Every finding on record at Goodwin House Palliative Care and Hospice

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 1 of 13 (8%) clinical records reviewed with hospice aide services, the agency did not ensure the hospice aide provided services as ordered in the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025. The plan of care dated 04/03/2025 to 07/01/2025 included an order for hospice aide frequency of three times per week. A physician order dated 06/01/2025 changed the hospice aide frequency of visits to twice a week. Clinical record review revealed the hospice aide provided visits three times a week for the weeks of 06/01/2025 to 06/07/2025, 06/08/2025 to 06/14/2025, 06/15/2025 to 06/21/2025, and 06/22/2025 to 06/28/2025. During an interview on 07/09/2025, the Administrator stated that the visit frequency was never decreased to two times a week from three times a week, but that the clinical staff is fairly new and still learning the electronic medical record.

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 4 of 13 (31%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide was supervised by the Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/02/2025. The physician ordered Hospice Aide frequency two times a week starting on 06/03/2025. Clinical record review revealed one aide supervisory visit dated 07/07/2025. There was no documented evidence of an aide supervisory visit from 06/03/2025 through 07/06/2025, a total of 34 days and 20 days outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/25/2021. The plan of care for the benefit period dated 04/06/2025 to 06/04/2025 included an order for hospice aide frequency three times per week. The clinical record included documentation of hospice aide visits that were provided as ordered, three times per week. There was no documented evidence in the clinical record that the Registered Nurse completed aide supervisory visits for the benefit period dated 04/06/2025 to 06/04/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/16/2024. The plan of care for the benefit period dated 02/20/2025 to 05/20/2025 included an order for hospice aide visit frequency of two times a week. Clinical record review revealed an aide supervisory visit was documented on 01/23/2025 and the next aide supervisory visit was dated 03/27/2025, a total of 63 days and 49 days outstanding. There was an aide supervisory visit documented on 05/05/2025 and the next aide supervisory visit was dated 06/12/2025, a total of 38 days and 24 days outstanding. During an interview on 07/03/2025, the Administrator stated that the clinical staff is fairly new and still learning the electronic medical record and are not opening up the supervisory section to document the supervisory visit. He also stated that they will be providing additional education.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with volunteer services provided, the agency did not ensure that the volunteer services were provided as ordered in the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/30/2024. The recertification plan of care dated 03/29/2025 to 05/27/2025 included an order for volunteer services at a frequency of twice per month. Clinical record review revealed the hospice volunteer made one visit per month for March and April. The volunteer visit notes were dated 03/29/2025 and 04/26/2025. There was no documented evidence in the clinical record that the volunteer provided two visits per month for March and April as ordered on the plan of care. During an interview on 07/02/2025, the Administrator stated that he did not know how the second visit was missed during that time frame but that they would monitor the volunteer frequency more closely.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record included physician orders. CLINICAL RECORD 1: Clinical record review revealed the nursing assessment dated 07/03/2025 included documentation that the nurse inserted a 16 fr. Foley catheter. There was no documented evidence in the clinical record of a physician order to insert the Foley catheter. During an interview on 07/03/2025, the Administrator stated that the clinical staff is fairly new and were under the impression that an order was not required if a standing order was used. He stated that additional education would be provided for the clinical staff.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 6 of 13 (46%) records reviewed revealed the spiritual assessment was not completed by the interdisciplinary group within five (5) calendar days after the election of hospice care. The agency's policy #4-042.1 "Comprehensive Assessment" stated in part, "...a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least (underlined for emphasis) the following information, as relevant...