Every finding on record at Hospice Advantage, LLC

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: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and document review. Agency policy #HOS-C_09A "Individualized Plan of Care" (reviewed 12/27/2024) stated in part, "Content of the Plan of Care...All services needed to manage the terminal illness and related conditions... A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...Scope = what services are part of the plan of care." In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that the patient's plan of care included a detailed statement of the scope of services necessary to meet the patient's needs. CLINICAL RECORD 3: The patient elected hospice care on 03/03/2025 with diagnoses of senile degeneration of the brain, not elsewhere classified, hyperlipidemia, and muscle weakness. The patient resided in a skilled nursing facility (SNF). The plan of care established by the Interdisciplinary Team (IDG) dated 03/03/2025 through 05/31/2025 ordered Hospice Aide services two (2) times per week for one (1) week and three (3) times per week for 12 weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, and assistance with activities of daily living (ADLs). CLINICAL RECORD 4: The patient elected hospice care on 05/29/2025 with diagnoses of cerebral infarct due to embolism of the left middle artery, aphasia, dysphagia, and spastic hemiplegia. The patient resided in a SNF. The plan of care established by the IDG dated 05/29/2025 through 08/26/2025 ordered Hospice Aide services two (2) times per week for 12 weeks and one (1) time per week for one (1) week. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, and assistance with ADLs. CLINICAL RECORD 6: The patient elected hospice care on 07/03/2025 with diagnoses of malignant neoplasm of the skin, unspecified, and Alzheimer's disease. The plan of care established by the IDG, dated 07/03/2025 through 09/30/2025, ordered Hospice Aide services as follows: one (1) time per week for one (1) week, two (2) times per week for 12 weeks, and one (1) time per week for one (1) week. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, and assistance with ADLs. CLINICAL RECORD 7: The patient elected hospice care on 04/27/2025 with diagnoses of senile degeneration of brain, not elsewhere classified, unspecified dementia, anxiety disorder, and malignant neoplasm of unspecified site of unspecified female breast. The plan of care established by the IDG dated 04/27/2025 through 07/25/2025 ordered Hospice Aide (HA) services two (2) times per week for 13 weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, and assistance with ADLs. CLINICAL RECORD 9: The patient elected hospice care on 06/23/2025 with diagnoses of senile degeneration of the brain, not elsewhere classified, and anxiety disorder. The plan of care established by the IDG dated 06/23/2025 through 08/21/2025 ordered HA services two (2) times per week for nine (9) weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, and assistance with ADLs. CLINICAL RECORD 10: The patient elected hospice care on 09/25/2024 with diagnoses of heart failure, unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, and chronic kidney disease. The plan of care established by the IDG dated 06/22/2025 through 08/20/2025 ordered HA services one (1) time per week for one (1) week and two (2) times per week for eight (8) weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, nail care, oral care, and turning/repositioning assistance. CLINICAL RECORD 12: The patient elected hospice care on 04/29/2025 with diagnoses of malignant neoplasm of the prostate, secondary and unspecified malignant neoplasm of intrapelvic nodes. The plan of care established by the IDG dated 04/29/2025 through 07/27/2025 ordered HA services one (1) time per week for one (1) week and two (2) times per week for 12 weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, hair care, shaving, and linen changes. CLINICAL RECORD 14: The patient elected hospice care on 05/07/2025 with diagnoses of congestive heart failure, chronic kidney disease, and hypertensive heart disease with heart failure. The plan of care established by the IDG dated 05/07/2025 through 07/05/2025 ordered HA services one (1) time per week for one (1) week and two (2) times per week for eight (8) weeks. The plan of care did not document the scope of services the HA was to provide. The HA was providing bathing, dressing, oral care, peri-care, shampoo, and linen changes.

