Every finding on record at Hospice Hawaii, Inc

Based on record review and interview with staff members, the facility failed to ensure one of 16 patients  (Patient (P) 19) comprehensive assessments were completed no later than five calendar days after the election of hospice care (EOHC). This puts P19 at risk of not receiving individualized and collaborated ongoing care. Findings include: --- P19's EOHC was 03/28/25. A review of P19's Electronic Health Record (EHR) found that the Registered Nurse (RN) completed her initial comprehensive assessment on 03/30/25. In the initial assessment, the RN noted for social worker to provide "welcome call to mom" due to parents separation. Review of the "Combined Disciplinary Comprehensive Assessment" created on 04/02/25 found only the RN and spiritual counselor completed their assessment within five days. On 09/12/25 at 11:06 AM, an interview was conducted with Quality and Compliance Officer (QCO). QCO stated the RN, spiritual counselor, social worker, and attending or hospice physician are included in the interdisciplinary group (IDG). QCO confirmed the social worker did not complete P19's comprehensive assessment and the pediatric physician did not review the assessment within 5 days and/or complete an assessment until  04/13/25.

Based on record review and interview, the facility failed to ensure an initial bereavement risk assessment was completed, therefore, a bereavement plan of care was not developed for one of 19 patients (Patient (P) 19). A a result, P19 and her family were not assessed for personalized support identifying interventions, care and resources, for individuals at risk of difficult grief. Findings include: --- P19's election of hospice care was 03/28/25. Review of P19's Electronic Health Record (EHR) documented on 04/02/25 a combined disciplinary comprehensive assessment was created and the bereavement assessment was not completed. On 09/12/25 at 11:06 AM, an interview was conducted with Quality and Compliance Officer (QCO). QCO stated the social worker does the initial bereavement assessment. Concurrent review of P19's EHR found the initial bereavement assessment was not completed.

Based on record review and interview the facility failed to ensure an individualized plan of care was developed for two of 10 patients sampled with no home visits, (Patient (P) 10 and P11). P10 and P11 did not have a plan of care in place for pain management. Findings include: --- 1) On 09/12/25 at 10:40 AM a review of P10's Electronic Health Record (EHR) was conducted. Record review revealed P10 had her Combined Disciplinary Comprehensive Assessment and Combined Disciplinary Plan of Care done on 09/03/25. Review of P10's Combined Disciplinary Comprehensive Assessment revealed P10 is unable to report her pain and the nurse documented "Person answering pain questions: Other -- No verbal response."On this same assessment the nurse documented:"Pain Site Location/ Label: generalizedPain frequency: OccasionalPain characteristic: Unable to describeCurrent pain value: 0 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Best pain value: 0 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Worst pain value: 0 [sic.] on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Acceptable/ Goal, Pain value: 0 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)"Review of P10's physician order for pain management ordered on 08/31/25 included "morphine concentrate 100 mg/ 5 mL [milligrams/milliliters] (20 mg/mL) oral solution" with instructions for mild pain or shortness of breath (SOB) to take 5 mg by mouth or sublingually every hour as needed, for moderate pain or SOB to take 10 mg by mouth or sublingually ever hour as needed, and for severe pain or SOB to take 20 mg by mouth or sublingually every hour as needed. Review of P10's plan of care revealed it did not include any interventions to manage P10's pain including the physician order medication for mild, moderate, and severe pain. P10's Plan of Care for pain documented "Pain - Issues" states, "Issue Status: Current" and "Goal Status: Current". On 09/12/25 at 02:20 PM an interview was conducted with the Quality and Compliance Officer (QCO) in the conference room. Concurrent review of P10's Combined Disciplinary Comprehensive Assessment and Combined Disciplinary Plan of Care that was created on 09/03/25 was done with QCO. Inquired of QCO if P10 should have a plan of care for pain and she confirmed the plan of care stated "Current" for "Issue Status" and "Goal Status" and confirmed it should have been filled out. QCO explained their computer system is not bringing over information from the patient's Combined Disciplinary Comprehensive Assessment and this is being looked at to correct. 2) On 09/12/25 at 10:55 AM a review of P11's EHR was conducted. Record review revealed P11 had her Combined Disciplinary Comprehensive Assessment and Combined Disciplinary Plan of Care done on 08/28/25. Review of P11's Combined Disciplinary Comprehensive Assessment revealed the hospice nurse documented P11's "Pain status: Medication not always taken as directed (pain is controlled otherwise)" and "Pain interferes with: Energy; Mood; Activity; Non-verbal pain symptoms: None; Person answering pain questions: Patient; What makes pain worse: movement; What makes pain better: rest, immobility; PRN doses since last visit: Yes -- Tylenol 500 mg PRN"On this same assessment the nurse documented:"Pain Site Location/ Label: left rib cagePain frequency: OccasionalPain characteristic: AcheCurrent pain value: 8 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Best pain value: 0 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Worst pain value: 10 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)Acceptable/ Goal, Pain value: 0 on a scale of 0 (Very Low Pain Intensity) to 10 (Very High Pain Intensity)"Review of P11's plan of care for "Pain - Issues" revealed it did not include any interventions to manage P11's pain although P11 was prescribed with pain medication on 08/22/25, "gabapentin 600 mg tablet Take have a tablet by mouth in the afternoon for pain. Hold for sedation. Take one tablet by mouth twice daily for pain. Hold for sedation." On 09/12/25 at 02:25 PM an interview was conducted with the Quality and Compliance Officer (QCO) in the conference room. Concurrent review of P11's Combined Disciplinary Comprehensive Assessment and Combined Disciplinary Plan of Care that was created on 08/28/25 was done with QCO. Inquired of QCO if P11 should have a plan of care for pain and she confirmed the plan of care stated "Current" for "Issue Status" and "Goal Status" and confirmed it should have been filled out. Requested a copy of facility's policy for Plan of Care which QCO was able to provide.Review of facility "Plan of Care - Content Policy Number: PC.P45" states "Policy Statement: The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. Procedures: 1. The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. 2. The plan of care includes, but is not limited to: a. interventions to manage pain and symptoms, ..."

