Every finding on record at Hospice Advantage, LLC

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. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that planned interventions based on problems identified in the initial and updated comprehensive assessments were included in the patients' individualized written plans of care. CLINICAL RECORD 1: This patient elected the hospice benefit on 01/20/2025 with a terminal diagnosis of Alzheimer's Disease. The Registered Nurse initial comprehensive assessment dated 01/20/2025 stated the patient was diagnosed with dysphagia in October 2024 and was at risk of aspiration. The plan of care dated 01/20/2025 through 10/21/2025 did not include interventions related to dysphagia. CLINICAL RECORD 8: This patient elected the hospice benefit on 06/06/2025 with a terminal diagnosis of COPD. The initial Registered Nurse initial comprehensive assessment dated 06/06/2025 stated the patient was admitted with Doxycycline 100 mg two times a day for the diagnosis of pneumonia. The drug profile was reviewed for the dates of 06/06/2025-12/11/2025 and included a Z-Pack for a respiratory infection initiated on 09/12/2025. The plan of care dated 06/06/2025 through 12/11/2025 did not include interventions related to the diagnosis of pneumonia or respiratory infection. During joint clinical record review and an interview on 12/11/2025, the Administrator stated there were no interventions in the plans of care to address the problems identified in the assessments.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 4 (25%) home visit observations, the agency did not ensure that the accepted standards of practice to prevent the transmission of infections and communicable disease, including hand hygiene and use of gloves, were observed by the staff. The Agency Procedure: IPC.11_A2 "Infection Control: Bag Technique and Hand Hygiene with Competency", stated in part, "When to wash hands with soap and water...after using gloves.... When to use hand gel (sanitizer): before donning gloves and after removing gloves...moving between clean and contaminated body surfaces/sites...after contact with inanimate objects in the patient's environment...before and after entering your bag." HOME VISIT 2/CLINICAL RECORD 2: This patient elected the hospice benefit on 10/10/2025 with a diagnosis of senile degeneration of the brain. During an observed home visit conducted with the Hospice Aide (HA - Personnel Record 2) on 12/17/2025, the HA was observed to sanitize her hands and don gloves. She removed the patient's wet brief and pad and used a washcloth to cleanse the perineal area and placed the soiled washcloth in the wash basin. The HA then used disposable wipes to cleanse the patient's face and upper body. The HA reached for mouth swabs from the nightstand and cleansed the mouth without changing gloves or sanitizing hands. The HA then opened the drawer of the chest to retrieve new socks and grabbed the same washcloth from the basin and used the same water and wash cloth to cleanse the legs and feet that was used to cleanse the perineal area. The HA did not change gloves or sanitize hands during the bed bath. During an interview conducted on 12/17/2025, The Area Director of Quality Outcomes stated that it was surprising that this HA did not follow the infection control policy.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review, document review, and interview. The agency procedure number C_09A titled Individualized Plan of Care with revision date 1/20/2020, stated in part, "(4) Updates to the Plan of Care...(f) The Plan of Care should be reviewed and revised as often as the needs of the patient indicate but not less often than every 15 calendar days. The revisions to the plan of care should be based on information collected in the updated comprehensive assessments and should include the patient's progress toward goals as documented in the plan of care...The documentation of progress toward goals can be found in IDG notes documented as part of the IDG discussion about the patient's plan of care and the effectiveness of interventions. Thus, each discipline is providing CARE PLAN (capitalized for emphasis) direction that informs the comprehensive update for the entire PLAN OF CARE (capitalized for emphasis)." In 3 of 13 (23%) clinical records reviewed revealed, the agency did not update the care plan with problems and goals related to identified needs in the comprehensive assessment. Clinical Record 1: The patient with an election of hospice benefit dated 12/9/2021 had a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The RN Visit Note dated 12/10/2021 documented "patient currently having symptoms of UTI. Urinary frequency. Pain with urination and urine retention. Antibiotic ordered. Education provided on how to give and complete in full." Physician order dated 12/10/2021 documented Keflex 250mg 1 capsule by mouth twice daily (BID) for seven (7) days for UTI. There was no documentation in the IDT Meeting titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/15/2021 and 12/29/2021 reporting the UTI or goals discussion. There was no documentation of care plan problems or pathways, or goals regarding urinary tract infections under genitourinary included in the Plan of Care. Clinical Record 6: The patient with an election of hospice benefit dated 6/26/2021 had a primary diagnosis of severe protein malnutrition. The RN visit note dated 10/4/2022 documented in the narrative, "on nurses visit patient fell when trying to get off the chair to kill a bug. The nurse was in the chair on one side, and son in law was in the chair on the opposite side of the patient. The patient lost balance and landed posterior on the tile floor. The patient denied any pain but shortly after complained of