Every finding on record at Exalting Hospice and Palliative Care LLC

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records review with bereavement services accepted, the agency did not ensure a bereavement plan of care was developed. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/30/2024. The date of death was 10/15/2024. Clinical record review revealed bereavement services were offered and accepted. However, there was no documented evidence in the clinical record that a bereavement plan of care was developed. During an interview on 05/30/2025, the Bereavement Coordinator stated that she did not know how she had missed that one but that she would conduct an audit of bereavement files to ensure that she did not miss any others.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced document review and interview. The agency did not ensure volunteers provided day-to-day administrative and direct patient care services. During a review of the agency’s volunteer program on 05/28/2025, the agency’s Administrator/Director of Nursing stated that the agency had one volunteer, but that she was hired as a full-time employee in June of 2024. She explained that they have not had another volunteer since that time. She did explain that they are currently in the onboarding process for a volunteer that started with the agency last week, but the volunteer had not finished her training and orientation at this time. During a review of the agency administrator/director of nurses on 05/28/2025, she stated that they had one volunteer, but that she was hired as a full-time employee in June of 2024. They have not had another volunteer since that time. However, they are currently in the onboarding process for a volunteer, but she has not finished her training or orientation at this time.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge from hospice care, the agency did not ensure the hospice discharge summary was sent to the patient's attending physician. CLINICAL RECORD 13: The patient elected the hospice benefit on 05/11/2024 and was discharged on 01/16/2025. There was no documented evidence in the clinical record that the discharge summary was sent to the attending physician. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/23/2024 and was discharged on 05/30/2024. There was no documented evidence in the clinical record that the discharge summary was sent to the attending physician. During an interview on 05/30/2025, the Administrator stated that she will be putting together education to present to her staff regarding the discharge process.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 3 of 5 (60%) records reviewed revealed the hospice did not conduct and document a patient-specific comprehensive assessment that identifies the patient’s need for physical, psychosocial, emotional, and spiritual care. . Record #1 was reviewed and identified the patient elected hospice care on 5/11/2022. The initial comprehensive assessment completed on 5/11/2022 by the Registered Nurse (RN) and the psychosocial assessment completed on 5/13/2022 did not contain a spiritual assessment. The record was missing evidence of a completed spiritual comprehensive assessment. Record #4 was reviewed and identified the patient elected hospice care on 5/25/2022. The patient refused all services except the skilled nurse. The initial comprehensive assessment completed on 5/25/2022 by the Registered Nurse (RN) and the skilled nurse visit completed on 5/30/2022 contained no evidence of a psychosocial assessment. The record was missing documentation of a comprehensive psychosocial assessment. Record #3 was reviewed and identified the patient elected hospice care on 5/25/2022. The RN initial comprehensive assessment dated 5/25/2022 did not have documentation of a psychosocial or spiritual assessment. The routine skilled nursing assessment completed on 5/30/2022, did not contain documentation of a psychosocial or spiritual assessment. The record was missing documentation of the comprehensive spiritual and psychosocial assessments. The agency's policy "Assessments" stated in part, "The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies...the patient's need for physical, psychosocial, emotional and spiritual care." During an interview on 8/10/2022, the Administrator confirmed the comprehensive assessments were not completed for record 1, record 2 and record 3 during a joint record review.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice failed to ensure include the patient's drug profile, a medication review and drug profile updates. Record #4 was reviewed and identified the patient elected hospice care on 5/25/2022. The review of the clinical record revealed the patient's medications were not documented on the initial and current plans of care dated 5/25/2022 through 8/22/2022. As of 8/11/2022, a medication profile was missing from the clinical record. The Administrator confirmed the patient's medications were not entered on the drug profile during an interview and a joint review of the record on 8/11/2022.