Every finding on record at Hospice Advantage, LLC

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 measures 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, document review, and interview. Agency policy #HOS-C_15C "Medication Reconciliation and Management" (dated 01/24/2025) read in part, "It is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation according to the following steps: Document a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand." In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient's medications were included in the drug profile. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial nursing assessment dated 02/21/2024 documented, "Patient is on oxygen continuously." The drug profile dated 02/21/2024 did not document oxygen. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed the finding, stating, "During audits in October 2024, it was identified that some patients on oxygen did not have oxygen on their medication profiles."

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 the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient's plan of care included drugs and treatments to meet the patient's needs. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial plan of care dated 02/21/2024 through 05/18/2024 documented, "Administer oxygen as needed for dyspnea." The plan of care did not document the flow rate, route, or frequency of oxygen administration. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed the finding, stating, "There was not a specific order for the oxygen dosage and route added until October 2024."

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 the following: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 23 (17%) clinical records reviewed, the agency did not ensure that the patient's plan of care included the medical supplies and appliances necessary to meet the patient's needs. Clinical Record 10: The patient elected the hospice benefit on 06/23/2023. The initial plan of care dated 06/23/2023 through 08/21/2023 ordered: "Oxygen 8 liters via nasal cannula continuously." The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 12: The patient elected the hospice benefit on 01/24/2025. The initial plan of care dated 01/24/2025 through 04/23/2025 ordered: "Oxygen 2 liters via nasal cannula at night while asleep." The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 13: The patient elected the hospice benefit on 01/06/2025. The initial plan of care dated 01/06/2025 through 04/05/2025 ordered: "Oxygen 6 liters via nasal cannula continuously." The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial nursing assessment dated 02/21/2024 documented, "Patient is on oxygen continuously." The initial plan of care dated 02/21/2024 through 05/18/2024 did not include documentation of the oxygen concentrator and oxygen supplies. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed that oxygen supplies were not included in the durable medical equipment section of the plan of care.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (dated 08/18/2022) stated in part, "The Registered Nurse is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days." In 1 of 18 (6%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that supervisory visits were completed at least every 30 days per agency policy. Clinical Record 16: The patient elected the hospice benefit on 10/03/2024. The plan of care dated 10/03/2024 through 12/31/2024 ordered: "SN 1 time per week." A clinical record review revealed a LPN visit dated 11/08/2024. The clinical record did not include documentation of a LPN supervisory visit. During a joint record review on 02/25/2025, the Area Executive of Clinical Operations confirmed the LPN supervisory visits were not completed every 30 days per agency policy.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a 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 3 of 21 (14%) clinical records reviewed of patients with Hospice Aide (HA) services provided, the agency did not ensure that the HA care plan included all written patient care instructions. Clinical Record 3: The patient elected the hospice benefit on 11/30/2023. On 12/01/2023, the physician ordered wound care with a wound dressing to a wound on the patient's right and left buttocks. The plan of care dated 11/30/2023 through 02/27/2024 ordered "HA 2 times per week." The HA care plan dated 11/30/2023 assigned the HA the relevant task of "shower at every visit." The HA care plan did not include documentation of instructions for the patient's wound dressing on the buttocks should it become wet or dislodged during the shower. Clinical Record 5: The patient elected the hospice benefit on 12/12/2024. On 12/13/2024, the physician ordered wound care with a wound dressing to a wound on the patient's coccyx. The plan of care dated 12/12/2024 through 03/11/2025 ordered "HA 2 times per week." The HA care plan dated 12/13/2024 assigned the HA the relevant task of "bed bath at every visit." The HA care plan did not include documentation of instructions for the patient's wound dressing on the coccyx should it become wet or dislodged during the bed bath. Clinical Record 10: The patient elected the hospice benefit on 06/23/2023. On 06/23/2023, the physician ordered "Oxygen 8 liters via nasal cannula continuously." The plan of care dated 06/23/2023 through 08/21/2023 ordered "HA 2 times per week." The HA care plan dated 06/24/2023 did not include documentation of safety precautions and instructions related to the patient's use of oxygen during personal. During a joint record review on 02/25/2025, the Area Executive of Clinical Operations confirmed the findings, stating, "We identified some aide care plans that did not include wound dressing or oxygen instructions during audits in October 2024."

