Every finding on record at Hospice Advantage, LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the volunteer cost savings report on August 20, 2025, with the Regional Director of Clinical Operations revealed that hospice volunteers provided day-to-day administrative or direct patient care services at a rate of 2.37% for the calendar year 2024. During the joint review of the volunteer cost savings report for calendar year 2024 on 08/20/2025, the Regional Director confirmed and agreed that the agency did not meet the 5% requirement stated in the standard. During review of the volunteer cost savings report on 08/20/2025 with the Regional Director of Clinical Operations, it was discovered that the agency did not ensure that the hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for the calendar year 2024. The percentage in 2024 for the agency was 2.37%.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document reviews, interviews and personnel record reviews. In 6 of 12 (50%) records, the agency did not ensure emergency training was documented annually for all employees. Agency Policy P01 Management and Staff Training [revision date 01/20/2022 states in part, "Agency provides ongoing/training/education for all direct care colleagues including patient care volunteers and contracted individuals with attention to the same topics covered in onboarding. The minimum annual education requirements include Emergency Preparedness update, Infection Control, Professional Boundaries, Hospice Benefit, and Recognizing and reporting abuse." Staff 6 - Nurse Practitioner, hired 1/5/2015: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. Staff 5 - Hospice Aide, hired 5/2/2012: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. Staff 3 - Licensed Practical Nurse, hired 5/20/2019: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. Staff 7 - Medical Social Worker, hired 12/16/2019: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. Staff 8 - Volunteer Coordinator/Bereavement Coordinator, hired 6/23/2014: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. Staff 1 - Chaplain, hired 1/17/2019: There was no emergency preparedness training documented in 2020, 2021, or yet in 2022. The area executive of clinical operations and vice president of quality standards, on interview, stated that the changes in education software the last couple years did not identify the specific documentation of emergency preparedness training. Updates for COVID have been very consistent during 2020 and 2021 and 2022; arrangements with the software for emergency preparedness education have been corrected and added to annual education in 2022.

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 document reviews and interviews. In 1 of 13 (8%) records, the agency did not ensure completion of the initial bereavement assessment within the required 5-day window. Clinical Record 9 The patient was admitted on 12/1/2021 and was discharged on 1/13/2022. The social worker documented the initial bereavement assessment on 12/7/2021 (6 days). The Director of Clinical Services reviewed the record and stated that the bereavement assessment was not completed in the required 5 days.

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. 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 a review of clinical records and interviews. In 4 of 13 (31%) records, the hospice did not verify a current medication profile at the time of the comprehensive assessment and when new medications were added during the provision of care. Clinical Record 10: The 1/9/2022 nursing start of care note documented the patient is on oxygen at 2 liters per minute via nasal cannula, however oxygen was not listed on the medication profile as of the date of review, 10/14/2022. The Director of Clinical Services reviewed the record and stated that the medication profile was not updated to include oxygen. Clinical Record 12: The 11/22/2021 nursing start of care note documented an oxygen order was placed to be delivered. The 11/26/2021 nursing visit note documented intermittent oxygen use prn [as needed] however the medication profile did not include oxygen as of the date of review, 10/14/2022. The Director of Clinical Services reviewed the record and stated that the medication profile was not updated to include oxygen. Clinical Record 11: The 12/15/2021 nursing visit note documented Monistat [an antifungal medication] ordered by the physician, however the medication was not included on the medication profile as of the date of review, 10/14/2022. The Director of Clinical Services reviewed the record and stated that the medication profile was not updated to include Monistat. Clinical Record 8: The 10/10/2022 signed physician order for comfort kit medications was not listed on the medication profile as of the date of review, 10/14/2022. The Director of Clinical Services reviewed the record and stated that the medication profile was not updated with the ordered comfort kit medications.

