Every finding on record at Healing Hands Hospice Care, Inc.

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 clinical record review and interview. In 1 of 5 (20%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide reported changes related to the plan of care to the Registered Nurse. CLINICAL RECORD 4: The aide care plan dated 01/10/2026 assigned the aide the bathing task of "Shower" every visit. The aide frequency of visits was ordered two (2) times per week. The aide documented on the visit notes dated 01/21/2026 and 01/23/2026 a check mark next to the task "Shower" and in the comments the aide wrote, "Bed bath provided." The record did not include documentation as to the reason a "Shower" was not completed by the aide and did not include documentation that the Hospice Aide notified the Registered Nurse of the changes in the patient's medical needs related to the ordered bathing task of "Shower." The Director of Patient Care Services and the Licensed Vocational Nurse stated in an interview on 04/21/2026, while completing joint clinical record review, that they both agreed the aide did not notify the registered nurse about the changes in the patient's medical needs as related to not completing the bathing task, "Shower" that was ordered on the aide care plan.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that revoked the hospice benefit to pursue curative treatment at the hospital, the agency did not ensure the hospice discharge summary was forwarded to the receiving facility/hospital. CLINICAL RECORD 7: The patient and family revoked the hospice benefit on 12/14/2025 to pursue curative treatment at the hospital. There was no documented evidence that the agency forwarded the discharge summary to the receiving facility/hospital. The Director of Patient Care Services and the Licensed Vocation Nurse stated in an interview while performing joint clinical record reviews on 04/21/2026 that they both agreed the clinical records for the patients that revoked the hospice benefit to pursue curative treatment at the hospital was missing evidence that the discharge summary was forwarded to the receiving facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation 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 3 (67%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient and family revoked the hospice benefit on 02/25/2026 because they felt the patient had stabilized. There was no documented evidence that the agency forwarded the hospice discharge summary to the patient's attending physician. CLINICAL RECORD 8: The patient and family revoked the hospice benefit on 03/19/2026 to pursue curative treatment. There was no documented evidence that the agency forwarded the hospice discharge summary to the patient's attending physician. The Director of Patient Care Services and the Licensed Vocational Nurse stated in an interview while performing joint clinical record reviews on 04/21/2026 that they both agreed the clinical records for the patients that revoked the hospice benefit were missing evidence that the hospice discharge summaries were forwarded to the patient's attending physician.

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. This standard was not met as evidenced by clinical record review, document review and interview. 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. Agency Policy #1-021, "Bereavement Assessment (Dated: 11/2020)," stated in part, "Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator." Clinical Record 1: The patient elected the hospice benefit on 4/27/23. The clinical record did not include documented evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 4/27/23. The clinical record did not include documented evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 5/9/23. The clinical record did not include documented evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment. In an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed the clinical records did not include an initial bereavement assessment.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the skilled nursing (SN) visits were completed as ordered on the patient's individualized plan of care (POC). Agency Policy #9-017, "The Plan of Care (Dated 11/2020)," stated in part, "Policy: 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." Clinical Record 1: The patient elected the hospice benefit on 4/27/23. The SN visit frequency ordered was 1x/wk starting the week of 4/30/23. The clinical record did not include documented evidence that a Licensed Vocational Nurse (LVN) visit was provided the week of 4/30/23. The patient refused the visit on 5/11/23; the patient was scheduled for a visit on 5/18/23. Clinical Record 2: The patient elected the hospice benefit on 4/27/23. The SN visit frequency ordered was 1x/wk starting the week of 4/30/23. The clinical record did not include documented evidence that an LVN visit was provided the week of 4/30/23. The patient refused the visit on 5/11/23; the patient was scheduled for a visit on 5/18/23. In an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed the agency did not ensure that SN visit frequencies were being completed as ordered on the POC.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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, document review and interview. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure the patient's individualized POC included goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy #9-017, "The Plan of Care (Dated: 4/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group . . . This plan will focus on identified problems, goals, and interventions." Clinical Record 3: The patient elected the hospice benefit on 5/9/23. The initial nursing assessment dated 5/9/23 stated the patient was on 2 LPM of oxygen continuous use. The interdisciplinary group POC dated 5/9/23 did not include documented evidence of a goal and interventions related to the oxygen. In an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed that the POC did not include documentation of a goal and interventions for oxygen.

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 physician orders. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure a physician order was written for care and treatment provided to the hospice patient. Agency Policy #2-002, "Verification of Physician Orders (Dated: 11/2020)," stated in part, "Policy: Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients." Clinical Record 3: The patient elected the hospice benefit on 5/9/23. The initial nursing assessment narrative and the certificate of terminal illness dated 5/9/23 stated the patient was on Oxygen 2 LPM continuous. The clinical record did not include documented evidence of a physician order for Oxygen. in an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed the patient was on oxygen, and the record did not include a physician order for the oxygen.

