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 and observation. Agency policy #IPC.11_A2 "Infection Control: Bag Technique and Standard Precautions" (reviewed 01/01/2025) stated in part, "Hand Hygiene 1. Appropriate hand hygiene is the gold standard and primary method of basic infection control practice. Hand hygiene is divided into two (2) aspects... Hand washing using soap and water. b. Use of alcohol-based hand gel (sanitizer) when soap and water are not available or feasible for use... When washing hands with soap and water... wet hands with clean, running water (warm or cold), turn off tap, and apply soap...lather your hands by rubbing them together.....rinse your hands under clean, running water...dry your hands using a clean paper towel... faucet to be turned off with paper towel used to dry hands. If the air-dry method is used, turn the faucet off with the elbow... Repeat process 1-5 before and after patient contact, before and after entering your bag, before and after donning and doffing gloves, before and after any patient contact, or after contact with inanimate objects in the patient environment." In 1 of 4 (25%) home visit observations, the agency did not ensure that hand hygiene was performed correctly, when indicated per the agency's policy and procedure.. Home Visit 1: During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 07/09/2025, the HA washed their hands in the assisted living facility (ALF) memory care unit's dining room. There were no paper towels, so one of the ALF's attendants went to get paper towels. While waiting for the paper towels, the HA turned off the faucet using their elbow, then held their hands out of the sink (hands pointing down), dripping water on the floor. After drying their hands, the HA walked to the patient's room. While walking to the patient's room, the HA pulled out their phone from their pocket and stated, "I have to start my visit when I walk in and see the patient." Outside of the patient's room was a utility cleaning cart, so the HA pulled one glove out of a box of gloves and used this glove to open the patient's door. Once in the room, the HA walked over to the patient's bed, touched the patient's blanket by the patient's left shoulder, walked over to the patient's dresser, opened a blue pad, put their cell phone on the blue pad, and then donned two pairs of gloves without sanitizing their hands. During a review of the home visit on 07/09/2025, the Administrator/Area Executive of Clinical Operations stated, "They have had in-service after in-service on 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, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviews of patients who received Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse (RN) supervised the HA services no less frequently than every 14 days. Clinical Record 15: The patient elected hospice care on 06/04/2024 with a diagnosis of malignant neoplasm of the prostate and hypertension and expired at home on 11/20/2024. The plan of care dated 10/02/2024 ordered HA services one time a week. The HA completed the weekly visit as ordered. The RN completed HA supervisory visits on 10/15/2024 and 10/31/2024, with 16 days outstanding. During the joint record review on 07/11/2025, the Area Director of Quality Improvement stated, "It was 2 days late; they must have put a Licensed Practical Nurse (LPN) visit on the date the RN was to go for the supervisory visit."

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 orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's clinical record included the physician's orders for the care and services provided. Clinical Record 3: The patient elected hospice care on 05/22/2025. The benefit period dated 05/22/2025 through 08/19/2025 included the diagnoses of malignant neoplasm of unspecified main bronchus, acute respiratory distress, and essential primary hypertension. The plan of care ordered oxygen at six (6) liters, continuous via nasal cannula. The Registered Nurse (RN) visit note dated 05/29/2025 documented in the narrative, “Patient states that he got out of bed and took his oxygen off. Unable to tolerate being off oxygen. Patient situated in bed. Oxygen increased to 8 liters.” The skilled nurse (SN) visit note dated 06/02/2025 documented in the narrative, “Oxygen (O2) 3-6 liters intermittent for shortness of breath.” The Licensed Practical Nurse (LPN) visit note dated 06/06/2025 documented, “O2 at 4 liters per nasal cannula, nurse titrated to 6 liters.” The interdisciplinary group (IDG) note identified the following for the patient’s O2 saturation (sat) and oxygen rate: 05/29/2025 O2 sat 79%/O2 8 liters (L), 06/02/2025 O2 sat 97%/O2 at 3L, O2 sat 77%/O2 4 L. There was no evidence of a physician's order for the change in the oxygen liter flow during the skilled nursing visits. During an interview on 07/10/2025, the Director of Clinical Services (DCS) stated, “Normally, oxygen orders are written for titrations, based on the patient’s needs. I have written an order to update the plan of care for titration of the oxygen based on the needs of the patient.” The written updated order was included in the clinical record after the interview with the DCS.

