Every finding on record at Hospice Advantage, LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy and procedure #IPC.11_A2 "Bag Technique and Standard Precautions" (review date 10/30/2024) stated in part, "Perform hand hygiene before and after entering the bag." In 1 of 6 (17%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. Home Visit 2: The patient elected hospice care on 10/14/2024 with a diagnosis of unspecified severe calorie malnutrition. During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 2] on 04/23/2025, the LPN reached into the nursing bag to retrieve a protective barrier. The LPN then washed their hands and donned gloves. Hand hygiene was not performed before entering the bag per the agency's policy. During an interview on 04/24/2025, the Area Executive of Clinical Operations confirmed that the Licensed Practical Nurse did not follow the agency's policy related to hand hygiene.

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 to 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, document review, and interview. Agency policy and procedure #C_12A "Supervision of Hospice Aides and LP/LV Colleagues" (review date 12/31/2024) read in part, "At every scheduled visit, the RN is responsible to evaluate the care provided by the hospice aide; it is required that this supervision be completed not less than every 14 days." In 1 of 19 (5%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Clinical Record 13: The patient elected hospice care on 12/10/2024 with a diagnosis of atherosclerotic heart disease. The hospice plan of care dated 12/10/2024 through 03/09/2025 ordered HA services two (2) times weekly beginning 12/10/2024. The HA visits were provided beginning the week of 12/10/2024 as ordered. The HA supervisory visits were provided on 12/19/2024 and 01/09/2025, with 21 days outstanding. In a joint record review and interview on 04/24/2025, the Area Executive of Clinical Operations confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.

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 and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure the plan of care identified specific fall precautions or safety interventions. Clinical Record 3: Election of benefit 2/9/23. Comprehensive nursing visit note, from 3/20/23, stated, "patient reported fall over the weekend." Documentation also reported that patient ambulated with a walker and "leaned" to the side. On the patient's "problem list" safety was listed without any additional details. The plan of care, effective from 2/9/23 to current, did not include any goals or interventions related to falls or safety measures. During the joint clinical record review, the Administrator (ACO) confirmed that the patient should have the safety problem, with goals and interventions, on the care plan.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 6 (17%) clinical records reviewed, the hospice did not ensure that the nursing services were provided according to the agency process to meet the patient needs following an admission. Clinical Record 6: Election of benefit was signed on 12/23/22 and the initial comprehensive assessment was completed by the on-call nurse at that time. No pain or symptom management needs were noted, but the RN documented orders were obtained for the comfort kit (which included Morphine and Ativan) and education provided regarding when and how to administer. The initial nursing visit frequency was set up as one visit for week one (which was the Friday admission visit), then two visits for the remaining weeks of the benefit period. The patient was seen for the admission visit on 12/23/22 and then for the death visit on 12/27/22. Home Visit 1: Per phone interview with the patient's wife, on 4/13/23, she stated that the nurse told her she would visit tomorrow (12/24/22), however the nurse did not visit and did not contact the patient or wife via phone. The wife ultimately called the hospice 12/26/22, in the afternoon, to report the patient had a fever, the wife reports that nurse returned the call promptly and provided guidance on what to do. A visit was declined by the wife at this time. The nurse and wife agreed upon a visit on 12/27/22, but the patient passed prior to the visit. An interview was conducted with the Administrator (ACO) who confirmed that the hospice had documented this complaint and performed an internal investigation. It was determined that the admission on-call RN did not follow the hospice process of making a follow-up visit the day after an admission, or at minimum a phone call if the visit was declined. Furthermore, it was noted that nurse who performed the admission, and remained on-call for the weekend, did not provide the on-coming nurse with "hand-off" report alerting of the admission.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 16 (6%) clinical records reviewed revealed that the initial bereavement assessment was not completed timely. Record 4: The patient elected the hospice benefit on 6/17/2022. The initial bereavement assessment was completed on 7/13/2022. The Administrator and Director of Clinical Services were interviewed on 7/13/2022 and agreed that the initial bereavement assessment was not completed timely. 1 of 16 (6%) of clinical records reviewed revealed that the initial bereavement assessment was not completed timely.