upon patient record review, 4 of 19 (Patient #2, 5, 13, 14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2 - SOC 01/18/2023 no evidence of initial bereavement assessment. Patient #5 - SOC 02/24/2023 no evidence of initial bereavement assessment. Patient #13 - SOC 02/24/2023 no evidence of initial bereavement assessment. Patient #14 - SOC 03/29/2023 no evidence of initial bereavement assessment.

Upon patient record review, 5 of 19 (Patient #2, 3, 4, 11, 12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 - POC dated 01/18/2023 did not include wound care site on updated order written 01/25/2023. Patient #3- POC dated 03/30/203 contained Glucagon 1mg uses as directed PRN - no frequency or modifier for PRN. Nitrostat as needed PRN no frequency or modifier for PRN. Novolog 70/30 TID per instructions - no dosage. Travatan eye drops 1 drop at bed time - did not distinguish if L, R or both eyes. Wound care order written on 04/03/2023 did not contain site. Patient #4 - POC dated 02/27/2023 contained Hyoscyamine sulfate 0.125mg 1 tab as directed - no frequency. Patient #11 - POC dated 02/11/2023 wound care order did on 02/16/2023 not include site. Nutrem 1.5 at 65 ml per hour did not include frequency. Patient #12 - POC dated 03/16/2023 contained Hyoscyamine sulfate 0.125mg 1 tab as directed - no frequency.

Upon client record review, 1 of 19 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 - POC dated 02/27/2023 PT referral 03/19/2023 - PT never saw patient.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #11 - Aide POC did not contain that patient HOB elevation due to G-tube feedings.

Upon patient record review 4 of 19 (Patient #1, 2, 4, 6) did not have evidence documentation in the patient record 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 by such hospice aide • Consistent with the hospice aide training Patient #1 - Aide care plan visit frequency 3 x week. Bed bath Monday and Friday shower every Thursday. Week 02/27/2023, 03/06/2023 and 03/13/2023 - Bed bath and shower documented completed on all visits. Shampoo to be completed every visit - not completed on 03/09/2023. Patient #2 - Aide care plan visit frequency 3 x week. Bed bath Monday and Wednesday shower every Friday. Week 04/03/2023 and 04/10/2023 - Bed bath and shower documented completed on all visits. Patient #4 - Aide care plan visit frequency 3 x week. Shower ordered every visit but gave bed bath on 03/04/2023, 03/07/2023 and 03/28/2023, also shampoo ordered every visit but not completed on these dates. Patient #6 - Aide care plan visit frequency 3 x week. Shower and shaving every Monday and bed bath Wednesday and Friday. Week of 03/06/2023 and 03/20/2023 shaved every visit.

Upon patient client record review, 4 of 19 (Patient # 9, 11, 14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #14 - SN visit on 03/29/2023 states patient has a #22 foley catheter and SN visit note 03/30/2023 states patient has a #16 foley catheter but no documentation that foley was changed.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #4 - Did not contain evidence in patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.

Upon client record review, 6 of 19 (Patient #1, 2, 3, 5, 9, 13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1 - POC dated 01/24/2023 SC and MSW visit frequency effective 01/29/2023 3wk1, 1 every 4wk8 - no visits week of 01/29/2023. Patient #2 - POC dated 01/18/2023 SC visit frequency 1wk1, 1 every 2wk2 - no visits week of 01/29/2023 as ordered. MSW visit frequency 1wk1, 2wk1, 1wk1, 1 every4 week 8 - No visit made week of 01/22/2023 or week of 04/02/2023 as ordered. Patient #3 - POC dated 03/30/2023 - wound care to sacrum apply xerform to wound bed but applied alginate on 04/04/2023 and 04/26/2023 nursing visits. Patient #5 - POC dated 02/24/2023 MSW visit frequency effective 02/26/2023 4 wk1, 1every 4 week 12 - only 1 visit made week of 02/26/2023. Patient #9 - POC dated 03/20/2023 SN visit frequency 2wk 13 - only 1 visit made week 03/26/2023 and 0 visits made week of 04/02/2023. Patient #13 - POC dated 02/24/2023 SN visit frequency 2wk1, 1wk13 - no visit made week 03/26/2023 or 04/09/2023.