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, documents, and interviews. Agency policy states in part, "The Social Worker completes the initial bereavement risk assessment during the social worker's comprehensive assessment conducted within five days of the hospice election. A Spiritual Counselor (Chaplain) or RN Case Manager may be asked to complete the assessments the Social Worker is not able to complete the assessment timely." In 2 of 5 (40%) clinical records reviewed, the interdisciplinary team did not complete the initial bereavement risk assessment within five days. Clinical Record 4: The patient elected the Hospice Benefit on 1/30/23 with a primary diagnosis of Myelodysplastic Syndrome. The RN and Social Worker completed an initial comprehensive assessment within the 5-day timeframe. The Chaplain attempted to conduct a visit, but the family refused at that time and asked for a visit at a later date. There was documentation for this. There was no documented evidence that the RN or Social Worker completed the initial bereavement risk assessment. Clinical Record 5: The patient elected the Hospice Benefit on 1/6/2023 with a primary diagnosis of Alzheimer's Disease. The RN, Chaplain, and Social Worker completed an initial comprehensive assessment within the 5-day timeframe. There was no documented evidence any persons on the interdisciplinary team completed the initial bereavement risk assessment. After an interview and joint clinical record review with the Regional Director of Quality and the Area Executive of Clinical Operations, it was confirmed that this assessment should have been done by the Social Worker or RN Case Manager. Agency policy states in part, "The Social Worker completes the initial bereavement risk assessment during the social worker's comprehensive assessment conducted within 5 days of the hospice election. A Spiritual Counselor (Chaplain) or RN Case Manager may be asked to complete the assessment is the Social Worker is not able to complete the assessment timely." In an interview and joint clinical record review with the Regional Director of Quality and the Area Executive of Clinical Operations, it was confirmed that this assessment should have been done by the Social Worker or RN Case Manager.

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 a review of clinical records and interview. 6 of 13 (46%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment, including social work and spiritual assessment, was completed within five calendar days after the election of hospice care. Clinical Record 10: Date of Election of Hospice services was signed on 5/31/2022—date of death 6/12/2022. There was no Chaplain assessment completed. Plan of care dated 5/31/2022 orders Chaplain 1 mo 1 effective 6/1/2022. There is no documentation in the record indicating the reason a chaplain did not assess. Clinical Record 6: Skilled Nursing initial comprehensive assessment was completed on 7/21/2022. The Chaplain's comprehensive spiritual assessment was not completed as of 9/21/2022. There is no documentation in the clinical record to indicate why a spiritual assessment was not completed. The plan of care dated 7/21/22 reveals physician orders for Chaplain 1 mo 1. Clinical Record 11: The date of election of Hospice Services was signed on 7/12/2022. The clinical record does not include a Social Work (SW) or Chaplain assessment. Clinical Record 9: The date of election of Hospice Services was signed on 9/14/2022. The Skilled Nursing comprehensive assessment was completed on 9/14/2022. As of 9/22/2022, Chaplain has not completed a spiritual assessment. There is no documentation related to refusal or resistance to spiritual assessment. Clinical Record 5: The date of election of Hospice Services was signed on 5/19/2022. The Skilled Nursing comprehensive assessment was completed on 5/19/2022. A Social Work assessment was completed on 5/23/2022. The Chaplain assessment was completed on 7/12/2022 via phone. Skilled Nursing assessment completed on 5/19/2022 notes in part, referral made to Chaplain/Spiritual Counselor. There are no notations in the clinical record to indicate why a Chaplain's comprehensive spiritual assessment was not completed within five calendar days. Clinical Record 8: The date of election of Hospice Services was signed on 9/14/2022. The Skilled Nursing comprehensive assessment was completed on 9/14/2022. As of 9/22/2022, the Chaplain has not completed an assessment. There is no documentation related to refusal or resistance to spiritual assessment. Interview with Regional Director of Hospice Quality Outcomes on 9/20/2022 stated in part, "we have identified timeliness of chaplain and SW assessments as Performance Improvement Project (PIP)." 6 of 13 (46%) of clinical records reveal that the agency did not ensure that the comprehensive assessment including social work and spiritual assessment was completed within 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, supplements, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records, the agency did not ensure that the medication profile contained all prescriptions and alternative treatments. Clinical Record 10: Skilled Nursing (SN) initial assessment on 5/25/2022 notes that the patient has had worsening shortness of breath and productive cough. SN Assessment reports that DME ordered includes oxygen. SN visit note on 6/7/2022 reads patient is on continuous oxygen at 3L via NC. Medication profile dated 6/1/2022 contains no updates and does not include oxygen. Interview with the Regional Director of Hospice Quality Outcomes states on 9/22/2022, "I have double-checked and can not find an order or updated med list to include oxygen." 1 of 13 (7%) of clinical records reveal that agency did not ensure that medication profile contained all prescriptions and alternative treatments.