Based on record review and interview, the facility failed to ensure the care and services for two of 19 patients sampled (Patient (P) 13 and P18) was provided in accordance with the plan of care. As a result, P13 and P18 did not receive social work services and spiritual counseling as ordered.Findings include: --- 1) P13 election of hospice was 06/25/25 for routine home care. A review of P13's plan of care created on 06/26/25 found P13 was ordered social worker visits once every four weeks. Record review of P13's medical record from 06/25/25 to 09/11/25 found no documentation visits were made by the social worker. Interview with the Quality and Compliance Officer (QCO) on 09/12/25 at 08:46 AM. Asked if there are any social worker notes for P13 and a bereavement assessment.  The QCO stated when they have a pediatric patient, the provision of care is sensitive, and the nurse will assess whether the family is open to discussing bereavement counseling.  The QCO confirmed that P13 did not have visits by the social worker.   2) P18's election of hospice care was 05/31/24. A review of P18's plan of care created on 08/28/25 found P18 receives spiritual care and social worker visits once every four weeks. P18's physician orders documented effective 11/12/24, spiritual care visit 1 visit per 4 week(s) and effective 10/08/24, social worker visit 1 visit per 4 week (s). Review of P18's Electronic Health Record (EHR) found between 07/25/25 to 09/11/25 the social worker last visited P18 on 08/07/25, with no subsequent visits. The spiritual counselor visited P18 on 08/05/25 and then visited on 09/09/25, the fifth week. On 09/12/25 at 11:06 AM, an interview was conducted with Quality and Compliance Officer (QCO). QCO confirmed the social worker and spiritual counselor should have visited P18 by the fourth week of their last visit, between 08/31/25 and 09/06/25, and did not visit P18 as ordered.