It is required that a hospice aide provides services: consistent with the hospice aide training. This standard was not met as evidenced by document review and observation. Agency policy "Bed Bath" (revised 05/19/2025) stated in part, "Equipment for bathing using water, skin cleanser, and washcloths...For bathing using water, skin cleanser, and washcloths. Clean the patient's face...clean, rinse, and dry the patient's abdomen, and then the groin and perineum. Remove and discard your gloves. Perform hand hygiene. Put on new pair of gloves. Clean, rinse, and dry the patient's left leg, left foot." In 1 of 4 (25%) home visits observed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA performed the bath according to the agency's policy. Home Visit 3: The patient elected hospice care on 03/03/2025 with diagnoses of senile degeneration of the brain, not elsewhere classified, hyperlipidemia, and muscle weakness. The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 07/16/2025, with a washcloth, the HA washed the patient's face and ears and bathed the patient's upper body, rinsed the washcloth in the water basin, washed the patient's midsection (including the abdomen, groin, perineum), rinsed the washcloth, and washed the patient's lower extremities. The patient was turned onto their right side. The patient's back, buttocks, and area between the buttocks were washed using the washcloth. The washcloth was then rinsed, and the lower extremities were washed. The patient was bathed using one washcloth. After the HA washed the patient's abdomen, groin, and perineum, the HA did not change their gloves or perform hand hygiene per the agency's bath procedure.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; [and] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA was supervised by a Registered Nurse no less frequently than every 14 days to: assess the quality of care and services provided. CLINICAL RECORD 8: The patient elected hospice care on 06/19/2024 with a diagnosis of senile degeneration of the brain, not elsewhere classified, and supravalvular aortic stenosis. A review of the plans of care dated 04/15/2025 through 06/13/2025 and 06/13/2025 through 08/12/2025 identified that the patient was receiving HA services 2 times per week. The Registered Nurse performed an HA supervisory visit on 05/30/2025 and 07/07/2025 (35 days outstanding).

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C-31 "Clinical Records" (revised 02/04/2025) stated in part, "The clinical record contains complete and accurate information... All entries into the clinical record are legible, clear, accurate, complete, and authenticated...(Agency) specifically prohibits the practice of cloning, which is defined by CMS as copy-pasting of evidence that entries in the medical record are exactly the same or similar in language or construction as previous entries." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's clinical record contained accurate clinical notes, including information on the care and services provided. CLINICAL RECORD 2: The patient, born on 05/31/1936 (89 years old), elected hospice care on 05/14/2025. The narrative note section of the skilled nurse (SN) visit notes dated 05/14/2025, 05/15/2025,05/21/2025, 05/27/2025, 05/29/2025, 05/30/2025, 06/02/2025, 06/05/2025,06/09/2025, 06/12/2025,06/13/2025, 06/18/2025, 06/25/2025,07/03/2025, and 07/10/2025, and the Chaplain note dated 05/19/2025, documented the same statement "PT is a 61-year-old female admitted to hospice services for malignant neoplasm of unspecified site of left female breast, comorbs include HTN, Gout, DM, HLD, Arthritis, and kidney disease. Family wished for no further unnecessary hospitalization and decided on hospice services." The visit notes did not include the patient's correct age. CLINICAL RECORD 3: The patient, born on 07/01/1928 (97 years old), elected hospice care on 03/03/2025. The patient resided in a skilled nursing facility (SNF). A clinical record review of the documentation for the benefit periods dated 03/03/2025 through 05/31/2025 and 06/01/2025 through 08/29/2025 revealed that the plan of care, updated on 05/19/2025, ordered, "Assess patient's physical needs to determine if GIP status still indicated." There was no documented evidence in the clinical record that the patient had ever received General Inpatient Care (GIP) services.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C-31 "Clinical Records" (revised 02/04/2025) stated in part, "The clinical record contains complete and accurate information... All entries into the clinical record are legible, clear, accurate, complete, and authenticated." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's clinical record contained a physician certification of terminal illness that accurately reflected the patient's information, as per the agency's policy. CLINICAL RECORD 3: The patient, born on 07/01/1928 (97 years old), elected hospice care on 03/03/2025 with diagnoses of senile degeneration of the brain, not elsewhere classified, hyperlipidemia, and muscle weakness.. The patient resided in a skilled nursing facility (SNF). The certificate of terminal illness written by the Hospice Medical Director dated 05/19/2025 documented, "patient is a 69-year-old female on hospice for senile degeneration of the brain."