It is required that each patient’s individualized written plan of care includes the drugs and treatment necessary to meet the patient's needs. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 13 (31%) clinical records reviewed, the agency did not ensure that a written plan of care specified the drugs and treatments necessary to meet the patient's needs. Clinical Record 2: Skilled Nursing (SN) assessment dated 9/15/2022 documents that the patient has a wound on the coccyx, left heel, and right heel. The assessment documents that the wounds were cleaned, and the wound on the coccyx is covered with an ABD pad and secured with tape. The assessment documented that the wounds on the heels are cleaned with soap and water, dried, and the heels are "floated." The plan of care, dated 9/15/2022, includes orders for observation and assessment of integumentary status for early detection of skin issues, however, there are no wound care orders or mention of defined wounds. During an interview on 9/20/2022, the Regional Director of Hospice Quality Outcomes stated, "I had my counter-part check as well and we double-eyed verified that the record does not contain orders." Clinical Record 12: The SN visit on 4/26/2022 documents that the patient had a Pleurex catheter drain placed with 2000 ml drained during this visit. The clinical record contains physician orders on 4/26/2022 stating, "clean drain site to the right abdomen with wound cleanser daily and covers with an adhesive dressing. Patient to provide wound care." There is no physician order present to drain the Pleurex catheter. The SN visit on 5/10/2022 documents in part, "3000 ml drained this visit." The LPN visit on 5/12/2022 documents, in part, "was able to drain 4 liters of clear orange fluid from abdominal drain today." The SN visit note on 5/17/2022, "Pleurex drain on the right side. I attempted to drain, but nothing would come out. I tried another bottle, but nothing would drain. I called the facility where the drain was placed, and they recommended the patient go to ER. Patient refused. I called the medical director, who advised he could not be directly admitted but suggested he go to an alternate ER where the wait would be shorter. Flushed Pleurex with 20 ml of NS (normal saline) per MD instructions, but there was still no return." There are no orders in the clinical record to flush the Pleurex drain. Clinical Record 10: The plan of care dated 5/31/2022 does not include orders for oxygen or a Foley catheter. The SN assessment dated 5/31/2022 documents, "oxygen has been initiated, oxygen is stored safely, and family/CG (caregiver) verbalize understanding of oxygen." There are no additional physician orders for oxygen. The SN visit on 6/3/2022 notes that a condom catheter was placed. There are no physician orders for a condom catheter. The SN visit on 6/7/2022 notes that the patient has an indwelling Foley catheter,16F, and continuous oxygen at 3L/min via nasal cannula. There are no physician orders for the Foley catheter or the oxygen. The SN visit on 6/10/2022 notes that the Foley catheter was discontinued on 6/10/2022. There is no evidence of orders or communication with the physician to discontinue the Foley catheter. Clinical Record 6: SN assessment 7/21/2022 reveals that the patient requires oxygen PRN. The Plan of care does not include physician orders for oxygen. Interview with Regional Director of Hospice Quality Outcomes stated in part on 9/21/2022, "I have looked and double verified and the oxygen is not on the plans of care." 3 of 13 (23%) of clinical records revealed that the agency did not ensure that a written plan of care specified the specific needs of the patient.

