Every finding on record at Hospice Advantage, LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, the documented discussion of the plan provided to the patient/family, and maintained by the hospice, follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. 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 that an individualized disaster plan was developed and discussed with the patient/family as part of the comprehensive assessment. Clinical Record 14: The patient elected hospice benefit on 02/24/2023 and expired on 02/27/2023. The patient resided at a private residence. A review of the clinical record revealed no documented evidence that the patient's individual emergency plan was developed and discussed with the patient, family, and/or caregiver as part of the comprehensive assessment. The DCS was interviewed and confirmed that an individualized emergency plan was not completed and discussed with the patient and family on admission.

It is required that 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). This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the hospice care and services followed the patient's plan of care. Clinical Record 1: The patient elected hospice care on 03/07/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) documented the patient's wounds on both lower extremities. On 03/07/2023, the Medical Director ordered the Skilled Nurse (SN) to assess the wound weekly and perform wound care. The SN visit note for the week of 03/14/2023 did not include documentation of a wound assessment or wound care. The Director of Clinical Services was interviewed on 01/25/2024 and confirmed that the nurse did not complete a wound assessment and dressing change as ordered by the physician.

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 2 of 2 (100%) clinical records reviewed of patients who revoked the hospice benefit to seek aggressive treatment at a hospital, the hospice did not ensure the discharge summary was forwarded to the receiving hospital for continuity of care. Clinical Record 13: The patient elected the hospice benefit on 10/18/2023 and transferred to the hospital on 12/14/2023 to seek aggressive treatment. A clinical record review revealed no evidence that a discharge summary was forwarded to the receiving hospital as of the review date, 01/24/2024. Clinical Record 12: The patient elected the hospice benefit on 08/30/2023 and transferred to the hospital on 11/01/2023 to seek aggressive treatment. A clinical record review revealed no evidence that a discharge summary was forwarded to the receiving hospital as of the review date, 01/24/2024. Interview with the Director of Clinical Services on 01/24/2024 confirmed that the clinical records did not contain documentation that any of the required elements (plan of care, physician orders, summary of hospice stay) were forwarded to the receiving hospital.