feeling nauseated. The nurse assessed the patient on the floor and no injuries were noted. The daughter was contacted by a nurse of a fall. The patient tried to ambulate independently without using a walker or calling for assistance." There was no documentation or problem statement on the care plan for fall prevention. The RN documented the patient was a high fall risk without updating the plan of care with updated problems, interventions, or goals related to fall prevention. Clinical Record 10: The patient with an election of hospice benefit dated 12/14/2021 received hospice services at an assisted living facility. The patient had a primary diagnosis of Parkinson's disease and a history of multiple urinary tract infections (UTIs). Since June of 2022, the patient has been prescribed antibiotics seven times to treat UTIs: Cefdinir on 6/25/2022, Cefdinir on 7/29/2022, Cefdinir on 9/23/2022, Cipro 10/11/2022, Cefdinir on 12/16/2022, Levofloxacin on 1/24/2023 and Levofloxacin on 2/4/2023. Additionally, there were physician orders dated 12/17/2022 documented to collect urine for urinalysis (U/A) and culture/sensitivity (C&S), and the physician order dated 12/28/2022 recorded to collect urine for urinalysis (U/A) and culture/sensitivity (C&S). In addition, the patient was on Keflex 500 mg by mouth daily and AZO cranberry two tablets daily to prevent UTI. There was no documentation of care plan problems, pathways, or goals regarding urinary tract infections under genitourinary included in the Plan of Care. The patient was receiving hospice aide services twice weekly. An interview on 3/2/2023 with the Area Director of Clinical Operations stated the assisted living facility staff toileted the patient on a schedule and that she would get the nurse on the next visit to open and document the care plan problem/pathway.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. The agency procedure number C_09A titled Individualized Plan of Care with revision date 1/20/2020, stated in part under the subsection "(2) Content of the Plan of Care: (a) All services needed to manage the terminal illness and related conditions...(f) Medical supplies and appliances/DME needed to support patient care needs (i) All DME, (ii) Medical supplies are those which are medically needed to support the patient's clinical care (not incontinence supplies or grooming supplies). If a physician must write an RX for them in order to have Medicare cover them, then they are medical supplies (items such as ostomy supplies, catheters, O2 tanks, etc.)." In 4 of 13 (31%) records reviewed revealed the agency did not include in the plan of care the DME and medical supplies necessary to meet the patient's needs. Clinical Record 12: The patient with an election of hospice benefit dated 12/23/2022 received hospice services at a nursing home facility. The plan of care dated 12/23/2022 for the benefit period of 12/23/2022 through 3/22/2023 documented "none" for DME and supplies. The functional limitations were documented as bowel/bladder incontinence. During an interview with the Director of Clinical Services stated that the patient received briefs, wipes, and body wash from the hospice agency. Additionally, she noted the hospice agency was not providing any DME. Clinical Record 11: The patient with an election of hospice benefit dated 2/25/2023 received hospice services at a nursing home facility. The plan of care dated 2/25/2023 for the benefit period 2/25/2023 through 5/25/2023 documented "none" for DME and supplies. The RN Visit dated 2/28/2023 documented the facility requested supplies. An interview with the Director of Clinical Services confirmed the hospice agency provided the oxygen concentrator and its supplies and the following medical supplies were also provided: briefs, chuxs and wipes, razors and shaving supplies, and nail sticks. The Director of Clinical Services documented on 3/1/2023 the hospital bed and oxygen supplies. Clinical Record 3: The patient with an election of hospice benefit dated 7/22/2022 received hospice services at a nursing home facility. The plan of care dated 7/22/2022 for the benefit period 7/22/2022 through 10/19/2022 documented "none" for DME and supplies. The Hospice RN Start of Care note dated 7/22/2022 documented under genitourinary, the patient had incontinence with a frequency of always, and protective devices used were diapers and under pads, with a quantity of three diapers used in 24 hours. The RN documented that for activities of daily living, the patient needed assistance from a human and used a walker. An interview on 3/2/2023 with the Area Director of Clinical Operations stated the agency did not order any DME, and the incontinence supplies were not documented on the plan of care. Clinical Record 5: The patient with an election of hospice benefit dated 6/17/2022 had a primary diagnosis of senile degeneration of the brain. The plan of care dated 6/17/2022 for the benefit period 6/17/2022 through 9/14/2022 documented "none" for DME and supplies. The RN Start of Care hospice note documented indwelling Foley catheter and bowel incontinence. The RN Hospice Death at Home Visit note dated 2/6/2022 documented that the hospital bed (owned by the patient) and oxygen concentrator were to be removed by the DME company. The agency provided the oxygen concentrator. An interview on 3/2/2023 with the Area Director of Clinical Operations stated the patient had a short stay, died on 8/4/2022, and had a surplus of supplies, including wound supplies, that did not need any to be provided by the agency, but confirmed regardless not being documented on the plan of care. An interview with the Area Director of Clinical Operations on 3/2/2023 stated the agency was instructed not to include supplies in the plan of care.