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. 4 of 13 (30%) clinical records reveal that the agency did not ensure that medical supplies and appliances necessary to meet the patient's needs were included on the plan of care. Clinical Record 8: Plan of care dated 3/21/2022 includes physician orders for oxygen 2 Liters continuous "orally." The plan of care also lists oxygen precautions. Skilled Nurse (SN) assessment documents that the patient requires incontinence supplies. The Plan of care dated 3/21/2022 documents NONE under supplies. Clinical Record 2: SN assessment dated 9/15/2022 documents that the patient has a wound on the coccyx, left heel, and right heel. Assessment documents that wounds cleaned and wound on coccyx are covered with ABD pad and secured with tape. Assessment reveals that wounds on heels are cleaned with soap and water, dried, and heels are floated. The plan of care dated 9/15/2022 includes orders for observation and assessment of integumentary status for early detection of skin issues, however, there are no wound care orders or mention of defined wounds. The plan of care does not include dressing supplies. Clinical Record 7: SN assessment and Plan of Care reveal that the patient has oxygen PRN; oxygen supplies are not listed on the plan of care dated 3/21/2022. SN assessment dated 3/21/2022 also reveals that the patient is incontinent of bowel and bladder. Incontinent supplies are not included in the Plan of Care. SN assessment also reveals that a Hospital bed, overbed table, oxygen concentrator, and wheelchair were ordered, but the Plan of care documents NONE under supplies and DME Interview with the Regional Director of Hospice Quality Outcomes stated on 9/21/2022, "I looked, and the supplies are not listed." Clinical Record 6: SN assessment 7/21/2022 reveals that the patient requires a condom catheter, oxygen PRN and wound care supplies. The plan of care dated 7/21/2022 includes orders for wound care to apply a thin layer of wound gel and cover with hydrocolloid dressing. The supplies section of the Plan of Care documents NONE. 4 of 13 (30%) of clinical records reveal that the agency did not ensure that medical supplies and appliances necessary to meet the needs of the patient were included on 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 a review of clinical records and interview. 7 of 12 (58%) clinical records for patients receiving aide services, the agency did not ensure that the aide care plan provided written patient care instructions that would allow the aide to perform effectively within the scope of practice. Clinical Record 8: Skilled Nursing (SN) assessment on 9/1/2022 reveals that the patient has a stage III pressure on her coccyx. Wound care orders on 9/2/2022 reveal that dressing is applied to the site. Aide plan of care provides no mention of wound or direction to aide should the dressing become soiled or dislodged. Clinical Record 13: Plan of care dated 9/9/2022 contains orders for oxygen 1-5 L PRN. Additional orders were written on 9/11/2022 for wound care on the upper left buttock fold. Aide care plan dated 9/9/2022 and 9/10/2022 did not include instructions to the aide related to oxygen. An aide care plan was not updated on 9/11/2022 or after to include directions to the aide related to a wound on the upper left buttocks. Clinical Record 6: Plan of care dated 7/21/2022 reveals orders for wound care. SN assessment dated 7/21/2022 describes a wound on the patient's back and the use of a condom catheter. There are no instructions to the aide on the aide care plan dated 7/21/2022 related to the wound or the condom catheter. Clinical Record 3: SN visit note on 8/24/2022 notes that the patient was placed on oxygen 1.5L/min via NC. The aide care plan dated 7/30/2022 was not updated and did not include any direction to the aide-related oxygen. Clinical Record 5: Plan of care dated 5/19/2022 includes oxygen 1-5 L/min per NC. Aide care plan dated 5/19/2022 and updated 7/14/2022 does not include instruction to the aide related oxygen. SN note on 7/5/2022 reveals that patient is using oxygen at 3 L/min via Nasal Cannula (NC). Clinical Record 2: SN Assessment dated 9/15/2022 notes that patient has wounds on coccyx, left heel and right heel. Assessment notes a dressing on coccyx wound and heels to float for healing wounds. Aide care plan dated 9/15/2022 does not include any direction to the aide related to wound areas or dressings or to float the heels. Clinical Record 12: SN assessment dated 4/15/2022 notes that patient is on continuous oxygen. Assessment on 4/26/2022 notes that patient had a pleurex drain placed. The aide care plan dated 4/15/2022 does not include instruction to the aide related to oxygen and there were no updates to include notification and instruction related to the pleurex drain. Interview with Regional Director of Hospice Quality Outcomes stated in part in interview on 9/21/22, I have verified, there are no specific orders to the aides related to oxygen and wound care, we will provide further education to all staff. 7 of 12 (58%) of relevant clinical records reveal that the agency did not ensure that the aide care plan provided written patient care instruction that would allow the aide to perform effectively within the scope of practice.

