Every finding on record at Hope Healthcare and Hospice, LLC

Based on record review and interview, the agency failed to provide evidence that continued contact for bereavement counseling and services were made to the family following the death of the patient for 1 (#15) out of 19 patient records reviewed. --- Findings: Review of the patient’s electronic clinical record revealed SOC (start of care) date was 08/09/2025 and the admitting diagnosis was acute leukemia.  The benefit period reviewed was 08/09/2025 to 11/06/2025. Review of the patient’s Death Summary note dated 08/15/2025 revealed the patient died at home.  Further review of the patient’s electronic clinical record revealed no evidence the patient’s family was contacted by S1BC (Bereavement Coordinator) or the agency after 08/22/2025 following the patient’s death. On 02/11/2026 at 12:20 p.m., an interview was conducted with S1BC.  S1BC reviewed the patient’s electronic clinical record and confirmed she could not provide evidence that further contact was made with the patient’s family after 08/22/2025.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the SN (skilled nurse), HA (Hospice Aide), and MSW (Medical Social Worker) followed the POC as ordered for 1 (#2) out of 13 sampled patients. --- Patient #2. Review of the patients electronic clinical record revealed a start of care date 11/3/2022. The patients admitting diagnosis was Alzheimers disease. The benefit period reviewed was 2/1/2023 to 5/1/2023. Review of the patient's POC for benefit period 2/1/2023 to 5/1/2023 revealed an order for SN visits 2x week and 5 prn (skilled nurse visit two times a week and five visits as needed). The POC revealed an order for HA visits 2x week and 5 prn (hospice aide visit two times a week and five visits as needed). Further review of the POC revealed an order for MSW 1 visit per 4 weeks and 5 prn (Medical Social Worker one visit every 4 weeks and five visits as needed). Review of the patients electronic clinical record for the week of 2/1/2023 revealed that 2 SN visits and 2 HA visits were not made for that week as ordered per the benefit period POC. Review of the visits for the week of 2/19/2023 revealed that 2 HA visits were not made for that week as ordered. Further review of the patients record revealed that MSW visits were not made for the month of February and no visits were made for the month of March as of 3/29/2023. On 3/28/2023 at 10:19 a.m., an interview was conducted with S1DON (Director of Nurses). She reviewed the patients electronic clinical record and confirmed that the SN and the HA did not make the visits as ordered per the POC for the weeks of 2/1/2023 and 2/19/2023. On 3/29/2023 at 4:49 p.m., an interview was conducted with S1DON. She reviewed the patients clinical record and confirmed that the MSW did not make visits as ordered per the patients benefit period POC dated 2/1/2023 to 5/1/2023.

Based on record and policy and procedure review, and interview, the agency failed to maintain a system of communication and integration in accordance with its own policies and procedures to ensure that coordination of care was provided by all disciplines to assure follow up was done to assess the needs for 1 (#10) out 13 sampled patients. --- Review of the agency policy and procedure for Coordination of Patient Care revealed, ";Policy: (Hospice agency) staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the IDG (Interdisciplinary Group) plan of care. Purpose: To ensure that quality services are being provided to patients... Procedure: 1. Hospice agency has developed and maintains a system of communication and integration to: ...Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement..." Patient #10. Review of the patient's electronic clinical records revealed the start of care date was 2/24/2023. The patient's diagnosis included Malignant Neoplasm of Liver. The benefit period reviewed was 2/24/2023 to 5/24/2023. Review of the patient's POC (plan of care) for benefit period 2/24/2023 to 5/24/2023 revealed an order for SN 1x week 2/24/2021, SN 2x week and 5 prn start 2/26/2023 (skilled nurse visit one time a week 2/24/2023, skilled nurse visit two times a week and five visits as needed). Further review of POC revealed an order for HA 3x week start 2/26/2023 (hospice aide visits three times a week). Review of the patients Hospice Aide Visit note dated 3/27/2023 at 10:56 a.m. revealed, ";... (The patient) has pressure sore on right hip and outer left ankle. Reported to S3RN (Registered Nurse). Review of the patients electronic clinical record revealed that there was no evidence that S3RN or other nursing staff addressed the pressure areas reported by the hospice aide. Review of the patients Skilled Nurse Visit note dated 3/28/2023 revealed that there was no evidence the patient was assessed for pressure sores on the right hip and to the left ankle. On 3/29/2023 at 9:30 a.m., an interview was conducted with S1DON (Director of Nurses). She stated that she spoke with S3RN on the telephone and he confirmed the hospice aide reported to him the patient had pressure sores on the right hip and left ankle. S1DON stated that S3RN informed her that he did not notify the physician and that he did not address the pressure sores that were reported to him. On 3/29/2023 at 10:20 a.m., an interview was conducted with S2RN. S2RN stated that she made a skilled nurse visit to the patients home on 3/28/2023. She confirmed that prior to making the home visit, she was not aware that the patient had a pressure sore on the right hip and on the left ankle. She stated that S3RN and no other nursing staff informed her the patient had the pressure sores.