Every finding on record at Expert Hospice Care Inc

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: Patient has left hip wound (closed 3x3x0.1 cm), left buttocks wound (closed 2.0x2.0x0.1cm) and coccyx pressure wound (stage II 1x0.2x0.2cm). The nurse ordered an alternating air pressure mattress on 2/27/25 (nurse visit was 2/26/25). The equipment was not present during home visit on 3/3/25. Patient has developed new Stage 1 to right hip. There was no indication in patient record for the delay in DME delivery. The agency followed up during survey and indicated that the air mattress would be delivered 3/3/25 between 2p-6p.

Upon patient record review, 1 of 5 (Patients #3) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #3: On routine nursing visit (2/24/25), the patient record indicated a BP reading of 179/57.  There was no indication in patient record that a second BP reading was taken, the physician notified or any other interventions.  Patient has a diagnosis of  End Stage 5- Renal disease. Medication profile indicates patient has Coreg and amlodipine on hand.

Upon patient record review, 2 of 5 (Patients #4,5) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #4: On admission (2/28/25), the patient record indicated a BP reading was 171/70 (left arm-sitting). There was no indication in patient record that a second BP reading was taken, ALF staff collaboration any other interventions.  Patient medication profile at SOC included losartan. Patient #5: On admission (3/1/25), the patient record indicated BP reading was 220/87 (left arm-lying). There is no indication in patient record that a second BP reading was taken, the ALF staff collaboration or any other interventions.  Patient has a history of CVA.  Patient medication profile at SOC indicates the patient had metoprolol tartrate.

Upon patient record review, 5 of 5 (Patients 1,2,3,4,5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients 1,2,3,4,5: The election statement did not have Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contact information on the form.

Upon patient record review, 1 of 5 (Patient #1) 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 #1: The nursing visit(s) indicated to obtain left mid-arm circumference (LMAC) every visit. There were variations in this measurement as follows. -On 2/24/25, the LMAC reading was 19cm -On 2/26/25, the LMAC reading was 25cm and patient eating less than 50% of meals. The NP stated this reading was an error and removed this entry from EMR during survey. -On 3/3/25, the LMAC reading on home visit was 17.5 cm. The nurse did not remove the sleeve protector when taking this measurement and verbally indicated patient LMAC fell from 19cm to 16cm since her last visit on 2/24/25.

Condition of Participation: Patient’s rights. The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #4, No evidence of patient right to effective pain management and symptom control was provided to patient.

Upon patient record review, there was no evidence the patient has the right to be free of mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property. Patient #4, No evidence patient right to be free of neglect and mistreatment was prevented.

Upon patient record review 2 of 16 (Patient #2,10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2, SC initial assessment completed on 11/29/24, seven days after start of care. No evidence SC assessment was completed within 5 days. Patient #10, MSW initial assessment completed on 4/16/24, start of care was on 4/9/24. No evidence MSW assessment was completed within 5 days.

Upon patient record review 1 of 16 (Patient #7) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7, SC initial assessment refused, no evidence that the RN completed the spiritual assessment.

Upon patient record review, 4 of 16 (Patient #2,6,7,10) 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 #2,6,7,10, No evidence of bereavement assessment completed.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4, No evidence of RN continued assessment and coordination with members of the IDG.

Upon patient record review, 2 of 16 (Patient #4,8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4, No evidence of documentation of initial Plan of Care including goals and interventions to address coccyx wound and bilateral heel wounds. Patient #8, No evidence of psych-social care plan addressing patient's full code status.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #4, No evidence of interventions for pain and symptoms management for deep coccyx wound and bilateral heel wounds in patient chart.

Upon patient record review, 1 of 16 (Patient #4) 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 #4, No evidence of wound care orders in patient chart for deep coccyx wound and bilateral heel wounds.

Upon patient record review, 8 of 16 (Patient #1,2,3,4,5,8,9,10) 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 equipment and supply needs. Patient #1,2,3,4,5,8,9,10, No evidence of DME equipment listed on the Plan of care.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #4, No evidence of Plan of Care was updated for deep coccyx wound and bilateral heel wounds.

Upon patient record review, 2 of 16 (Patient #3,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3, No evidence visits followed the SC frequency of 1x/month and 3 PRN. SC visits completed on 12/6/24 and 12/30/24, both visits were documented as scheduled visits. Patient #7, SC frequency 1x/month with 3 PRN every 30 days. No evidence to change frequency since patient declined SC visits.

Upon patient record review 1 of 16 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #4, No evidence of care provided based on assessment of the patient needs.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #4, No evidence of documentation to reflect coordination of care with Wound Pro or facility.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patient #4, There was no evidence of hospice providing core services with the patient requiring wound care related to the hospice diagnosis. There was no evidence that the coccyx wound and bilateral heel wounds were unrelated to the hospice diagnosis. The agency has a contract with Wound Pros for wound care. In addition, there was no evidence of the hospice providing nursing services in a manner consistent with standards of practice. There was no evidence of SN managing deep coccyx wound and bilateral heel wounds that occurred after admission to the hospice.

Upon patient record review, 1 of 16 (Patient #4) did not have evidence the hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient's attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: 1. All physician employees and those under contract must function under the supervision of the hospice medical director. 2. All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. 3. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. Patient #4, No evidence of MD involvement with deep coccyx wound and bilateral heel wounds in order to meet the medical needs of the patient.