(T) an assessment of the patient's and family/caregiver's spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc." Record #6 was reviewed and identified the patient elected hospice care on 4/1/2021. The initial comprehensive assessment completed by the Registered Nurse (RN) on 4/1/2022 and the Medical Social Worker (MSW) assessment completed on 4/1/2022 did not include a spiritual assessment. The clinical record was missing a spiritual assessment. Record #1 was reviewed and identified the patient elected hospice care on 5/6/2021. The initial comprehensive assessment completed by the RN on 5/6/2021 and the assessment completed by the MSW did not include a spiritual assessment. The record included evidence the spiritual counselor phone called the patient's daughter on 5/10/2021, with no return call. The spiritual counselor's follow up phone call was documented on 6/21/2021 and a visit scheduled on 7/21/2021. There was no evidence that a spiritual assessment was completed no later than five (5) calendar days after the election of hospice care and no evidence of communication with the physician and family to delay the visit until 6/21/2021. Record #7 was reviewed and identified the patient elected hospice care on 6/4/2021. The initial comprehensive assessment completed by the Registered Nurse (RN) on 6/4/2021 and the Medical Social Worker (MSW) assessment completed on 6/7/2022 did not include a spiritual assessment. There was no evidence that a spiritual assessment was completed no later than five (5) calendar days after the election of hospice care and no evidence of communication with the physician or patient. Record #2 was reviewed and identified the patient elected hospice care on 6/15/2022. A spiritual care phone call dated 6/17/2022, documented the patient's son was contacted and would "follow up." The spiritual assessment was completed on 6/28/2022, 13 days outstanding. There was no evidence of communication with the physician or patient requesting to delay the visit. Record #4 was reviewed and identified the patient elected hospice care on 7/8/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) on 7/8/2022 and the MSW assessment did not include a spiritual assessment. The spiritual assessment was completed on 7/14/2022, 6 days outstanding. There was no evidence of communication with the physician or patient requesting to delay the visit. Record #1 was reviewed and identified the patient elected hospice care on 7/1/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) on 7/1/2022 and the MSW assessment completed on 7/1/2022 did not include a spiritual assessment. The spiritual counselor documented calling the family on 7/3/2022, and leaving a message. The spiritual assessment was completed on 7/12/2022, 11 days outstanding. A communication note documented the returned phone call from patient, but included no reason or justification of the spiritual assessment delay. During an interview and a joint record review, the Director of Nursing and Compliance Officer confirmed the comprehensive spiritual assessments were not completed within the required 5 days.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This CONDITION was not met as evidenced by a review of clinical records and interview. The hospice failed to ensure that the individualized written plan of care was prepared in consultation with, and submitted to the attending physician and/or hospice medical director for review, approval, and signature [HCPC.18.I/L537]; failed to ensure that the patient’s individualized written plan of care included orders for treatments necessary to meet the needs of the patient [HCPC.21.I/L545; and failed to ensure to identify medical supplies related to the palliation and management of the patient’s terminal illness and related conditions in the plan of care [HCDT.26.I/L687]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment. THIS IS A CMS CONDITION LEVEL DEFICIENCY.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 13 of 13 (100%) records reviewed revealed the hospice did not ensure that the individualized written plan of care was prepared in consultation with, and submitted to the attending physician and/or hospice medical director for review, approval, and signature for each of the hospice patients. The agency’s policy #4-027 “The Plan of Care” (updated 11/2019), stated in part, “a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...this plan of care must be initiated at start of care… the plan of care will be provided to both the attending physician and the hospice medical director for approval of verbal orders…” Clinical Record #8: The patient elected hospice care on 7/1/2022. On 8/18/2022, the patient was discharged from the hospice due to moving out of service area. The plans of care orders were not signed by the attending physician or the hospice medical director as of 9/22/2022. There was no documented evidence that the plans of care was prepared in consultation with the attending physician or the hospice medical director. Clinical Record #1: The patient elected hospice care on 5/6/2021. A review of the written plan of care for the initial benefit period through the current benefit period (8/29/2022-10/27/2022), revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #5: The patient elected hospice care on 2/28/2022. A review of the written plan of care for the initial benefit period through the current benefit period (8/27/2022-10/25/2022), revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #9: The patient elected hospice care on 12/27/2021. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to revocation on 8/1/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #12: The patient elected hospice care on 2/25/2021. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to death on 3/23/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #6: The patient elected hospice care on 4/1/2021. A review of the written plan of care for the initial benefit period through the current benefit period (9/23/2022-11/21/2022), revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #7: The patient elected hospice care on 6/4/2021. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to death on 8/23/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #13: The patient elected hospice care on 10/08/2021. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to death on 3/9/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #2: The patient elected hospice care on 6/15/2022. A review of the written plan of care for the initial benefit period through the current benefit period (9/13/2022-12/11/2022), revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #10: The patient elected hospice care on 5/4/2022. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to revocation on 5/12/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #3: The patient elected hospice care on 9/16/2022. A review of the written plan of care for the initial benefit period, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of a physician's order and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #4: The patient elected hospice care on 7/8/2022. A review of the written plan of care for the initial benefit period, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. Clinical Record #11: The patient elected hospice care on 10/23/2021. A review of the written plan of care for the initial benefit period through the patient’s discharge, due to death on 3/31/2022, revealed the plans of care orders were not signed by the attending physician or the hospice medical director and did not include evidence of signed physician's orders. There was no documented evidence that the plans of care were prepared in consultation with the attending physician or the hospice medical director. During an interview and a joint review of the records on 9/21/2022, the Director of Nursing (Staff #9), Executive director/Administrator (Staff #10) and the Compliance Officer confirmed that the written plans of care were not submitted to the attending physician or medical director for signature. The review of the hospice agency’s electronic medical record (EMR) revealed the plans of care included the required elements and the staff accessed the plan of care in the EMR when providing care and services. The hospice agency did have elements of the plan of care documented at times in the medical record but did not generate the written plan of care for submission to the attending physician or medical director for approval signature.

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, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 13 (100%) records reviewed revealed the hospice did not ensure that patient’s individualized written plan of care included orders for treatments necessary to meet the needs of the patient. Clinical Record #2 was reviewed and identified the patient elected hospice care on 6/15/2022. Review of the skilled nursing visit notes dated 6/15/2022, 7/5/2022, 7/29/2022, 7/26/2022, 8/2/2022, 8/10/2022, 8/16/2022, 8/23/2022, 9/6/2022, and 9/19/2022, revealed the hospice nurse and the assisted living facility (ALF) nurse documented providing treatment and flushing the cholecystectomy drain tube at least every other day. During the home visit (HV#2) conducted on 9/20/2022, the Registered Nurse (RN) (Staff #6) assessed, changed the dressing of the cholecystectomy drain tube located on the right upper abdominal quadrant of patient, and connected the drain tube to the gravity drainage bag. The ALF Licensed Practical Nurse (LPN) facility nurse was present and assisted the hospice RN. There was no evidence of a physician's order in the record detailing the treatment of the cholecystectomy drain tube. During an interview and a joint record review, the Director of Nursing confirmed that there was not a physician order for the treatment of the cholecystectomy drain tube as of 9/21/2022. The physician order was later entered and signed by the Medical Director on 9/22/2022.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and document reviews. 6 of 8 (75%) records reviewed of patients receiving hospice aide services, revealed the hospice did not ensure that the hospice aide notified the registered nurse of assigned tasks that were not completed per the hospice aide care plan. The agency's policy #4-003.1 "Hospice Aide Services," stated in part, "..hospice aide duties include.. reporting changes in the patient's condition and needs... hospice aide will document care provided in accordance with the hospice aide assignment." Clinical Record #6: The patient elected hospice care on 4/1/2021. The aide care plan dated 5/26/2022, assigned the hospice aide the tasks, "every visit.. assist dress, complete shower, light housekeeping, make bed, assist ambulation, assist transfer." The aide visit note dated 5/27/2022, documented "D" (declined) for