Based on record review and interview, the facility failed to ensure the physician's orders were appropriately authenticated by the ordering physician for eight of 19 patients sampled (Patient (P) 12, P13, P14, P19, P10, P11, P9, and P15). This deficient practice puts these residents at risk of patient safety and care continuity. Findings include: --- ) On 09/12/25 at 08:35 AM, conducted a review of Patient (P) 15’s Electronic Health Record (EHR). Review of the physician’s orders documented an order on 08/06/25 for CeraVe Itch Relief 1% Topical Cream was not signed or electronically acknowledged by the physician after the most recent Interdisciplinary Team meeting (IDT).  On 09/12/25 at 08:45 AM, conducted a concurrent interview and record review with the Quality and Compliance Officer (QCO). QCO reviewed the physician’s order for CeraVe and confirmed the physician did not sign the order.  QCM reviewed the most recent IDT meeting notes, which occurred on 09/11/25, and confirmed the physician should have signed or electronically acknowledged the order yesterday but did not. ) On 09/09/25 at 01:30 PM an Electronic Health Record (EHR) review was conducted for P10. Record review revealed P10 had orders written on 08/31/25 that were not signed by the physician.On 09/09/25 at 01:45 PM an interview was conducted with the Quality and Compliance Officer (QCO) in the conference room. Concurrent review of P10's orders was done at this time. Inquired of QCO if P10's orders dated 08/31/25 are to be signed by the physician and she confirmed they were not signed and should have been signed by the physician.  ) On 09/11/25 at 01:30 PM an EHR review was conducted for P11. Record review revealed P11 had orders written on 09/07/25 that were not signed by the physician.On 09/11/25 at 01:45 PM an interview was conducted with the QCO in the conference room. Concurrent review of P11's orders was done at this time. Inquired of QCO if P11's orders dated 09/07/25 are to be signed by the physician and she confirmed they were not signed and should have been signed by the physician. ) On 09/11/25 at 03:35 PM an EHR review was conducted for P9. Record review revealed P9 had orders written on 08/07/25 that were not signed by the physician.On 09/12/25 at 10:55 AM an interview was conducted with the QCO in the conference room. Concurrent review of P9's orders was done at this time. Inquired of QCO if P9's orders dated 08/07/25 are to be signed by the physician and she confirmed they were not signed and should have been signed by the physician.   ) P12 was admitted for Hospice on 08/27/25. Review of P12's electronic health record (EHR) found the last interdisciplinary group (IDG) meeting was on 09/11/25. The order for social worker visit one time weekly effective 09/02/25 was not signed by the physician. Interview and Record review with the Quality and Compliance Officer (QCO) on 09/12/25 at 02:23 PM in her office.  The QCO confirmed that the orders were not signed by the physician.  The QCO stated that the orders are reviewed at the IDG meeting and the physician usually signs the orders at that time.     ) P13 was admitted for Hospice on 06/25/25. Review of P13's EHR found the last IDG meeting was on 09/08/25. The following orders were not signed by the physician:1. On 06/25/25, change level of care to routine. Registered Nurse (RN) visits one-time weekly, Spiritual care, one time every four weeks.2. On 07/02/25, gabapentin 250 milligrams (mg/ 5 milliliters (mL) oral solution. Give 100 mg (2 mL) via GJT (feeding tube) every night at bedtime for one week, then increase to 100 mg (5 mL) three times a day; sodium Chloride 0.9 for nebulization. Give one vial via nebulizer every four hours as needed for thick secretions. 3. On 07/05/25, sucralfate 100 mg/mL oral suspension. Give 3 mL (300 mg) via GT three times a day for 14 days. 4. On 08/09/25, discontinue gabapentin 250 mg/5mL. Interview and Record review with the Quality and Compliance Officer (QCO) on 09/12/25 at 02:23 PM in her office.  The QCO confirmed that the orders were not signed by the physician.  The QCO stated that the orders are reviewed at the IDG meeting and the physician usually signs the orders at that time.    ) P14 was admitted for Hospice on 03/12/25. Review of P14's EHR found the last IDG meeting was on 09/09/25. The following orders were not signed by the physician:1. On 08/01/25, tussin 100 mg/5mL oral liquid. Take 10 mL (200 mg) by mouth every four hours as needed for cough. 2. On 08/13/25, discontinue amlodipine five mg tablet. 3. On 08/15/25, discontinue Spiritual care frequency. 4. On 08/20/25, discontinue senna 8.6 mg tablet one tablet by mouth every day for constipation. Interview and Record review with the Quality and Compliance Officer (QCO) on 09/12/25 at 02:23 PM in her office.  The QCO confirmed that the orders were not signed by the physician.  The QCO stated that the orders are reviewed at the IDG meeting and the physician usually signs the orders at that time.        ) P19's election of hospice care (EOHC) was 03/28/25. Review of P19's physician orders from EOHC to current found none of the orders were signed by the physician, which included medications, hospice services, and medical equipment. On 09/12/25 at 11:06 AM, concurrent review review and an interview was conducted with Quality and Compliance Officer (QCO). QCO confirmed P19's physician orders were not signed.