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 review of the clinical record, document review, and interview. 2 of 13 (15%) records reviewed failed to document all disciplines completed their comprehensive assessment within 5 days after the election of hospice care. Record #82860: hospice benefit of election dated 02/02/2022. A phone call was documented from the chaplain on 02/02/2022, stating that the dad was Catholic, and prayers were provided to the son. The next documentation from the chaplain was 02/21/2022, the spiritual assessment was completed on that date. Nursing documented that no identified spiritual concerns were stated by the patient or family, on 02/02/2022. No documented spiritual assessment until day 20 which is 15 days late. Record #48278: hospice benefit of election dated 02/27/2022. No psychosocial assessment from medical social work was documented. On the interdisciplinary meeting documented on 03/09/2022, the social worker documented refusal of social work. Nursing documented on 02/27/2022 that no social needs were identified. The refusal of social work was not documented until day 9 which is 4 days late. AGENCY POLICY: 'Completing the Initial and Comprehensive Assessments' [Revision date 07/26/2021] stated in part, "If the social worker cannot compete for the psychosocial portion of the first comprehensive assessment, the RN will use the coordination note in the electronic medical record...If the Spiritual Counselor cannot complete the spiritual portion of the first comprehensive assessment, the RN will use the coordination note in the electronic health record... Interview with the Director of Clinical Services and Regional Director on 04/13/2022 stated that a new process included a coordination note that nursing performed a spiritual and social work assessment. The two records reviewed failed to include these notes.

It is required that the hospice designates a Registered Nurse member of the IDG to: ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 13 (08%) records reviewed failed to document that the nurse followed the physician-ordered plan of care. Agency Policy: 'Individualized Plan of Care' [revision date, 1/20/2021] stated in part, "the updated plan of care when making patient visits to sustain continuity of care and address identified problem from the plan of care." Record #48278: Admitted 02/27/2022 with diseases not limited to, COPD [a condition involving the airways making it difficult to breath], and a decubitus ulcer [pressure ulcer]. The initial plan of care ordered a Duoderm [a hydrocolloid dressing] dressing for the coccyx decubitus ulcer. Nursing documentation on twice a week visit notes, dated 03/24/2022 thru 04/11/2022 that the wound care provided was to clean with wound cleanser, dried with gauze, and Medihoney [brand name wound and burn gel] dressing applied. The order for the wound care that included Medihoney was documented on 04/11/2022. The plan of care was updated on 04/11/2022 for the wound care that had been provided and documented for the three previous weeks. Documented wound measurements reflected wound improvement but the care documented was not delivered as written on the individualized plan of care. Interview with the Director of Clinical Services and Regional Director on 04/13/2022 stated that the order was not documented and that care by the nurse did not follow the written plan of care.

It is required that each patient’s individualized written plan of care: 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. 5 of 13 (38%) of the individualized plans of care failed to include all interventions and goals identified in the initial comprehensive or updated assessments. Record #82860: The patient was admitted on 02/02/2022 with a red coccyx and multiple skin tears from a prior fall, as well as wearing compressions socks and using a compression pump daily. There was no skin intervention or goals on the initial plan of care from 02/02/2022 - to 05/02/2022. The interventions and goals for skincare and compression were not documented on any updated plan of care as of review 04/12/2022. Additionally, on 02/21/2022, the patient reported a blood sugar of 57 and below for the last 3 days. Physician orders were documented to stop glipizide [ a medication to control blood sugar levels]. The plan of care failed to document any update for diabetes management as of review 04/12/2022. Record #17390: The patient was admitted on 10/19/2021 with end-stage heart failure. The initial comprehensive assessment documented three falls in the last month. There was no intervention or goal documented for fall risk on the initial or updated plans of care. Record #74318: The patient was admitted on 02/21/2022. The initial comprehensive assessment documented that the patient was straight catheterized, 3 -4 times a day and that the patient had a skin opening requiring intervention to apply a cream as the skin area had previously been open. The initial plan of care and updated plans of care failed to document skin interventions/goals or interventions and goals for catheterization. Record #82860: A spiritual assessment conducted on 02/21/2022 identified assistance needed for funeral planning, security support, love support, and support with the sacraments with continued visits, The updated plan of care failed to document any interventions or goals for spiritual care as of review 04/12/2022. Record #65834: A spiritual assessment conducted on 03/24/2022 identified the patient religious preference as Catholic and accepting of prayer. The updated plan of care failed to include any interventions or goals for spiritual care who continued to provide care as of review 04/12/2022. Agency Policy: 'Individualized Plan of Care', revision date 01/20/2020, stated in part, "The initial plan of care is based on the assessment information using SMART goals and interventions to support patients identified goals of care... updates to the plan of care are based on information gathered in the course of the comprehensive and ongoing assessments." The interview with the Director of Clinical Services on 04/13/2022 stated the interventions and goals are missing even though we are working on our plans of care.

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 the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by review of the clinical record, document review, and interview. 1 of 13 (08%) records reviewed failed to include all medications and treatments ordered on the plan of care. Record #74318: The patient was admitted on 02/21/2022. The nursing visit note on 03/03/2022 documented that the patient's bottom was reddened and cream applied. The documentation for the cream to be applied continued through nursing visits on 04/11/2022, but the medication was not included in any updated plan of care. Agency Policy: Individualized Plan of Care. {revision date 01/20/2020] stated in part, "Content of the plan of care: interventions to manage pain and other symptoms, medications, non-pharmacological interventions …. drugs and treatments necessary to support patient care." An interview on 04/13/2022 with the Director of Clinical Services stated that the cream is likely a zinc ointment but was not documented on any of the plans of care.