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including: ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG). This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-15B "Wound Management" (revised 01/01/2024) stated in part, "Wound care...If the patient is in a facility, collaborate with the individual at the facility responsible for wound management (the hospice nurse is responsible for inspecting the wound at least 1x/wk and should plan accordingly to work with the facility personnel to accomplish this). f. Ensure all wounds are labeled correctly, accurately, and consistently." In 2 of 5 (40%) clinical records reviewed of patients that resided in a skilled nursing facility (SNF), the agency did not ensure that the hospice was responsible for the ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice IDG. CLINICAL RECORD 6: The elected hospice care on 07/03/2025 with diagnoses of malignant melanoma of skin, unspecified, Alzheimer's disease, and Essential (primary) hypertension. The patient resided at the (State) Veterans' home. The initial comprehensive assessment dated 07/03/2025 stated, "Cranial sup, skin tear measuring 5 cm x 6 cm x 0cm with a small amount of exudate." The plan of care (POC) dated 07/03/2025 through 09/30/2025 ordered skilled nursing services (SN) two (2) times a week for one (1) week and one (1) time a week for 13 weeks. The SN visit notes dated 07/10/2025 and 07/11/2025 documented, "was wound assessed... No, caregiver (facility staff) completed care." The SN visit notes dated 07/14/2025 and 07/16/2025 documented, "was wound assessed... No, caregiver (facility staff) completed care." On 07/09/2025, the hospice physician ordered "cleanse stage 3 wound to head with wound cleanser, pat dry with gauze, apply 4x4 border gauze. Change daily or prn if soiled per facility nurse or hospice nurse." The patient's wound record report documented, "07/10/2025, 07/11/2025,07/14/2025, and 07/16/2025. "Wound care was not provided; the caregiver (facility staff) completed care." A clinical record review revealed no evidence that the hospice nurse collaborated with the facility staff nurse on the wound management. CLINICAL RECORD 7: The elected hospice care on 04/27/2025 with a diagnosis of senile degeneration of the brain, not elsewhere classified. The patient resided in a skilled nursing facility (SNF). During the benefit period dated 04/27/2025 through 07/25/2025, the Licensed Practical Nurse (LPN) visit note dated 05/01/2025 documented that the patient had a wound on the left breast measuring 1.5 cm x 0.5 cm x 0 cm. On 05/01/2025, the physician ordered "cleanse mass to left breast with wound cleanser, pat dry with gauze. Apply bacitracin, cover with dry dressing. Change daily or as needed (PRN) if soiled by a Facility Skilled Nurse (FSN) or hospice nurse." On 06/09/2025, the SN identified a stage 2 wound to the patient's sacrum and a deep tissue injury (DTI) to the patient's left heel. On 06/09/2025, the physician ordered, "cleanse stage 2 wound to sacrum with normal saline, pat dry with gauze, apply calcium alginate to wound bed. Cover with dry dressing. Change daily or prn if soiled per hospice nurse or facility nurse. Paint DTI to left heel with Betadine, wrap with Kerlix, secure with tape. To be performed daily by a hospice or facility staff nurse." A clinical record review revealed no evidence that the hospice nurse collaborated with the facility staff nurse on the wound management.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent Hospice plan of care, Hospice election form and any advance directives, Physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, Hospice medication information and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by document reviews, interviews, and observations. 1 of 2 (50%) observations during home visits for patients receiving hospice care in a Skilled Nursing Facility (SNF), the agency failed to ensure the required documents were provided to the SNF. Home Visit 1: During an interview on 9/13/2022 and observation with the Director of Nurses (DON) for the SNF regarding how to contact the hospice provider and what documents the Hospice had provided to the SNF, she reported the Hospice Agency is excellent at providing anything the patient needs when the Hospice Agency is called. The DON was unable to locate the Hospice record. The DON instructed the SNF Social Worker to tell the hospice provider to fax the hospice patient’s documents to the SNF, which the Social Worker asked the Hospice Agency to do as the DON had instructed. The DON looked in the Medical Records Department, however, the DON did not find the patient’s hospice record. A review of the Hospice Agency’s contract, "Nursing Facility Hospice, General Inpatient and Respite Care Services Agreement, states in part, " Part II page 2 Services to be provided by Hospice 3. Hospice will furnish a copy of each Hospice Patient’s Plan to the facility at the time of the resident’s admission into the Hospice Program. In addition, for each Hospice patient residing in the Facility, Hospice will also provide the Facility with (i) a copy of the Hospice patients election form and any advance directives specific to such patient, (ii) a copy of the physician certification, and recertification of the terminal illness specific to the Hospice Patient, (iii) a list of names and contact information for Hospice personnel involved in the hospice care for each Hospice patient, (iv) instructions on how to access the Hospice’s twenty-four (24) hour on-call system, (v) Hospice medication information specific to each Hospice patient, and (v) copies of Hospice physician and attending physician, if any, orders specific to each Hospice patient. Signed by both parties June 9, 2016." In an interview with the Director of Quality Outcomes (DQO) on 9/14/22, the DQO stated, "I contacted the nurses seeing this patient, and they have seen the hospice record at the SNF nurse's station. I received a call from the SNF administrator this morning complaining about the fax they received from us. The Administrator wanted to know what she was to do with the 800 pages of faxed material."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 20 (10%) contracts, during a joint review of contracts, the agency failed to ensure the supplier contract included the clause, “in writing, between the contractor/contracted, for the provision that requires criminal background checks.” The Director of Quality Outcomes provided an “addendum” to the supplier contract signed 9/14/2022, which included the criminal background clause.