the assigned tasks: complete shower; assist ambulation; and assist in transfer. The record was missing documentation that the aide notified the registered nurse (RN) of the declined tasks. Clinical Record #4: The patient elected hospice care on 7/8/2022. The aide care plan dated 7/13/2022, ordered hospice aide services twice weekly and assigned the aide the tasks, "every visit... shower, shampoo hair, change linens, turn or position." The aide visit notes dated 7/15/2022, 7/22/2022, 7/25/2022, and 7/27/2022, documented the patient declined aide assigned tasks as ordered in the aide care plan. The record was missing documentation that the aide notified the registered nurse (RN) of the declined tasks. Clinical Record #7: The patient elected hospice care on 6/4/2021. The aide care plan dated 2/1/2022, ordered hospice aide services twice weekly and assigned the aide the tasks, "every visit... assist to dress, complete bed bath, peri-care, back rub/massage, change linens." The aide visit notes dated 2/1/2022, 2/8/2022, 2/15/2022, 2/17/2022, and 2/22/2022,documented the patient declined aide assigned tasks as ordered in the aide care plan. The record was missing documentation that the aide notified the registered nurse (RN) of the declined tasks. Clinical Record #11: The patient elected hospice care on 10/23/2021. The aide care plan dated 1/31/2022, assigned hospice aide the tasks, "every visit ..comb hair, peri-care, shower, shampoo hair, skin care, turn or position, incontinent care." The aide visit notes dated 2/1/2022 and 2/2/2022, documented the patient declined aide assigned tasks as ordered in the aide care plan. The record was missing documentation that the aide notified the registered nurse (RN) of the declined tasks. Clinical Record #10: The patient elected hospice care on 5/4/2022. The aide care plan dated 5/10/2022, ordered hospice aide services twice weekly and and assigned the aide the tasks, "every visit... assist to dress, complete bed bath, skin care, change linens" The aide visit note dated 5/10/2022, documented "D" (declined) documented "D" (declined) for the assigned tasks: assist to dress; complete bed bath; skin care; and change linens. The record was missing documentation that the aide notified the registered nurse (RN) of the declined tasks. Clinical Record #5: The patient elected hospice care on2/28/2022. had a documented aide care plan dated 3/2/2022 with assigned hospice aide tasks to be completed at every visit. The aide visit note dated 3/2/2022, documented the patient declined aide assigned tasks as ordered in the aide care plan. The patient had a documented diagnosis of Alzheimer's disease. The record was missing documentation that the aide notified the registered nurse (RN) that all of the assigned hospice aide tasks were declined by the patient.

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, the patient's record, if requested. This standard was not met as evidenced by clinical record reviews and interviews. 3 of 3 (100%) records reviewed of patients that revoked the election of hospice care or were discharged from hospice, revealed the hospice did not ensure to forward a copy of the hospice discharge summary to the patient's attending physician. Record #10 was reviewed and identified the patient elected hospice care on 5/4/2022. The patient revoked the election of hospice care on 5/12/2022. The record revealed no evidence that discharge summary or notification was completed and sent to the attending physician. Record #9 was reviewed and identified the patient elected hospice care on 12/27/2021. The patient revoked the election of hospice care on 8/1/2022, and was admitted to a local hospital. The record revealed no evidence that discharge summary or notification was completed and sent to the hospital. During an interview, the compliance officer stated the registered nurse called report to the hospital. Record #8 was reviewed and identified the patient elected hospice care on 7/1/2022. The patient was discharged from the hospice on 8/1/2022, moved out of service area. The record revealed no evidence that discharge summary or notification was completed and sent to the attending physician. During an interview, the Director of Nursing (DON) and Compliance Officer stated a template for discharge summaries was created that was emailed to the nurses to document in the event of a live discharge, however the DON confirmed the nurses were not consistently using the template.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are identified in the plan of care and checked for expiration dates. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (38%) records reviewed revealed the hospice did not ensure to identify medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions in the plan of care. Clinical Record #1 was reviewed and identified the patient elected hospice care on 5/6/2021. The patient plan of care did not include documentation of medical supplies the patient was receiving from the hospice. During an interview and a joint review of the record, the Director of Nursing confirmed the patient was receiving briefs, gloves, chux, wound care supplies, barrier cream and silicon boarder from the hospice.