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, interview and observation. In 1 of 1 (100%) home visit observed where the hospice aide was present revealed that the aide care plan did not include all tasks completed by the hospice aide. Clinical Record 12/Home Visit 2: The patient with an election of hospice benefit dated 12/23/2022 received hospice aide services twice weekly at a nursing home facility. The aide care plan dated 12/30/2022 documented assigned tasks to be completed every visit, including bed bath, skin care, oral care, nail care, and dressing. Home Visit 2: During an interview with the hospice aide on 2/28/2023, before entering the patient's room, she verbally reviewed the care typically provided, which included changing the linens and underpads. The hospice aide stated that the tasks of changing linens and underpads were not on the aide's care plan. Additionally, when entering the patient's room, the bed linens and underpads were in the patient's chair for the hospice aide to complete the tasks.

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed where the patients had a Foley catheter revealed the agency did not have a physician order documented for the Foley catheter or its maintenance. Clinical Record 5: The patient with an election of hospice benefits dated 6/17/2022 had a primary diagnosis of senile degeneration of the brain. The plan of care dated 6/17/2022 for the benefit period 6/17/2022 through 9/14/2022 had no documentation of physician orders or interventions for Foley catheter management. The Hospice RN Start of Care note dated 6/17/2022 documented indwelling Foley catheter, 16 French with 10cc balloon size, to change monthly PRN and no irrigation ordered. Under the narrative, RN documented the patient was discharged from a local hospital where she was found to have reoccurring pyelonephritis and worsening colitis. The patient had pyelonephritis three times in the past three months. The patient currently had two (2) ureteral stents in place. The patient's Foley catheter was documented as draining frank red blood. An interview on 3/2/2023 with the Area Director of Clinical Operations confirmed the physician order for the Foley catheter was missing during the joint record review.

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 identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy number C26 titled Care in the Nursing Facility with an effective date of October 2008, and revision date of 5/17/2018 stated in part under subsection Hospice Plan of Care "(1) The agency collaborates with the facility to establish a coordinated plan of care is maintained by both the facility and hospice. Care is provided according to the plan of care. (2) The hospice plan of care identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care." In 2 of 3 (67%) clinical records reviewed where patients received hospice services at nursing care facilities, the hospice plan of care did not identify the care and services that were needed or specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 11: The patient with an election of hospice benefit dated 2/25/2023 received services at a nursing home facility after being at a previously contracted facility for a general inpatient level of care stay. The RN visit note dated 2/28/2023 documented under the integumentary/wounds section that the integumentary was not assessed due to the patient's refusal and that the facility nurse would complete wound care with hospice support. The patient had documented PEG tube and an indwelling catheter. Because the coordinated plan of care was not uploaded to the clinical record as of 3/2/2023, the Area Director of Clinical Operations provided the agency form titled Hospice and Facility Coordinated Plan of Care dated 2/28/2023. The paper documented the routine level of care and expected visit schedule of the hospice team members, the nurse, the aide, the social worker, and the chaplain. However, the hospice RN's signature was dated 2/28/2023, and the facility's signature was without a date. In addition, the wound care, ostomy care, and Foley catheter sections were not completed, which did not designate the responsible party. Clinical Record 3: The patient with an election of hospice benefit dated 7/22/2022 received services at a nursing home facility. The agency form titled Hospice and Facility Coordinated Plan of Care was missing during the record review. The Area Director of Clinical Operations stated on 3/2/2023 that the agency form was not in the clinical record during the joint record review.