Every finding on record at Emmanuel Hospice

It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the advanced directives were documented in a prominent part of the patient's record. Agency Policy, “Full Code” stated in part: "3. Hospice staff will update the electronic medical record to reflect current treatment decision." CLINICAL RECORD 9: This patient elected the hospice benefit 01/23/2025 with a terminal diagnosis of unspecified severe protein calorie malnutrition. In review of the Registered Nurse comprehensive assessment dated 01/23/2025 it was noted the patient was full code. In review of the clinical record and the face sheet, the advanced directive (Full Code status) was listed within assessment visit notes thus it was not documented in a prominent part of the patient's record. In an interview conducted with the Quality Manager on 02/06/2025, it was stated that the agency's practice was to document the patient's advanced directives on the patient's face sheet, and it was confirmed that the advanced directives were not documented in a prominent part of the patient's record, specifically the face sheet.

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 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: This patient elected the hospice benefit on 08/01/2024 with a terminal diagnosis of Alzheimer's Disease. In review of the Registered Nurse (RN) assessment dated 01/08/2025, documentation stated the RN discovered a peri wound 0.8 cm X 0.6 cm which was cleansed with soap and water and barrier cream applied. The RN comprehensive assessment dated 01/28/2025, documented the patient had a decubitus/pressure ulcer Stage II with onset 01/08/2025, and the wound was cleansed and dressing changed as per care plan. The plan of care dated, 01/08/2025-02/06/2025, did not include any goals or interventions for wound/wound care. In an interview with the Quality Manager on 02/05/2025, it was confirmed that the plan of care did not include a care plan for wound care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visits observed, it was revealed that the agency did not ensure the staff followed the hand hygiene policy. Agency Policy, “Hand Hygiene” stated in part, "1. Staff perform hand hygiene frequently: h. Before handling clean wound care supplies." HOME VISIT 2: During the home visit, on 02/04/2025, the Registered Nurse (Personnel Record 2) donned gloves, removed the soiled coccyx wound dressing, cleansed the wound, then applied a new wound dressing. The Registered Nurse did not perform hand hygiene before handling clean wound care supplies. In an interview with the Quality Manager on 02/04/2025, it was confirmed hand hygiene policy was not followed.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including contributing to patient and family counseling and education. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the coordination of all aspects of patient care including contributing to patient and family counseling and education, specifically regarding the education of the policy for full code. Agency policy, “Full Code” stated in part, "6. In the event patient, patient advocate, and/or guardian choose not to institute or sign a do not resuscitate order, hospice staff provide education… 4. If a patient wishes to be resuscitated, the family/caregiver is trained on the following: a. To call 911 in the event of cardiac or respiratory arrest and notify emergency personnel of patient being on (agency name) Hospice Services… i. To subsequently call (agency name) Hospice." CLINICAL RECORD 11: This patient elected the hospice benefit on 02/03/2025 with a terminal diagnosis of malignant neoplasm of the left bronchus of the lung. The Registered Nurse initial comprehensive assessment dated 02/03/2025 documented the patient was full code. In a joint visit on 02/05/2025, the Master of Social Worker (MSW) documented the patient's code status as full code and the education of the patient and children on the definition of full code. The MSW documented the Registered Nurse Case Manager (RNCM) clarified that the hospice was always to be the first call in the event that the patient became unresponsive and that an ambulance (if chosen) would not be covered. The MSW documented the patient and family verbalized understanding of this process. The RNCM who had joined in this visit documented that hospice should be first called in the event that the patient becomes unresponsive. No documentation was present of education to the family/caregiver to call 911 in the event of cardiac or respiratory arrest and to notify emergency personnel of patient being on hospice services and then to call the hospice. In an interview conducted with the Vice President of Patient Care and Compliance on 02/07/2025, it was confirmed that the agency did not ensure the family/caregiver was educated to call 911 if the patient had cardiac or respiratory arrest as per hospice policy.

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, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the clinical record contained physician orders for interventions identified in the clinical record. CLINICAL RECORD 5: This patient elected the hospice benefit on 08/01/2024 with a terminal diagnosis of Alzheimer's Disease. In review of the Registered Nurse (RN) assessment dated 01/08/2025, documentation stated the RN discovered a peri wound 0.8 cm X 0.6 cm which was cleansed with soap and water and barrier cream applied. The RN comprehensive assessment record dated 01/28/2025 documented the patient had a Decubitus/Pressure Ulcer Stage II with onset 01/08/2025, and the wound bed was cleansed, and the dressing was changed per care plan. The clinical record lacked documented evidence of wound care orders; to include plan of care orders or other documented physician orders. CLINICAL RECORD 7: This patient elected the hospice benefit on 01/17/2025 with a terminal diagnosis of cholangitis. The Registered Nurse (RN) comprehensive assessment dated 01/17/2025 documented that a foley catheter was present. In review of the plan of care dated 01/17/2025-02/06/2025, a care plan was present for the indwelling catheter. The interventions stated to change foley catheter as ordered. Physician orders were reviewed with the Quality Manager for the dates of 01/17/2025-02/06/2025. There was no physician order written for the care of the indwelling catheter. During an interview conducted on 02/06/2025, the Quality Manager confirmed that the clinical records did not include these physician orders.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with live discharges, the agency did not ensure that the plan of care was included in the documentation sent to the patient's attending physician upon hospice discharge. CLINICAL RECORD 14: This patient elected the hospice benefit on 01/24/2024 with hypertensive heart and chronic kidney failure and was discharged from hospice for “no longer terminal” on 09/20/2024. In review of the hospice documentation for the discharge summary, there was no evidence that the hospice plan of care was sent to the attending physician. In an interview with the Quality Manager on 02/07/2025, it was confirmed that the agency did not provide documentation that the plan of care was included in the discharge summary sent to the attending physician.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, in which the patient resided in a SNF/NF, it was revealed that the agency did not ensure that the hospice plan of care identified which provider was responsible for performing the respective functions that were provided for the patient. CLINICAL RECORD 2: This patient elected the hospice benefit on 12/06/2024 with a terminal diagnosis of myeloma and resided in a SNF. The RN assessment dated 01/29/2025 documented a pressure ulcer stage II on the right buttocks which was identified on 01/28/2025. A physician's order was placed for 4X4 Mepilex. The plan of care included a care plan dated 01/29/2025 for impaired skin integrity and the intervention was to cleanse and apply Mepilex. The hospice plan of care did not specify which provider was responsible for the care of the wound. In an interview conducted with the Quality Manager on 02/05/2025, it was confirmed that the hospice plan of care did not include which provider was responsible for performing the wound care.

