Every finding on record at Hebrew Seniorlife Hospice Care, Inc.

It is required that during the initial assessment visit and in advance of providing care, the hospice provides the patient or his or her representative with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities, and this information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's or representative's signature was obtained confirming that he or she received a copy of the Bill of Rights and Responsibilities statement during the initial assessment. CLINICAL RECORD 12: A review of the clinical record revealed that the initial comprehensive assessment was documented on 02/19/2025. The "Admission Consent" form, which included acknowledgment of receipt of the Patient's Rights and Responsibilities, was signed by the patient's representative and dated 02/28/2025. The representative's signature confirming receipt of the Patient's Rights and Responsibilities was not obtained during the initial assessment, before the initiation of care. The Clinical Manager (Personnel Record 2) was interviewed on 06/26/2025 and stated, "The consent was emailed to [the patient's representative]. The form may have been misdated."

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 clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that evaluated for duplicate drug therapy. CLINICAL RECORD 1: A clinical record review revealed that the plan of care (POC) dated 05/12/2025-07/10/2025 included orders for Acetaminophen Extra Strength 500mg oral tablets, 1-2 tables every 8 hours as needed for fever/discomfort AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for fever. Comprehensive assessments were documented and dated on 05/13/2025, 05/27/2025, and 06/10/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. CLINICAL RECORD 3: A clinical record review revealed that the plan of care (POC) dated 05/26/2025-08/23/2025 included orders for Acetaminophen Extra Strength 500mg oral tablets, 1-2 tables every 8 hours as needed for pain or fever AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for fever. Comprehensive assessments were documented and dated on 05/20/2025, 05/27/2025, and 06/10/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. CLINICAL RECORD 4: A clinical record review revealed that the plan of care (POC) dated 06/19/2025-08/17/2025 included orders for Acetaminophen Extra Strength 500mg oral tablets, two tablets three times a day as needed for pain AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for elevated temperature. Comprehensive assessments were documented and dated on 05/13/2025, 05/27/2025, and 06/10/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. CLINICAL RECORD 5: A clinical record review revealed that the plan of care (POC) dated 05/19/2025-08/16/2025 included orders for Acetaminophen Extra Strength 500mg oral tablets, one tablet two times a day as needed for pain AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for elevated temperature. Comprehensive assessments were documented and dated on 05/19/2025, 05/27/2025, and 06/10/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. CLINICAL RECORD 6: A clinical record review revealed that the plan of care (POC) dated 06/05/2025-09/02/2025 included orders for Acetaminophen 500mg oral tablets, two tablets every 8hoursas needed for pain (Discontinue As Of 06/05/2025), acetaminophen 500mg oral tablets 2 tablets every 4 hours as needed for pain and discomfort, AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for elevated temperature. Comprehensive assessments were documented and dated on 06/05/2025 and 06/10/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. CLINICAL RECORD 8: A clinical record review revealed that the plan of care (POC) dated 04/15/2025-07/23/2025 included orders for Acetaminophen 325mg oral tablets, three tablets as needed for pain/fever AND acetaminophen 650mg rectal suppository, 650mg per rectum (PR) every 4 hours as needed for elevated temperature. Comprehensive assessments were documented and dated on 05/06/2025, 05/20/2025, 06/03/2025, and 06/17/2025. There were no interim orders present in the record for any change to the acetaminophen dosage. The medication profile dated 06/24/2025 also included both doses of acetaminophen. The documented comprehensive assessments did not include or document the identification of duplicate drug therapy. The Clinical Manager (Personnel Record 2) was interviewed on 06/26/2025 and agreed with the findings.

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 13 of 14 (93%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: Clinical record review revealed that the plan of care (POC) dated 05/12/2025-07/10/2025 included 14 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 3: Clinical record review revealed that the plan of care (POC) dated 05/26/2025-08/23/2025 included 17 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 4: Clinical record review revealed that the plan of care (POC) dated 06/19/2025-08/17/2025 included 18 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 5: Clinical record review revealed that the plan of care (POC) dated 05/19/2025-08/16/2025 included 15 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 6: Clinical record review revealed that the plan of care (POC) dated 06/05/2025-09/02/2025 included 16 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 9: Clinical record review revealed that the plan of care (POC) dated 06/01/2025-07/30/2025 included 14 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 10: Clinical record review revealed that the plan of care (POC) dated 06/18/2025-08/16/2025 included 17 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 11: Clinical record review revealed that the plan of care (POC) dated 10/28/2024-01/25/2025 included 10 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 13: Clinical record review revealed that the plan of care (POC) dated 12/31/2024-03/27/2025 included 9 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 14: Clinical record review revealed that the plan of care (POC) dated 04/05/2025-06/03/2025 included 20 goals. The POC did not include measurable outcomes anticipated from implementing and coordinating the plan of care. The Clinical Manager (Personnel Record 2) was interviewed on 06/26/2025 and validated, "The goals on these care plans are not measurable."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. The written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed where a hospice aide was ordered on the plan of care, the agency did not ensure that the written patient care instructions for a hospice aide were prepared by an RN who was responsible for the supervision of the hospice aide. CLINICAL RECORD 11: A record review revealed that the Plan of Care dated 10/28/2024-01/25/2025 included orders for a Hospice Aide (HA) with a visit frequency of one visit per week for one week, then two visits per week. There was one documented HA visit on 11/01/2024. There was no documented aide plan of care present in the clinical record. The registered nurse who was responsible for the supervision of the HA did not create an aide plan of care. The Clinical Manager (Personnel Record 2) was interviewed on 06/23/2025 and stated, "This patient ended up declining aide services, but there is no aide plan of care in the chart for this patient."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) discharge records reviewed, the agency did not ensure that a discharge summary was created that included treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or the receiving facility or the attending physician requests that. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 12/22/2021. Documentation in a telephone note dated 05/10/2025 stated that the patient's caregiver called to notify the agency that the patient had fallen and was admitted to the hospital. A signed revocation was present in the chart dated 05/10/2025, and the patient was discharged from hospice. There was no discharge summary present in the clinical record. The agency did not create a discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or the receiving facility or the attending physician requests that. The Clinical Manager (Personnel Record 2) was interviewed on 06/26/2025 and stated, "We looked at the chart and there is no discharge summary."

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: The patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. 8 of 8 (100%) records reviewed revealed that the agency did not ensure that patient's/family's goals for pain management was assessed. . Clinical Records 2, 3, 6, 7, 8, 9, 10, and 13: The comprehensive pain assessment utilized by the agency, beginning with the change in electronic medical record systems (implemented February 2022), did not address the patient/ family goal for pain. The care plan goal for these patients stated "patient or caregiver will report that pain is at an acceptable level," but did not define an acceptable level. In an interview on 9/8/22, the Clinical Director (Staff 10) reported the agency was unable to locate, within the comprehensive pain assessment or the patient's plan of care, anything that specifically showed how the patient's/family's goal was determined or defined. It was also reported that the agency changed electronic medical record systems in February 2022, and did not realize the comprehensive pain assessment did not include all required elements. The comprehensive pain assessment utilized by the agency, beginning with the change in electronic medical record systems (implemented February 2022), did not address the patient/ family goal for pain; furthermore the care plan goal, for these patients, stated "patient or caregiver will report that pain is at an acceptable level" but did not define an acceptable level. This impacted the following records: 2, 3, 6, 7, 8, 9, 10, and 13.