Based on record review and interview with staff members, the facility did not assure 2 (Patients 10 and 12) of 13 patients' comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. Findings include: 1) On 05/11/22 at 12:20 PM record review was done for Patient (P)12. P12's election of hospice care was 04/07/22. On 04/07/22, the physician ordered an initial spiritual assessment. Review of the record found no documentation an initial spiritual assessment was done. There was no documentation of progress notes to indicate the reason for not conducting the assessment. On 05/11/22 at 01:45 PM concurrent record review and interview was conducted with the Director of Clinical Operations (DCO). DCO reviewed P12's records and confirmed an initial spiritual assessment was not done and there was no documentation for the reason the assessment was not done. 2) Patient (P)10's election of hospice care was 04/09/22. A review of P10's electronic health record (EHR) found that the interdisciplinary group (IDG) completed the initial comprehensive assessment on 04/21/22. Although the Registered Nurse (RN) completed her initial assessment on 04/09/22, the remainder of the IDG had no assessments documented until 04/21/22. On 05/12/22 at 08:30 AM, during a concurrent record review and interview with the DCO, the DCO confirmed that the comprehensive assessment was not completed within 5 (days) as it should have been.

Based on record reviews and interviews with staff members, the facility did not assure the range of visits and PRN orders for visit frequencies were included in the plan of care for 3 (Patients 4, 11 and 12) of 13 patients in the sample. Findings include: 1) On 05/11/22 at 12:20 PM a record review was done for Patient (P)12. P12's election of hospice benefit was 04/07/22. A review of the Social Worker (SW) progress note documents that the family was anxious to speak with the volunteer coordinator to obtain companionship and respite services for the patient. On 04/13/22, the Volunteer Coordinator (VC) contacted the patient's family. The family requested volunteer services twice a week, Tuesdays and Thursdays. Review of P12's plan of care found volunteer services with the range of visit/visit frequency was not included. A review of the visit calendar noted volunteer services were provided once a week, starting on 04/21/22. Subsequent visits were provided on 04/29/22, 05/06/22 and 05/11/22. There was no physician order for volunteer services. On 05/11/22 at 01:45 PM concurrent record review and interview was done with the Director of Clinical Operations (DCO). DCO confirmed volunteer visits were being made and there was no documentation of an order for the services. Inquired whether an order is needed to provide volunteer services. DCO replied there should be an order for it and also documentation of why the patient's needs could not be met. DCO also confirmed there was no documentation of why the request for twice a week of volunteer services were not provided. 2) On 05/11/22 at 11:22 AM a record review was done for P4. P4's election of hospice care was 02/10/21. A review of P4's plan of care and physician orders noted an order with a start date of 02/11/21 for a SW initial assessment. Subsequent physician order dated 01/11/22 noted an order for three prn (as needed) SW visits for 01/12/22 through 02/04/22. Review of the SW visit notes found documentation visits were done outside of the timeframe of the order, 02/14/22 and 03/30/22 Further review found SW visit notes for March 2021, April 2021, May 2021, June 2021, August 2021, and October 2021. Further review of P4's initial certification period (02/10/21 to 05/10/21) and subsequent recertification periods until present (04/06/22 to 06/04/22) noted SW visits were not included in the plan of care or physician orders for prn visits. On 05/11/22 at 03:25 PM concurrent record review and interview was conducted with the DCO. DCO confirmed SW visits were made 03/23/21, 04/06/21, 05/18/21, 06/15/21, 06/21/21, 06/29/21, 08/10/21 and 10/05/21. DCO reviewed the patient's plan of care and physician orders and noted the only order was for an initial SW assessment. DCO confirmed there was no documentation in the plan of care or physician orders for SW services or prn visits. 3) On 05/11/22 at 10:47 AM a record review was done for P11. P11's election of hospice care was 03/10/22. A review of the Spiritual Counselor (SC) notes documents visits on 03/15/22, 03/22/22, 04/05/22, 04/12/22 and 04/19/22. Review of P11's plan of care documents SC to "Provide spiritual support and life-review." On 05/12/22 at 09:58 AM concurrent record review and interview was conducted with DCO and Quality and Compliance Manager (QCM). DCO reviewed the patient's plan of care and physician orders and noted the only order was for an initial SC assessment. DCO confirmed the care plan did not include the frequency of SC services. Inquired whether an order is needed to provide SC services, DCO stated there should be an order for it.

