Every finding on record at Hospicio Luz Celeste 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; includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care; and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical record review revealed the agency did not ensure that the individualized plan of care included planned interventions based on problems identified in the initial and comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/19/2024. An initial nursing assessment completed on 07/19/2024, contained documentation that the patient had a G-tube at the time of admission. Review of the initial plan of care for benefit period 07/19/2024 to 09/16/2024, lacked planned interventions addressing assessment and care of the G-tube. The clinical record lacked evidence that the individualized plan of care included planned interventions based on problems in the initial and comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/10/2024. A nursing assessment completed on 05/12/2025 documented that the wound was cleansed with wound cleanser and Vaseline gauze and covered with gauze for both malignant ulcers, one located in the right abdominal area and the other on the abdomen. The current plan of care benefit period 05/04/2025 to 07/02/2025 lacked planned interventions addressing wound care. The clinical record lacked evidence that the individualized plan of care included planned interventions based on problems in the initial and comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/29/2024. An initial nursing assessment completed on 04/29/2024, contained documentation that the patient had a G-tube at the time of admission. Review of the initial plan of care for benefit period 04/29/2024 to 07/27/2024 and for the current benefit period 04/24/2025 to 06/23/2025, lacked planned interventions addressing assessment and care of the G-tube. CLINICAL RECORD 7: The patient elected the hospice benefit on 09/17/2024. An initial nursing assessment completed on 09/17/2024, contained documentation that the patient had a nasogastric tube for nutrition at the time of admission. Review of the initial plan of care for benefit period 09/17/2024 to 12/15/2024/2024 and for the current benefit period 05/15/2025 to 07/14/2025, lacked planned interventions addressing assessment and care of the nasogastric tube. The clinical record lacked evidence that the individualized plan of care included planned interventions based on problems in the initial and comprehensive assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/25/2024. initial nursing assessment completed on 10/25/2024, which contained documentation that the patient had a G-tube at the time of admission. Review of the initial plan of care for benefit period 10/25/2024/2024 to 01/22/2025 and for the current benefit period 04/23/2025 to 06/21/2025, lacked planned interventions addressing assessment and care of the G-tube. The clinical record lacked evidence that the individualized plan of care included planned interventions based on problems in the initial and comprehensive assessments. During an interview with the Director of Nurses on 06/05/2025 he stated that he did not know why the plans of care were not updated as required by the regulation.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical record review of patients who chose spiritual counseling indicated that the agency did not ensure documentation that the spiritual needs of the patient were met according to the frequency established with the patient and family. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/10/2024. The clinical record review revealed that during the benefit period from 03/05/2025 to 05/03/2025, the spiritual counseling frequency was one time per month. The clinical record review lacked evidence of a spiritual counseling visit in March or April of 2025. During an interview with the Director of Nurses on 06/04/2025 he stated that the patient declined spiritual counseling, upon further review he admitted that the spiritual counseling frequency was not updated at that time.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record review of a patient who was discharged revealed that the agency did not ensure that a copy of the hospice discharge summary was sent to the patient's attending physician at the time of discharge. CLINICAL RECORD 14: The hospice benefit was elected on 11/11/2023, and the patient revoked the hospice benefit on 11/18/2024 to seek aggressive treatment. The clinical record review lacked evidence that the discharge summary was sent to the attending physician. During an interview with the administrator on 06/04/2025 she stated that they do send the discharge summary when the patient is transferred or they give a copy to the family. However, she stated that they have not been sending the discharge summary to the attending physician on a routine basis.