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 review of clinical record, document review and interview that 2 of 2 (100%) records which included acupuncture which is provided by the agency, failed to document interventions for the goals of pain management for this discipline. Agency Policy: Plan of Care { 03/2022] stated in part, "The plan of care reflects the patient/family/caregiver goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments" Record #52237: Acupuncture ordered and started 03/15/2022. The plan of care was updated to include a frequency and duration for acupuncture and a goal for pain management. As of review date 05/03/2022, the patient continued acupuncture treatment, the plan of care failed to include interventions of location or duration of treatment. The visit notes from the clinician document treatment on shoulder, low back and knee, with a medium insertion for 15 minutes but the interventions were not included on the the plans of care. Record #57897: Acupuncture ordered and started 04/13/2022. The plan of care was updated to include a frequency and duration for acupuncture and a goals for pain management. As of review date 05/03/2022, the patient continued acupuncture treatment, the plan of care failed to include interventions of location or duration of treatment. The visit notes from the clinician document treatment on leg and finger with medium insertion for 20 minutes but the interventions were not included on the plan of care. . Interview with the acupuncture licensed clinician on 05/04/2022 stated that the treatment orders including site and duration made sense for this therapy.

It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. The following “non-core” services are provided in a manner consistent with current standards of practice: Physical therapy. This standard was not met as evidenced by clinical record review and interview that in 1 of 8 (13%) records which accepted non core services, the service of physical therapy was not provided as ordered in the plan of care. Record #88364, patient with an order written 02/08/2022 for physical therapy evaluation for a one time visit for safe transfer. No documentation was found for a physical therapy evaluation or evidence for why the service was not provided prior to patient revocation on 02/24/2022. Interview with the Director of Quality and Director of Clinical Services on 05/05/2022 stated that documentation was found that the referral was sent to the contract agency. No other documentation was evident for the reason the service was not provided.

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 not met as evidenced by review of clinical record, document review and interview that in 1 of 11 (09%) of applicable records in which a hospice aide was accepted, revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide scope of practice. Agency Policy: Hospice Aide [revised date 06/2021] stated in part, "Initiates and revises the hospice aide care plan to meet patient/family/caregiver needs." Record #43427 a patient with a large wound requirement of 3 abdominal dressing and was a complicated dressing that had a large amount of drainage. The hospice aide plan of care developed on 04/17/2022 with care tasks that did not include the large dressing with any direction for what to do if saturated, falls off, or if developed odors. Interview with the Director of Quality and the Director of Clinical Services on 05/05/2022 stated that the aide did have access to the entire interdisciplinary plan of care, and that the family had been trained in the wound care but agree that the dressing was not included specifically on the aide plan of care who had a duty, no limited to, providing a bed bath.

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 review of clinical record, document review and interview that in 1 of 11 (09%) records of patient who received aide services, the aide did not provide the services in accordance with the plan of care. Agency Policy, Hospice Aide [revised 06/2021] stated in part, "hospice aide services are included on the plan of care." Record #82262 with hospice aide tasks not limited to shampoo 1 time a week and bed bath 1 time a week. The week beginning 03/27/2022 and 04/04/2022 with aide visits twice each week that provided shampoo and bed bath twice for 2 weeks. Interview with the Director of Quality and the Director of Clinical Services that the aide did document more care than was ordered for the patient.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Documented in the patient record, including the time spent. This standard was not met as evidenced by review of clinical record and interview that in 1 of 2 (50%) records in which volunteer services were accepted, the volunteer failed to document service delivery ordered. Record #52237: The order for volunteer services for a frequency of 1-2 month1, and 3-4 month 2 to provide companionship and pet therapy. The month of June 2021, two visits made by the volunteer, not the ordered 3. No documented reason for why the third visit was not provided. Interview with the volunteer coordinator on 05/04/2022 stated that the 3 visit was not completed as the volunteer was not available. The clarification late entry was documented on 05/04/2022.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management. The patient’s current plan of care. The patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review and interview that in 1 of 3 (33%) of records with live discharges failed to document a discharge summary per agency policy. Agency Policy, Discharge [revised 11/2021], stated in part, " completes the following: submits a copy of the hospice benefit revocation form and the printed transfer/discharge summary" Record #88364, patient completed a revocation form on 02/24/2022 to pursue aggressive treatment. No discharge summary completed in the clinical record as of review 05/04/2022. The agency communication note that stated revocation form and medication profile faxed to the primary care physician. Interview with the Quality Manager and Director of Clinical Services on 05/05/2022 stated that the discharge was coordinated with the primary care physician but agreed that a that an agency discharge summary was not documented as of review 05/05/2022.