Based on record reviews and interviews with staff members, the facility failed to ensure that care and services were provided in accordance with the patient's plan of care for 5 (Patients 3, 6, 10, 11, and 12) of 13 patients. Findings include: 1) On 05/11/22 at 12:20 PM a record review was done for Patient (P)12. P12's election of hospice care was 04/07/22. A review of the patient's plan of care and physician orders documents hospice aide services were ordered for twice a week with a start date of 04/11/22. Review of the hospice aide notes and calendar found hospice aide services were provided once a week from 04/11/22 through 05/10/22. On 05/11/22 at 01:45 PM concurrent record review and interview was conducted with the Director of Clinical Operations (DCO). DCO confirmed the frequency of hospice aide services were not provided in accordance with P12's plan of care. DCO also confirmed that there was no change in the visit frequency to once a week. 2) P3's election of hospice care was 02/12/22. Review of P3's electronic health record (EHR) found a plan of care dated 02/17/22 for nursing services once a week. A review of services provided noted that there were no nursing services provided for the week of 03/22/22 and 04/19/22. On 05/12/22 at 08:18 AM, during a concurrent record review and interview with the DCO, the DCO confirmed that there was no documentation that nursing services were provided, refused, or canceled for P3 during the week of 03/22/22 and 04/19/22. The DCO also confirmed that this was not in accordance with the visit schedule or plan of care. 3) P6's election of hospice care was 03/08/22. Review of P6's EHR found a plan of care dated 03/14/22 for hospice aide services twice a week. A review of services provided noted that there was only one hospice aide visit provided for the weeks of 03/14/22 to 04/30/22, a period extending more than six weeks. On 05/12/22 at 08:35 AM, during a concurrent record review and interview with the DCO, the DCO confirmed that there was no documentation that more than one hospice aide visit a week was provided, refused, or canceled during the weeks of 03/14/22 to 04/30/22. The DCO also confirmed that this was not in accordance with the visit schedule or plan of care. 4) P10's election of hospice care was 04/09/22. Review of P10's EHR found a plan of care dated 04/21/22 for spiritual counseling "weekly." A review of services provided noted that there were no spiritual counseling services provided for the week of 05/01/22 to 05/07/22. On 05/12/22 at 08:32 AM, during a concurrent record review and interview with the DCO, the DCO confirmed that there was no documentation that spiritual counseling services were provided, refused, or canceled for P10 during the week of 05/01/22 to 05/07/22. The DCO also confirmed that this was not in accordance with the plan of care. 5) On 05/11/22 at 10:47 AM a record review was done for P11. P11's election of hospice care was 03/10/22. Review of P11's plan of care documents hospice aide services three times a week. A review of the services provided noted that only two hospice aide visits were provided for the week of 04/17/22 to 04/23/22. On 05/12/22 at 09:58 AM concurrent record review and interview was conducted with DCO and Quality and Compliance Manager (QCM). DCO confirmed hospice aide services was scheduled and canceled on 04/23/22. DCO also confirmed there was no documentation the patient or family was contacted regarding the canceled visit or documentation the facility attempted to reschedule or provide a different hospice aide

Based on review of employee personnel file and interview with staff member, the facility failed to assure a criminal background check for 1 (one) of 6 randomly selected employees was done. Findings include: On 05/12/22 a request was made to review the criminal background checks for employees who have direct patient contact. On 05/12/22 at 12:34 PM the Quality and Compliance Manager (QCM) provided documentation for five of the six employees. QCM reported they do not have documentation a criminal background check was performed for Registered Nurse (RN)1. QCM reported RN1's date of hire was 11/15/21.