Upon observation, there was no evidence the hospice provides nursing care and services by or under the supervision of a Registered Nurse. Patient #4, No evidence of wound care for deep coccyx wound and necrotic heels being provided by or under the supervision of the Registered Nurse. No documentation of wound care orders were documented in the EMR. The hospice agency was provided with pictures on 12/23/24 of pictures of the deep tissue coccyx wound and right heel with necrotic tissue picture. Alt Administrator made a referral to Wound Pro on 12/23/24. SN made scheduled visits every two weeks to see patient. There was no evidence of change in frequency of visits by nursing and/or wound care provided. Wound Pro did not make a visit until 1/6/25.

Upon patient record review, 6 of 16 (Patient #1,4,5,6,9,10) 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 #1, No evidence on the care plan when the partial bath and bed bath should be given during the week. Patient #4, Aide frequency 2x/week and 3 PRN for needs. No indication of PRN listed. In addition, there is no evidence of Foley catheter and nephrostomy tubes documented on the care plan with no directions of care. Patient #5, Aide frequency 2x/week, first visit completed on 11/22/24, 10 days after the start of care. RN assigned both bed bath and partial bath without evidence of directions for bathing. Patient #6, Aide frequency 2x/week. No evidence of visits completed in the first week. First visit completed on 12/11/24, 9 days after start of care. Patient #9, Aide frequency 2x/week. No evidence of visits completed in the first week. First visit completed on 8/6/24. Patient #10, Aide frequency 3x/week 3 PRN. No indication of PRN listed.

Upon patient record review 1 of 16 (Patient #5) 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 #5, Aide care plan directions for bed bound and reposition, document output, urine catheter, complete bed bath, complete partial bath were not completed by the aide as evidence of missing check marks on the visit form.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

Upon observation, there was no evidence the hospice provides care directly or under contract that optimizes comfort and dignity of the patient and is consistent with the patient/ family needs and goals. The patient needs and goals are a priority. Patient #4, There was no evidence of hospice nurses managing deep coccyx wound and bilateral heel wounds that occurred after admission to the hospice.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by the inability to provide core services for a patient requiring wound care related to the hospice diagnosis. There was lack of supervision of nursing services by the hospice administrator with no evidence of the hospice providing nursing services in a manner consistent with standards of practice. There was no evidence of hospice nurses managing deep coccyx wound and bilateral heel wounds that occurred after admission to the hospice. There is lack of agency oversight of medical and nursing services ensuring that patients have symptom control and are free of pain, neglect, and mistreatment. In addition, nursing services are not being provided in a manner to ensure continuous assessment of the patient and coordinating with other members of the IDG for the supervision and care of the patient.

Upon contract review, 1 of 4 (#2, Alt Medical Director Contract) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable Contract#2: No evidence of Alt Medical Director was contracted or employed until the last day of the survey.

Upon patient record review, 6 of 16 (Patient #2,3,4,5,7,9) 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 #2,3,4,5,7,9, No evidence of completion of form stating what was covered under hospice or not. Form was signed and dated.

Upon patient record review, 2 of 16 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11, #12, No evidence of discharge summary was sent to MD.

Upon patient record review, 2 of 16 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11, #12, No evidence of a discharge summary in the chart.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13, No evidence of a Speech Therapy HR record.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12, No evidence of a Occupational Therapy HR record.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #11, No evidence of a Physical Therapy HR record.

Upon personnel record review, 3 of 13 (Personnel #11,12,13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 11, 12, 13: No evidence of criminal background checks.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 5: The medication profile contained cetirizine 10 mg with dose identified incorrectly as 1 puff. Medication form is tablet to be consumed by mouth, not an inhaler.

Upon patient record review, 3 of 5 records (Patients #3,#5) 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 3: The medical record contains nursing documentation upon admission and care planning identifying patient requires foley catheter care. There was no evidence of physician treatment orders to identify catheter size and frequency of changes needed. Corrected on site. Patient 5: The medical record contained a physician order for cetrizine 10 mg with dose identified incorrectly as 1 puff. Medication form is tablet not inhaler.

Upon patient record review 1 of 1 applicable record (Patient #4) 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 Patient 4: The medical record contains aide visits identifying oral care and cleansing of dentures was completed 1/6/22, 1/8/22, 1/11/22, 1/13/22, and 1/18/22. The aide care plan does not contain task of oral care and cleansing dentures assigned by the RN.

Upon patient client record review, 2 of 5 records (Patients #2,#5) 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 2: The medical record contained an initial bereavement assessment dated 1/16/22, prior to hospice admission 1/22/22. Leadership verified with the social worker who completed the bereavement assessment that the date 1/16/22 was entered in error and visit was completed 1/24/22 along with initial MSW psychosocial assessment that was dated accurately 1/24/22. Documentation was corrected on site with MSW acknowledging error and correcting date she completed the visit. Patient 5: The medical record contains physician order and documentation stating patient refused home health aide services. The care plan identifies aide frequency of twice weekly. Leadership confirms frequency was a data entry error on the care plan. There was no evidence aide services were ordered by the physician and no visits occurred.