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 medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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 clinical records, interviews and observations. 1 of 13 (8%) clinical records reviewed revealed that the patient medication profile was not updated to reflect the patient's current prescriptions. . Clinical Record 8 was reviewed and identified that the patient elected the hospice benefit on 5/14/2021. During a home visit on 9/7/2022 the home medications were reviewed. The medication profile indicated that the patient was taking Losartan Potassium 50mg 1 po q day. The medication in the home was Lopressor 50mg 1 po q day and was last filled on 7/14/2022. The RN at the visit reviewed the finding and agreed that the medication list did not match the medications in the home. The Medical Director was interviewed on 9/8/2022. The medication profile was updated before the end of the site visit. There was no additional information to provide.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review clinical records and interviews. 8 of 13 (62%) clinical records reviewed revealed the hospice did not ensure hospice care and services followed the individualized plan of care established by the hospice IDG, patient and/or primary caregiver. Clinical Record 6 was reviewed and identified the patient elected the hospice benefit on 11/23/2020. The plan of care indicated that the Social Worker was to visit the patient 1 time each month. The record identified that the Social worker visited on 8/9/2022 and 8/29/2022. There was no order to change the visit frequency. Clinical Record 3 was reviewed and identified the patient elected the hospice benefit on 3/1/2022. The plan of care indicated that the Social Worker and Chaplain were to visit the patient 1 time each month. The record identified that the Social worker visited on 8/4/2022 and 8/24/2022. The record indicated that the Chaplain visited on 8/10/2022 and 8/16/2022. There was no order to change the visit frequency. Clinical Record 8 was reviewed and identified the patient elected the hospice benefit on 5/14/2021. The plan of care documented that the RN was to visit the patient 2 times each week. In August the nurse made visits with the patient on 8/6/2022, 8/7/2022, 8/8/2022, 8/9/2022, 8/10/2022 and 8/11/2022. There was no order to change the visit frequency. Clinical Record 11 was reviewed and identified the patient elected the hospice benefit on 5/27/2022. The plan of care indicated that the Social Worker and Chaplain were to visit the patient 1 time each month. The record indicated that the Social worker visited on 8/16/2022 and 8/23/2022. The record indicated that the Chaplain visited on 8/3/2022 and 8/20/2022. There was no order to change the visit frequency. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 3/16/2020. The plan of care documented that the Social Worker and Chaplain were to visit the patient 1 time each month. The record showed that the Social worker visited on 8/23/2022 and 8/29/2022. The record indicated that the Chaplain visited on 8/9/2022 and 8/23/2022. There was no order to change the visit frequency. Clinical Record 0 was reviewed and identified the patient elected the hospice benefit on 4/28/2022. The plan of care indicated that the Social Worker was to visit the patient 1 time each month. The record identified that the Social worker visited on 8/16/2022, 8/17/2022, 8/29/2022, 8/30/2022 and 8/31/2022. There was no order to change the visit frequency. Clinical Record 10 was reviewed and identified the patient elected the hospice benefit on 10/14/2021. The plan of care documented that the Social Worker and Chaplain were to visit the patient 1 time each month. The record indicated that the Social worker visited on 8/3/2022, 8/16/2022, 8/17/2022, 8/19/2022 and 8/31/2022. The record indicated that the Chaplain visited on 8/16/2022 and 8/30/2022. There was not an order to change the visit frequency. Clinical Record 1 was reviewed and identified the patient elected the hospice benefit on 7/11/2022. There was not an order to change the visit frequency. The plan of care indicated that the Social Worker and Chaplain were to visit the patient 1 time each month. The record identified that the Social worker visited on 8/8/2022 and 8/24/2022. The record indicated that the Chaplain visited on 8/10/2022 and 8/16/2022. There was no order to change the visit frequency. Review of records revealed that the hospice company failed to individualize the plan of care to meet the specific needs of the patient and family. The Administrator was interviewed on 9/7/2022 and agreed that visits were made outside of the frequencies ordered on the plan of care. She had no additional information to provide. Review of records revealed that the hospice company failed to individualize the plan of care to meet the specific needs of the patient and family. The Administrator was interviewed on 9/7/2022 and agreed that visits were made outside of the frequencies ordered on the plan of care. She had no additional information to provide.