Every finding on record at Family Care Hospice Inc.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 11/01/2024. The plan of care dated 11/01/2024 through 01/29/2025 included an order for "HA [Hospice Aide] 2 times per week starting 11/19/2024." There was no documented evidence in the clinical record that the HA provided visits the week of 11/17/2024 to 11/23/2024. Clinical record review revealed the HA provided one visit on 12/04/2024 for the week of 12/01/2024 to 12/07/2024. The HA did not provide visits twice a week as ordered on the plan of care. The clinical record did not include documentation of missed visit notes for the weeks of 11/17/2024 to 11/23/2024 and 12/01/2024-12/07/2024. Clinical Record 6: The patient elected the hospice benefit on 10/19/2024. The plan of care dated 12/18/2024 through 02/15/2025 included an order for "HA 2 times per week." Clinical record review revealed the HA provided one visit on 12/24/2024 for the week of 12/22/2024 to 12/28/2024 and one visit on 01/10/2025 for the week of 01/05/2025 to 01/11/2025. There was no documented evidence of HA visits for the week of 12/29/2024 to 01/04/2025. The HA did not provide visits twice a week as ordered on the plan of care. The clinical record did not include documentation of missed visit notes for the weeks of 12/22/2024 to 12/28/2024, 12/29/2024 to 01/04/2025, and 01/05/2025 to 01/11/2025. Clinical Record 13: The patient elected the hospice benefit on 11/20/2024. The plan of care dated 11/20/2024 through 01/27/2025 included an order for "HA 2 times per week." Clinical record review revealed no documented evidence of HA visits for the weeks of 11/17/2024 to 11/23/2024 and 11/24/2024 to 11/30/2024 and no documented evidence of missed visit notes for the weeks of 11/17/2024 to 11/23/2024 and 11/24/2024 to 11/30/2024. During joint record reviews and interview on 04/02/2025, the Director of Patient Care Services confirmed the findings and stated, "We do not have any missed visit documentation for these missed aide visits."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide was supervised by a Registered Nurse no less frequently than every 14 days. Clinical Record 9: The patient elected the hospice benefit on 01/09/2025. The plan of care dated 01/09/2025 through 04/08/2025 included an order for "HA [Hospice Aide] 2 times per week." Clinical record review revealed a HA supervisory visit was completed on 01/31/2025 and the next HA supervisory visit was dated 02/17/2025, a total of 17 days and 3 days outstanding. The next HA supervisory visit was dated 03/03/2025, however there was no documented evidence of HA supervisory visits being completed after 03/03/2025, as of the date of record review on 04/01/2025. During a joint record review and interview on 04/01/2025, the Director of Patient Care Services confirmed that the hospice aide supervisory visits were not completed every 14 days.