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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C09 "Written Interdisciplinary Plan of Care" (effective 08/01/2017) (revised 04/22/2024)stated in part, "The Interdisciplinary Group (IDG/IDT) ensures the provision of care and services according to the plan of care." Agency policy #HOS-C15 "Nursing Services" (effective 11/01/2017) (revised 08/29/2025) stated in part, "Nursing services include...Implementation of the individualized plan of care and recommendations for revision to the plan of care based on assessment/evaluation data...Initiation of appropriate rehabilitative and preventative nursing procedures, documentation of assessment/evaluation outcomes, interventions...planning for additional needs..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care included all treatments necessary to meet the patient's needs. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/22/2025 with diagnoses of Merkel cell carcinoma and malignant neoplasm of the meninges. The Registered Nurse's (RN) initial assessment dated 08/22/2025 documented that the patient had "developed debilitating chronic complications requiring trach placement with vent assist and peg tube placement with continuous feedings...Foley catheter was placed by urology due to difficult insertion...nonverbal due to cuffed trach and vent dependency...tube feeds Osmolite 1.5cal..." The RN initial assessment also documented that the patient had a "Shiley 6 cuffed tracheostomy tube, with oxygen via the ventilator at 30% FiO2." Ventilator settings were not included in the assessment note. The RN visit note dated 08/27/2025, documented that the patient had a 16 French (Fr) Foley catheter with a 10mL balloon, which was placed on 08/01/2025, with the next scheduled catheter change due on 09/01/2025. The hospital discharge instructions dated 08/21/2025 (scanned into the clinical record on 08/22/2025) documented "tracheostomy Shiley 6 cuffed, trach care per facility (NF) protocol, ventilator settings of (Assist-Control/Volume-Controlled) AC/VC mode, 30% FiO2 (Fraction of Inspired Oxygen), set respiratory rate of 20 with a tidal volume of 400mL and a PEEP of 5." A clinical record review revealed that no Foley size was included in the summary, and Foley care was directed according to facility protocol. There was no facility protocol scanned into the patient's clinical record. The plan of care for the benefit period dated 08/22/2025 to 11/19/2025 and the Interdisciplinary Group Meetings/plan of care updates dated 08/28/2025, 09/07/2025, and 09/18/2025 did not include documentation of the size of tracheostomy, care for the tracheostomy, or the ventilator settings; also not included was the Foley catheter/size or frequency of catheter changes. During a joint clinical record review and interview with the Area Executive of Clinical Operations on 09/19/2025, the evidence was confirmed.

It is required that a hospice aide provide services: ordered by the Interdisciplinary Group; included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care. CLINICAL RECORD 6: The patient elected hospice care on 03/09/2025 with a diagnosis of Parkinsonism. The plans of care for the benefit periods dated 06/07/2025 to 09/04/2025 and 09/05/2025 to 11/03/2025 ordered Hospice Aide (HA) services twice weekly, effective 07/12/2025. The Interdisciplinary Group Meeting (IDG)/plan of care update dated 08/28/2025, documented HA services twice a week. The IDG/plan of care updates dated 09/04/2025 and 09/18/2025, the Registered Nurse (RN) documented no changes in the HA visit frequency. The last HA visit was dated 08/28/2025. The Hospice Aide completed missed visits on 09/04/2025 and 09/11/2025 (no other HA visit or missed visit was documented for either week), which documented "no aide visits." During a joint clinical record review and interview on 09/19/2025, the Area Executive of Clinical Operations/RN confirmed that there was no order to discontinue Hospice Aide visits.

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. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C30 "Hospice Written and Verbal Orders" (effective 04/15/2017) (revised 12/26/2024) stated in part, "(Agency) ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, treatments ...all orders specify an exact...frequency..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's record included physician orders for patient care and services. CLINICAL RECORD 14: The patient elected hospice care on 08/22/2025 with diagnoses of Merkel cell carcinoma and malignant neoplasm of the meninges. The patient resided in a nursing facility (NF). The initial assessment completed by the Registered Nurse (RN) on 08/22/2025 documented an unstageable sacral wound. On 08/24/2025, the RN visit note documented a stage 2 pressure wound to the sacrum, with "treatment/dressing to clean the wound using saline or wound cleanser, employing aseptic technique. Then apply Medi Honey to the wound and cover with a bordered Mepilex dressing." Additionally, the RN visit note documented that wound care would be provided by facility staff on Mondays, Wednesdays, and Fridays, as needed. The physician's order for wound care dated 08/24/2025, did not include documentation of the frequency of dressing changes or whether the care was being provided by facility staff, the hospice nurse, or both. During a joint clinical record review and interview on 09/19/2025, the Area Executive of Clinical Operations/RN confirmed that there was no frequency for wound care or delineation of responsibility for Clinical Record 14.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes Information on the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 13 (15%) clinical records reviewed the organization did not ensure the Comprehensive Assessments were updated at the Hospice Interdisciplinary Group to include a change in the patient's condition. Clinical Record 2: This patient elected Hospice services on 7/19/2022. For the Certification beginning 10/17/2022 through 1/14/2023, diagnosis included CVA, COPD, HOH, Type DM, and heart disease, The client is residing at a Long Term Care Facility (LTCF). The Chaplain visit dated, 10/24/2022, documented " The patient is very emotional, depressed, struggling over the past few weeks because she and her family had a big falling out, they blame her, she wants to talk to them and feels lonely." In addition, she feels "abandoned," experiencing the loss of her family, as they will not take her out of the nursing home, or out to eat as other of the residents of the facility often do. The "Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 10/27/2022, under the section "Pastor/Counselor" documented there were no concerns related to "emotional issues," "Empathy Application had not been initiated" [and] no changes required to Spiritual Services being provided." In addition, the IDT frequencies remained at once-a-month visits by the Chaplain. Clinical Record 7: This patient elected Hospice services from 10/4/2022 through 1/1/2023. Diagnosis included Alzheimer's, Chronic Kidney disease, Stage 3, Atrial Fib, and Heart Failure. During the Skilled Nurse (SN) visit on 10/18/2022, under the section titled, "Narrative," the documentation stated, “Daughter was updated about the patient's condition, and concerns about the patient refusing food and meds, daughter informed that the patient has the right to refuse. He can make decisions for himself. The Daughter wants a feeding tube placed so [he] can no longer refuse food. Educated Daughter, hard to tell if she understands or has a Hospice mindset." The Hospice IDG Comprehensive Assessment and of Care Update Report" dated 10/20/2022, under the "Registered Nurse" document failed to address family concerns. This section was blank. In an interview with the Administrator, on 11/23/2022, it was stated that they were aware of this issue. She explained, 'the Electronic Medical Record (EMR) has preset questions in the Interdisciplinary meeting format and is lacking the ability to document information that is specific to the changes experienced by the client. The EMR is limited to a format of Yes and No checkboxes with no room to fully document what the changes entailed.”

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 a review of documents and interviews. In 1 of 6 (17%) contracts reviewed, the therapy contract for (PT, OT, and ST) services did not include the required verbiage. Contract #3: The therapy contract (OT/PT/ST) lacked evidence of the clause for criminal background checks for employees that have access to patients and their clinical records. In an interview with the Administrator on 11/23/2022, she stated, “unaware of the clause to do Criminal Background checks being a required component of contracts entered into with outside agencies that have direct contact with clients or having access to client medical records.” Prior to leaving the exit, the Administrator had sent an addendum to the Therapy companies to begin the corrective process.