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the hospice failed to ensure that an initial bereavement assessment completed. Record #1 was reviewed and identified the patient elected hospice care on 5/11/2022. The Registered Nurse (RN) completed an initial comprehensive assessment on 5/11/2022. The record included evidence of a completed psychosocial comprehensive assessment dated 05/13/2022. There was no evidence of an assessment for bereavement risk of the family or caregiver. The record did not contain an initial bereavement assessment as of 8/10/2022. Record #3 was reviewed and identified the patient elected hospice care on 5/25/2022. The initial comprehensive assessment completed by the RN on 5/25/2022 did not include documentation of a bereavement assessment. The skilled nursing visit completed on 5/30/2022, did not contain documentation of a bereavement assessment. The record did not contain an initial bereavement assessment as of 8/10/2022. The Administrator on 8/10/2022 confirmed the bereavement assessments were missing during an interview and a joint review of the records. The Administrator stated the task to complete was not added as part of the electronic medical record system.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice failed to ensure that medications necessary to meet the needs of the patient were identified in the patient's plan of care. Record #4 was reviewed and identified the patient elected hospice care on 5/25/2022. The review of the clinical record revealed the patient's medications were not documented on the initial and current plans of care dated 5/25/2022 through 8/22/2022. In addition, a medication profile was missing from the clinical record as of 8/11/2022. The Administrator confirmed the patient's medications were not entered on the drug profile during an interview and a joint review of the record on 8/11/2022.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed revealed the hospice failed to ensure the medical supplies were identified in the patient's plan of care. Record #1 was reviewed and identified the patient elected hospice care on 5/11/2022. The review of the record revealed patient received incontinent briefs, wet wipes and gloves. The supplies were not documented on the initial plan of care dated 5/11/2022 through 8/8/2022 or the recertification plan of care dated 8/9/2022 through 11/06/2022. Record #2 was reviewed and identified the patient elected hospice care on 5/12/2022. The review of the record revealed patient received tube feeding supplies. The tube feeding supplies were not documented on the initial plan of care dated 5/12/2022 through 8/9/2022. The Administrator confirmed the medical supplies were missing on the plans of care during an interview and a joint review of the records on 8/11/2022.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 2 (50%) records reviewed of patients who died did not contain a bereavement plan of care for the bereaved with a documented bereavement risk level. Record #2 was reviewed and identified that the patient elected hospice care and died on 5/12/2022. The interdisciplinary team meeting dated 6/8/2022 contained documentation by the registered nurse that the bereaved was a low bereavement risk. A bereavement plan of care was missing and there was no documentation of interventions completed. During an interview with the Bereavement Coordinator (BC) on 8/10/2022, the BC stated that a phone call and text were completed twenty-four (24) hours after the death, with no response from family. The attempted phone call and text were not documented in the record. The agency's policy "Bereavement Counseling Services', stated in part, "upon patient's death, the Bereavement Coordinator will open the bereavement plan of care for each bereaved and document the problem, risk level identified, goals and interventions to meet the needs of the bereaved." During an interview on 8/10/2022, the Administrator stated the patient was on service for one day, and the family was low bereavement risk. The Administrator confirmed during a joint record review that the bereavement plan of care and documentation was missing. On 8/11/2022, Administrator stated that the bereavement plan of care had been initiated and the three (3) month mailing had been scheduled.

It is required that organization policy and procedure states the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications; and a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications; and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. This standard was not met as evidenced by a review of documents and interviews. The agency failed to ensure that a policy and procedure stated the requirements for a medical and a spiritual exemption to be fully vaccinated for COVID-19. The agency did provide evidence of a spiritual exemption form for employees to complete, but not a medical exemption form. The agency did not have the written process and procedure of how and who will review and approve the submitted exemptions. During an interview the Administrator stated that all employees hired have been fully vaccinated and exemption process has not been applicable. The Administrator understood that a policy and procedure for exemptions does need to be formally in place. The agency failed to have a policy and procedure stating the requirements for a medical and a spiritual exemption to be fully vaccinate for COVID-19. The agency did have a spiritual exemption form for employees to complete, but not a medical exemption form. The agency did not have the written process and procedure of how and who will review and approve the submitted exemptions. Interview with the Administrator stated the all employees hired have been fully vaccinated and exemption process has not been applicable. Administrator understood that a policy and procedure for exemptions does need to be formally in place.