It is required that a hospice aide provides services 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 interview. 3 of 12 (23%) clinical records of patients receiving aide services, the agency did not ensure that the aide provided services as ordered in the plan of care. Clinical Record 8: Plan of care dated 9/1/2022 orders HHA 1w1, 3w12, 1w1. The week of 9/4/2022, the aide only saw the patient two times on 9/7/2022 and 9/9/2022 but did not complete three visits as ordered. There are no documented missed visits for the week of 9/4/2022. Clinical Record 12: Plan of care dated 4/15/2022 orders HHA effective 4/17/2022 2w12, 1w1. The week of 4/17/2022 through 4/23/2022, there are no aide visits, and only one documented missed visit. The week of 4/24/2022 through 4/30/2022, there was one aide visit and no documentation of missed visits for the second ordered visit that week. Clinical Record 1: Plan of care dated 8/11/2022 (Thursday) with the week ending 8/13/2022 includes orders for HHA 1 w 13. There are no aide visits or missed visit notes until 8/16/2022. Interview with the Regional Director of Hospice Quality Outcomes stated on 9/22/2022 that she could not find documentation of missed visits in the clinical record. 3 of 12 (23%) of relevant clinical records reveal that the agency did not ensure that the aide provided services as ordered in the plan of care.

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 orders. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 13 (31%) clinical records reviewed, the hospice did not ensure the clinical record included a physician’s order for the treatments provided. Clinical Record 2: Skilled Nursing (SN) assessment dated 9/15/2022 documents that the patient has a wound on the coccyx, left heel, and right heel. The assessment documents that the wounds were cleaned, and the wound on the coccyx is covered with an ABD pad and secured with tape. The assessment documented that the wounds on the heels are cleaned with soap and water, dried, and the heels are "floated." The plan of care, dated 9/15/2022, includes physician orders for observation and assessment of integumentary status for early detection of skin issues, however, there are no wound care orders or mention of defined wounds. During an interview on 9/20/2022, the Regional Director of Hospice Quality Outcomes stated, "I had my counter-part check as well and we double-eyed verified that the record does not contain physician orders." Clinical Record 12: The SN visit on 4/26/2022 documents in part that the patient had a Pleurex catheter drain placed with 2000 ml drained during this visit. The clinical record contains physician orders on 4/26/2022 stating, "clean drain site to the right abdomen with wound cleanser daily and cover with an adhesive dressing. Patient to provide wound care." There is no physician order present to drain the Pleurex catheter. The SN visit on 5/10/2022 documents in part, "3000 ml drained this visit." The LPN visit on 5/12/2022 documents, in part, "was able to drain 4 liters of clear orange fluid from abdominal drain today." The SN visit note on 5/17/2022, in part, "Pleurex drain on the right side. I attempted to drain, but nothing would come out. I tried another bottle, but nothing would drain. I called the facility where the drain was placed, and they recommended the patient go to ER. Patient refused. I called the medical director, who advised he could not be direct admit but suggested he go to an alternate ER where the wait would be shorter. Flushed Pleurex with 20 ml of NS (normal saline) per MD instructions, but there was still no return." There are no physician orders in the clinical record to flush the Pleurex drain. Clinical Record 10: The plan of care dated 5/31/2022 does not include physician orders for oxygen or a foley catheter. The SN assessment dated 5/31/2022 documents, "oxygen has been initiated, oxygen is stored safely, and family/CG (caregiver) verbalize understanding of oxygen." There are no additional physician orders for oxygen. The SN visit on 6/3/2022 notes that a condom catheter was placed. There are no physician orders for a condom catheter. The SN visit on 6/7/2022 notes that the patient has an indwelling Foley catheter,16F, and continuous oxygen at 3L/min via nasal cannula. There are no physician orders for the Foley catheter or the oxygen. The SN visit on 6/10/2022 notes that the Foley catheter was discontinued on 6/10/2022. There is no evidence of physician orders or communication with the physician to discontinue the Foley catheter. Clinical Record 6: SN assessment 7/21/2022 reveals that the patient requires oxygen PRN. The Plan of care does not include physician orders for oxygen. Interview with Regional Director of Hospice Quality Outcomes stated in part on 9/21/2022, "I have looked and double verified and the oxygen is not on the plans of care."