It is required that the hospice designates a Registered Nurse member of the IDG to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) records reviewed, the agency did not ensure that the Registered Nurse coordinated with the physician and provided a follow-up assessment when a change in patient condition occurred. Clinical Record 5: The patient was admitted 7/22/2022 with hypertension and heart disease. The 9/1/2022 nursing visit note documented the presence of cloudy urine with a foul odor with the Foley catheter change and planned to call the physician related to a possible infection. There was no evidence documented of coordination with the physician or follow-up to-date. The Director of Clinical Services reviewed the record and stated the follow-up and report to the physician were not documented.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 13 (23%) records, the hospice did not ensure that DME [durable medical equipment] required to meet the needs of the patient was included on the patients' plans of care. Clinical Record 3: The 8/31/022 start of care (SOC) plan of care (to-date) read "DME: none". The 8/31/2022 nursing assessment documented the patient was wheelchair-bound and required a Hoyer (lift) to be transferred. The Director of Clinical Services reviewed the record and stated that the patient required medical equipment that was not documented on the plan of care. Clinical Record 2: The 7/20/2022 SOC plan of care (to-date) documented "DME: none". The 7/20/2022 nursing assessment, and the most recent physician order dated 8/1/2022, documented that the patient was using oxygen at 2LPM [liters per minute] via nasal canula as needed for shortness of breath. The Director of Clinical Services reviewed the record and stated that the plan of care did not include the required medical equipment of a concentrator. Clinical Record 1: The 8/29/2022 SOC plan of care (to-date) documented "DME: none". The 8/29/2022 nursing SOC assessment documented that the patient has a wheelchair. The Director of Clinical Services reviewed the record and stated that the plan of care did not include the required medical equipment of a wheelchair.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and Included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 8 of 12 (67%) records reviewed, the hospice did not ensure that the hospice aide documented provision of services that correlated with the associated aide written assignment. Clinical Record 2: The 7/20/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 8/26/2022 aide visit note did not include the provision of nail care, which was assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 8: The 9/21/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 9/29/2022 aide visit note did not include the provision of the following tasks: bath, shampoo, linen change dressing, all assigned. Additionally, the 10/6/2022 aide visit note did not include provision of the following task: shampoo, also assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 9: The 12/1/2021 aide assignment included a task frequency of "every visit" for all assigned tasks. The 12/3/2021 aide visit note did not include provision of the following tasks: medication reminder, bath, shampoo, all assigned. The 12/6/2021 aide visit note did not include provision of the following tasks: feeding assistance, medication reminder, shampoo, all assigned. The 12/9/2021 aide visit note did not include provision of the following tasks: bath, medication reminder, all assigned. The 12/13/2021 aide visit note did not include provision of the following tasks: bath, medication reminder, shampoo, all assigned. The 1/6/2022 aide visit note did not include provision of the following tasks: bath, feeding assistance, shampoo, medication reminder, all assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 3: The 8/31/2022 aide assignment included a task frequency of "every visit" for all assigned tasks with the exception of a shower which was assigned to be performed weekly. The 9/17/2022 aide visit note did not include provision of the following tasks: bath, shower, all assigned. The week of 10/2/2022 the aide visits note did not include provision of a weekly shower as assigned. The 10/7/2022 aide visit note did not evidence documented provision of oral care as assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 1: The 8/29/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 8/31/2022 aide visit note did not include provision of the following tasks: bath, dressing, turn and reposition, as assigned. The 9/29/2022 aide visit note did not include the provision of the following tasks: oral care and turn and reposition, as assigned. The 10/4/2022 aide visit note did not include provision of oral care as assigned. The 10/7/2022 aide visit note did not include provision of the following tasks: dressing, nail care, oral care, bath, turn/reposition, all assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 7: The 9/17/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 9/23/2022 aide visit note did not include provision of the following tasks: weight, ambulation, toileting, shower, hair care, skin care, perineal care, as assigned. The 9/27/2022 aide visit note did not include provision of the following task: weight, as assigned. The 9/30/2022 aide visit note did not include provision of the following tasks: weight, bath, oral care, shampoo, hair care, skin care dressing, all assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 4: The 7/13/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 7/15/2022 aide visit note did not include provision of the following tasks: bath, oral care, skin care, dressing, as assigned. The 7/18/2022 aide visit note did not include provision of the following tasks: bath, dressing, as assigned. The 7/21/2022 and 7/25/2022 aide visit notes did not include provision of the following tasks: bath, oral care, dressing, as assigned. The 7/27/2022 and 7/28/2022 aide visit notes did not include provision of the following tasks: bath, dressing, as assigned. The 10/5/2022,10/6/2022 and 10/10/2022 aide visit notes did not include provision of the following tasks: bath. dressing, all assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks. Clinical Record 5: The 7/22/2022 aide assignment included a task frequency of "every visit" for all assigned tasks. The 10/7/2022 aide visit note did not include provision of the following task: oral care, which was assigned. The Director of Clinical Services reviewed the record and stated that the aide did not document all assigned tasks.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care must also identify the care and services that are needed and specify which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 5 (100%) records of patients residing in a SNF revealed the hospice did not ensure the plans of care included the delineation of responsibilities between the hospice and the skilled nursing facility nursing staff for any of the ordered care and services. Clinical Record 1: The 8/29/2022 start of care plan of care (to-date) did not delineate responsibilities of hospice versus skilled nursing facility staff for any of the ordered interventions related to observation, assessment, medication administration, catheter care and pain management. All orders read "skilled nurse to...". The area executive director of clinical operations, on interview, provided a document titled "Facility Coordinated Plan of Care" and stated that the agency had not yet implemented this form. Clinical Record 8: The 9/21/2022 start of care plan of care (to-date) did not delineate responsibilities of hospice versus skilled nursing facility staff for any of the ordered interventions related to observation, assessment, diabetic management, medication administration, catheter care and pain management. All orders read "skilled nurse to...". The area executive director of clinical operations, on interview, provided a document titled "Facility Coordinated Plan of Care" and stated that the agency had not yet implemented this form. Clinical Record 2: The 7/20/2022 start of care plan of care (to-date) did not delineate responsibilities of hospice versus skilled nursing facility staff for any of the ordered interventions related to observation, assessment, medication administration, catheter care and pain management. All orders read "skilled nurse to...". The area executive director of clinical operations, on interview, provided a document titled "Facility Coordinated Plan of Care" and stated that the agency had not yet implemented this form. Clinical Record 4: The 7/13/2022 start of care plan of care (to-date) did not delineate responsibilities of hospice versus skilled nursing facility staff for any of the ordered interventions related to observation, assessment, medication administration, catheter care and pain management. All orders read "skilled nurse to...". The area executive director of clinical operations, on interview, provided a document titled "Facility Coordinated Plan of Care" and stated that the agency had not yet implemented this form. Clinical Record 10: The 1/9/2022 start of care plan of care (to-date) did not delineate responsibilities of hospice versus skilled nursing facility staff for any of the ordered interventions related to observation, assessment, medication administration, catheter care and pain management. All orders read "skilled nurse to...". The area executive director of clinical operations, on interview, provided a document titled "Facility Coordinated Plan of Care" and stated that the agency had not yet implemented this form.