Every finding on record at Hope Care Hospice, Inc.

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 clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary group (IDG), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 3: The patient elected the hospice benefit on 04/06/2024. Clinical record review revealed the initial Social Worker visit and psychosocial assessment was dated 04/12/2024, six days after the election of hospice care and one day outstanding. There was no documented evidence in the clinical record that the initial psychosocial assessment was completed within five days of the election of the hospice benefit. Clinical Record 14: The patient elected the hospice benefit on 07/08/2023. Clinical record review revealed the initial Social Worker visit and psychosocial assessment was dated 07/15/2023, seven days after the election of hospice care and two days outstanding. There was no documented evidence in the clinical record that the initial psychosocial assessment was completed within five days of the election of the hospice benefit. During an interview on 01/09/2025, the Alternate Administrator/Licensed Vocational Nurse and the Director of Patient Care Services/Registered Nurse/Volunteer Coordinator agreed the members of the IDG did not complete an initial comprehensive assessment no later than 5-calendar days after the election of hospice care, or had documentation supporting the patient and/or family/caregiver refused or delayed social work services no later than five calendar days after the election of hospice 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 interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The initial nursing assessment dated 08/02/2024 included documentation that the patient had bladder incontinence with no indication that an indwelling foley catheter was present. The POC dated 08/02/2024 included the goal "Patient will not develop infection related to foley catheter use." The goal on the POC was not individualized to the patient when the patient did not have a foley catheter. Clinical Record 2: The initial nursing assessment dated 09/02/2025 included documentation that the patient had bladder incontinence with no indication that an indwelling foley catheter was present. The POC dated 09/02/2024 included the goal "Patient/family will demonstrate understanding of catheter use." The goal on the POC was not individualized to the patient when the patient did not have a foley catheter. During an interview on 01/10/2025, the Alternate Administrator/Licensed Vocational Nurse and the Director of Patient Care Services/Registered Nurse/Volunteer Coordinator agreed the plans of care did not include individualized patient goals.

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 described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients that transferred to the hospital and revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the receiving facility (hospital). Clinical Record 7: Clinical record review revealed the patient revoked the hospice benefit on 12/20/2024 and transferred to the hospital to pursue aggressive treatment. There was no documented evidence in the clinical record that the discharge summary was sent to the receiving facility (hospital). During an interview on 01/10/2025, the Alternate Administrator/Licensed Vocational Nurse and the Director of Patient Care Services/Registered Nurse/Volunteer Coordinator agreed the clinical record did not include evidence that the discharge summary was sent to the hospital.

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 and interview. In 4 of 5 (80%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 7: The patient revoked the hospice benefit on 12/20/2024 to pursue aggressive treatment with the patient's primary care provider (PCP). There was no documented evidence in the clinical record that the discharge summary was sent to the patient's PCP. Clinical Record 8: The patient revoked the hospice benefit on 10/17/2024 to pursue aggressive treatment with the patient's PCP. There was no documented evidence in the clinical record of the discharge summary being forwarded to the patient's PCP. Clinical Record 9: The patient revoked the hospice benefit on 10/15/2024 to pursue aggressive treatment with the patient's PCP. There was no documented evidence in the clinical record that the discharge summary was sent to the patient's PCP. Clinical Record 14: The patient revoked the hospice benefit on 06/30/2024 to pursue aggressive treatment with the patient's PCP. There was no documented evidence in the clinical record that the discharge summary was sent to the patient's PCP. During an interview on 01/10/2025, the Alternate Administrator/Licensed Vocational Nurse and the Director of Patient Care Services/Registered Nurse/Volunteer Coordinator agreed the clinical records did not include evidence that the discharge summaries were sent to the receiving physician(s).

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 clinical record review, document review and interview. One of 5 (20%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Record #33110: election of hospice benefit dated 01/12/2022. The patient was admitted on 01/12/2022. The RN documented the initial comprehensive assessment on 01/12/2022. The SC documented the initial spiritual assessment on 01/18/2022 (6 days after the election of hospice care). The SW documented the initial social work assessment on 01/20/2022 (8 days after the election of hospice care). Agency policy 1-014 Comprehensive Assessment (revision dated 11/2020) states "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." Interview and record review with the Director of Patient Clinical Services on 2/23/2022 confirmed this finding.