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, document review and interview. 2 of 2 (100%) clinical records reviewed of discharged patients revealed the agency did not ensure that a copy of the hospice discharge summary was sent to the patient's attending physician. Agency Policy: Policy #1-025, "Discharge from Hospice Program (Dated: 11/2020)," stated in part, "Procedure: 9. A copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." Clinical Record 5: The patient elected the hospice benefit on 10/9/21. The patient was discharged on 11/12/21 for no longer being qualified to receive the hospice benefit. The clinical record did not include documented evidence that a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 4: The patient elected the hospice benefit on 10/9/21. The patient was discharged on 11/12/21 for no longer being qualified to receive the hospice benefit. The clinical record did not include documented evidence that a copy of the discharge summary was forwarded to the patient's attending physician. In an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed that the agency did not forward the discharge summary to the patients' attending physicians.

It is required that hospice staff, in coordination with SNF/NF or ICF/IDF staff, ensures orientation and training of staff providing care to hospice patients. At a minimum, the orientation and training includes: 1. Introduction to hospice philosophy; 2. Hospice policies and procedures regarding methods of comfort, pain control, and symptom management; 3. Principles about death and dying, and individual responses to death; 4. Patient rights; and 5. Appropriate forms and record keeping requirements. This standard was not met as evidenced by document review and interview. The agency did not ensure orientation and training of the contracted skilled nursing facility staff that would provide respite and general inpatient care if the agency patients require such care. Per the "Nursing Facility Services Agreement": 3. Responsibilities of the Hospice C. Hospice-Care Training: Hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. Hospice shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients and Facility shall ensure all such personnel attend the hospice care training. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements." The agency did not ensure this Education and Training was completed with the contracted facility. Agency Policy #1-030, "Provision of Care to Residents of SNF/NF or ICF/IID (Dated: 11/2020)", stated in part, "Procedure: 8. Hospice agency will consult with the SNF/NF or ICF/IID regarding the shared orientation and training responsibilities of staff furnishing care to patients, including: A. Hospice Philosophy; B. Hospice policies and procedures regarding methods of comfort, pain control, symptoms management, and postmortem care; C. Principles about death and dying and individual responses to death; D. Patient Rights; and E. Appropriate forms and record keeping requirements." in an interview on 5/18/23, the Administrator/Director of Patient Care Services Designee reviewed the findings and agreed the agency did not ensure the required orientation and training of staff at the contracted facility that would be providing care to hospice patients that are moved to either respite care or general inpatient care. The agency did not ensure orientation and training of the contracted skilled nursing facility staff that would provide respite and general inpatient care if the agency patient's require such care.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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 document review in which 2 of 6 (33%) records reviewed revealed a lack of goals and interventions for relevant treatment. Record #91849: The certificate of terminal illness (CTI) dated 12/11/21 for the certification period of 12/12/21 through 2/9/22 stated that the patient has bowel and bladder incontinence. The Interdisciplinary Group (IDG) Plan of Care (POC) dated 12/17/21 lacked a goal and interventions for bowel and bladder incontinence. Record #69042: The CTI dated 10/9/21 for the certification period of 10/9/21 through 12/7/22 stated that the patient has gouty arthritis. The IDG POC dated 10/22/21 lacked a goal and interventions for gouty arthritis. The Director of Patient Care Services reviewed and agreed with the above findings. Policy #9-017 (Dated 11/2020), "The Plan of Care", states in part, "This plan will focus on identified problems, goals, and interventions."

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 document review and clinical record review. 3 of 3 (100%) records revealed that for patients who revoked hospice care, the hospice did not ensure that the discharge summary was sent to the attending physician. Record #69042: The patient revoked services on 11/12/21 due to no longer wanting hospice services. A discharge summary was completed on 11/12/21. The record lacks evidence of the discharge summary, and required components being sent to the attending physician. Record #42645: The patient revoked on 11/18/21 due to no longer wanting hospice services. A discharge summary was completed on 11/18/21. The record lacks evidence of the discharge summary, and required components being sent to the attending physician. Record #63348: The patient revoked on 11/12/21 due to no longer wanting hospice services. A discharge summary was completed on 11/12/21. The record lacks evidence of the discharge summary, and required components being sent to the attending physician. The Director of Patient Care Services reviewed and agreed with the above findings. Policy #1-024 (Dated 11/2020), "Revocation of Hospice Benefit ”, states in part, ”The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician."