Every finding on record at Hudson Valley Hospice Inc.

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 if any of them so desire. The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) Clinical records of the community patients, the agency did not ensure that the registered nurse (RN) implemented the plan of care. CLINICAL RECORD 2: The patient’s election of the hospice benefit was dated 03/08/2025 with a primary diagnosis of Lung Cancer with Metastasis. The plan of care dated effective 03/08/2025 was reviewed and included an order effective 03/10/2025 for dressing change 2 times a week. The order effective 03/10/2025 and continued through 08/13/2025 stated, “RN to perform chest tube site care 2 x per week during drainage and if dressing is soiled: impaired. Cleanse the skin around the catheter site with an alcohol pad, allow to dry and discard the pad. Place the sterile foam pad around the catheter. Curl the catheter into loops and place it over the foam pad. cover the entire catheter with stere gauze pads, Secure the sterile self-adhesive or the absorbent dressing over the gauze pad, label the new dressing with date time and initials.” The nurse visit documented on 08/05/2025 stated, “ the lung was drained of 400 cc amber fluid and the site documented as 'C/D/I' (clean dry and intact) but no documentation of a dressing being replaced by sterile technique during the visit. There was no additional documentation for the dressing changed that week. During the home visit with the registered nurse (RN) (Personnel Record 2) on 08/12/2025 during the family stated that the dressing had been completed during the two visits the previous week. There was no documented evidence that the nurse clarified with the physician the frequency for the dressing changes. CLINICAL RECORD 7: The patient’s election of the hospice benefit was dated 07/14/2025 with a primary diagnosis of End stage renal disease. The Interdisciplinary Group (IDG )meeting on 07/23/2025 and 08/06/2025 included documentation from the respiratory therapist recommending Albuterol 2.5 mg every 4 hours as needed for shortness of breath. As of the record review on 08/12/2025 there has been no documentation that this was followed up with. During an interview with the Executive Vice President, who spoke with the respiratory therapist, who stated that the patient had refused the albuterol but agreed that this had not been documented correctly in the IDG and that the RN was aware, but they had not documented this coordination. During interview with the Executive Vice President on 08/14/2025 stated that the documentation was not present and that the staff members were new to hospice and follow up education was being done.

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 and interview. In 2 of 30 (7%) clinical records reviewed it was revealed that the agency did not ensure the plans of care included the specific interventions based on problems identified. CLINICAL RECORD 3: The hospice benefit of election was dated 01/24/2025 with a primary diagnosis of Alzheimer's Disease. A Physician order effective 07/17/2025 was for a Purewick Catheter. The plan of care updated on 07/30/2025 and on 08/13/2025 did not include any documented interventions for this catheter related to tubing and emptying of the drainage system. CLINICAL RECORD 18: The hospice benefit of election was 07/03/2025 with a primary diagnosis of Ischemic Cardiomyopathy. The initial plan of care dated 07/09/2025 and the updated plans of care every 2 weeks did not include interventions for the peripherally inserted central line catheter (PICC)) located in right chest. The PICC line had a continuous Milrinone infusion. There was no documented evidence of interventions for the infusion site assessment, the sterile dressing change, required tubing change and use of CADD infusion pump. During interview on 08/14/2025, the Executive Vice President stated that education would be provided especially for some of the newer staff as the interventions were not documented on the plans of care.

It is required that the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment; record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the plan of care was updated. CLINICAL RECORD 10: The hospice benefit of election was dated 05/13/2025 with a primary diagnosis of unspecified protein calorie malnutrition. The Interdisciplinary Group (IDG) notes dated 06/26/2025, 07/09/2025, 07/23/2025, 07/30/2023 and 08/06/2025 included a treatment for a foley catheter to be changed monthly and may be irrigated. The patient did not have a catheter, but the plan of care was not updated. During an interview, the Executive Vice President stated that the plan was not correct at the time of review but has been updated as the patient refused the catheter.

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 and interview. In 10 of 23 (43%) clinical records reviewed for patients that accepted the hospice aide, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 1: The patient’s election of benefit (EOB) was dated 02/04/2024 with diagnosis of Senile degeneration of the brain. The hospice aide assignment that was updated on 06/11/2025 included a task to apply barrier cream as directed but no directions for where to apply the cream and no identified decision maker. The hospice aide visited 2 times a week. CLINICAL RECORD 3: The patient’s election of benefit (EOB) was dated 01/08/2024 with diagnosis of Alzheimer’s. The hospice aide assignment that was updated 07/08/2025 included a task to apply barrier cream as directed but no directions for where to apply the cream and no identified decision maker. The hospice aide visited 4 times a week. CLINICAL RECORD 4: The patient’s election of benefit (EOB) was dated 07/20/2021 with a diagnosis of Alzheimer’s. The hospice aide assignment that was updated 07/09/2025 included a task to apply barrier cream as directed but no directions for where to apply the cream and no identified decision maker. The frequency for the aide was 5 days per week. CLINICAL RECORD 5: The patient’s election of benefit (EOB) was dated 07/02/2025 with a diagnosis of Parkinsons Disease. The hospice aide assignment dated 07/02/2025 included a frequency of 3 days per week and a task to apply barrier cream as directed however, there were no directions for where to apply and no identified decision maker. CLINICAL RECORD 6: The patient’s election of benefit (EOB) was dated 05/30/2025 with a diagnosis of Senile degeneration of the brain. The hospice aide assignment dated 05/30/2025 included aide frequency of 3 times a week and a task to apply barrier cream every visit however, there were no directions for where to apply and no identified decision maker. CLINICAL RECORD 10: The patient’s election of benefit (EOB) was dated 05/13/2025 with a diagnosis Unspecified protein-calorie malnutrition. The aide assignment dated 05/13/2025 included a task to apply barrier cream every visit however, there were no directions for where to apply it and no identified decision maker. The clinical record included an order dated 07/30/2025 for a Foley catheter that was placed. The aide assignment was not updated with directions for catheter care or emptying of the drainage bag. CLINICAL RECORD 16: The patient’s election of benefit (EOB) was dated 07/17/2025 with a diagnosis of breast cancer. The hospice aide assignment dated 07/17/2025 included a task to apply barrier cream every visit but no directions for where to apply it. There was no identified decision maker. CLINICAL RECORD 18: The patient’s election of benefit (EOB) was dated 07/03/2025 with a diagnosis of ischemic cardiomyopathy. The hospice aide assignment dated 07/03/2025 included a task to apply barrier cream every visit however, there was no direction for where to apply this. There was no identified decision maker. Additionally, the patient had a peripherally inserted central catheter (PICC) line in the right chest that was present upon admission 07/03/2025; that has an occlusive dressing. The hospice aide had a task for complete bed bath every visit but no direction for what to do if the dressing was off or had drainage. CLINICAL RECORD 19: The patient’s election of benefit (EOB) was dated 11/19/2024 with a diagnosis of Laryngeal C. The hospice aide assignment dated 11/19/2024 included a task to apply barrier cream every visit however, there was no direction for where to apply this. There was no identified decision maker. Additionally, the patient was admitted on 11/19/2024, with a G (gastric) tube. The bath assignment was a complete bed bath every visit. There was no direction for the aide for care around the G tube site or that it was located in the abdomen. CLINICAL RECORD 28: The patient’s election of benefit (EOB) was dated 02/18/2025 with a diagnosis of prostate cancer. The hospice aide assignment dated 07/09/2025 included a task to apply barrier cream every visit however, there was no direction for where to apply this. There was no identified decision maker. The hospice aide visit frequency was 5 times a week. Additionally, the patient was admitted on 02/18/2025; with nephrotomy tubes that attached to bag drainage. The bathing task assigned every visit was a bed bath. There were no directions for cleaning around the tubes or emptying of the drainage bag During interview with the Executive Vice President on 08/13/2025, she stated that the directions were not complete on the aide assignments. She stated that coordination happened with the aide but agreed that this was not documented

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 2 of 21 (10%) Clinical records in which a hospice aide was accepted and provided services for greater than 14 days, the agency did not ensure the aide supervision every 14 days by the registered nurse. CLINICAL RECORD 5: The first aide visit was documented on 07/08/2025 with a frequency of 4 times a week. There was no documented evidence of aide supervision in the clinical record as of the review date 08/13/2025. CLINICAL RECORD 18: A review of the clinical record on 08/13/2025 included aide supervisory visits every 14 days until 07/25/2025. The hospice aide was providing care three times a week as of the IDG dated 07/30/2025. There were no additional aide supervisor visits after 07/25/2025 as of the review date on 08/13/2025. During interview with the Executive Vice President on 08/14/2025 who stated that after reviewing the supervision was not documented but interview with the nursing staff revealed that the aide and nurse had made several visits together and supervision had been completed but not documented.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Noted in the plan of care. Documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical records in which a volunteer was accepted, the agency did not ensure the volunteer services were provided. CLINICAL RECORD 1: The hospice benefit of election was 02/04 2024 with a primary diagnosis of senile degeneration of the brain. A referral for volunteer to provide pet therapy was dated 06/02/2025. There were no documented visits as of review 08/12/2025 and no documentation why the visits were not provided. During interview with the Executive Vice President on 08/14/2025 stated that the patient had refused the volunteer but agreed that this had not been documented. CLINICAL RECORD 5: The hospice benefit of election was 01/25/2024 with a primary diagnosis of Alzheimer's Disease. The order for volunteer was dated 07/02/2025 for pet therapy. Volunteer visits were dated 7/7/2025 and 7/30/2025. The IDG (interdisciplinary group meeting) documented on 07/23/2025 and 08/07/2023 documented that the volunteer weekly continued. There was no documentation for why visits were missed. CLINICAL RECORD 6: The hospice benefit of election was 05/30/2025 with a primary diagnosis of Denile degeneration of the brain. An order for volunteer was documented on 06/05/2025. The order was for a volunteer harpist. There were no documented visits. The IDG on 07/232025 and 08/06 20/25 documented that referral for harpist received but no documentation to progress or coordination with the family. During interview with the Executive Vice President on 08/14/2025 who stated that coordination notes were not documented but the volunteer director had contacted each of the families and the families were refusing the volunteer or understood the delay and were appreciative of the notifications but that this coordination was not documented in the record.

It is required that the hospice inpatient facility documents the training and demonstration of competency in restraint or seclusion in each designated employee’s personnel record. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 2 (50%) personnel records for agency staff providing care in the inpatient unit (IPU), the agency did not ensure that staff received training in restraint and seclusion per the agency's policy. POLICY AND PROCEDURES: The agency's Restraint Free Environment of Care (Policy Number HH-733-PC, last revised 11/2023) stated, in part, "Staff will receive annual education on de-escalation techniques to ensure that all are prepared to address circumstances that could result in patient harm related to unsafe behavior. Staff will be assigned the training "Obtaining a Restraint Free Environment" within the (name of education) platform." PERSONNEL RECORD 7: The personnel record for this licensed practical nurse (LPN), who was hired on 01/30/2017 and who provided care in the agency's IPU, did not contain any documented evidence that the staff member completed training in de-escalation techniques or was assigned the required training in the agency's education platform. During an interview with the Vice President of Mission Quality (Personnel Record15), she confirmed that there was no documented evidence of the required trainings for this staff member in her personnel record. She also stated that she confirmed with the Executive Director of the IPU that additional evidence of such trainings was not present outside of the personnel record.

Based on clinical record review and staff interview, the Hospice failed to ensure the timely and effective symptom management related to the terminal illness of Acute Respiratory Failure with Hypoxia, COVID-19, Viral Pneumonia, unspecified, and Interstitial Pulmonary Disease, unspecified. This was evident in one (1) of three (3) records reviewed (Patient #1). Failure to ensure timely and effective symptom management measures, has the potential for negative patient outcome. --- Patient #1 has a start of care date of 1/6/2025 and expired on 1/8/2025. The ";Physician Orders" dated 1/6/2025 documents the active medications but lacks documented evidence of the start of care date, certification period, patient diagnoses, services/frequency/duration, interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information. The Hospice Physician Certification of Terminal Illness dated 1/6/2025 documents the following diagnoses, "Acute Respiratory Failure with Hypoxia, COVID-19, Viral Pneumonia, unspecified, and Interstitial Pulmonary Disease, unspecified". The Referral/Discharge instructions dated 1/6/2025 documents, "Patient will continue with IV (Intravenous) Solu-Medrol 60 milligrams every 6 hourly". ";Physician Orders" dated 1/6/2025 active medications orders lack documented evidence of Methylprednisolone. 1/8/2025 Physician Orders documents, ";Start Methylprednisolone 60 mg every 6 hours steroid therapy". The steroid was ordered 2 days after the patient arrived at the hospice. There is no documented evidence the patient received Intravenous Prednisone every 6 hours after the patient transferred to the hospice. There is no documented evidence the Hospice has methods in place to ensure all distressing symptoms are controlled effectively in a timely manner 24 hours a day/7days per week. During an interview with the Hospice team (Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services) on 2/18/25 at 2:50 PM , the team states, "the medication error was identified and a root cause analysis is completed". On 2/18/25 at 4:50 PM the findings were reviewed with the Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services.

Based on clinical record reviews and staff interviews the agency failed to ensure that patients/family participated at all times in the plan of care and give updated consent on all treatment/medication, including morphine administration/dosage. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure that patients/family are included in the plan of care and give updated consent on all treatment/medication, including morphine administration/dosage has the potential for negative patient outcomes. --- Patient #1 has a start of care date of 1/6/2025 and expired on 1/8/2025. The ";Physician Orders" dated 1/6/2025 documents the active medications but lacks documented evidence of the start of care date, certification period, patient diagnoses, services/frequency/duration, interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information. The skilled nursing note titled, "Hospice Nursing Assessment Update" dated 1/7/25 documents the following: ";10:00 AM respiratory rate 30, saturation 86 percent, on (High Flow nasal cannula settings) 6 Liters 100 percent; family declines morphine administration for dyspnea at this time. 11:20 AM respiratory rate 36, saturation 83 percent, 11:23 AM morphine 2 milligrams administered for dyspnea 1600 PM respiratory rate 40 saturation 75 percent, morphine administered 1850 PM morphine 2 milligrams STAT (immediately) one time dose administered". There is no documented evidence the patient and/or family consented/agreed to morphine administration. On 2/18/25 at 5:00PM the findings were reviewed with Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services.

Based on clinical record reviews and interview, the agency failed to ensure all comprehensive assessments are complete. This was evident for -- () of three (3) clinical records reviewed Failure to ensure all assessments are complete, has the potential for negative patient outcomes. --- Patient #1 has a start of care date of 1/6/2025 and expired on 1/8/2025. The ";Physician Orders" dated 1/6/2025 documents the active medications but lacks documented evidence of the start of care date, certification period, patient diagnoses, services/frequency/duration, interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information. On 2/18/25 at 2:50 PM during the interview with the Hospice team, the team states, ";the patient speaks another language other than English". 1/6/2025- The "Hospice Nursing Assessment Update" documents, "Mental Status: oriented to time, place, person, event; Vital Signs: blood pressure 107/56, pulse 83, respiration 22, temperature 97.6". There is no documented evidence of the pulse oximeter oxygen saturation for dyspnea screening. The assessment lacks documented evidence of the patient primary language and/or if the patient spoke adequate English for communication, and was able to understand the what was being said during the assessment. There is no documented evidence an interpreter was used and/or who translated for the patient during assessments. On 2/18/25 at 3:00 PM during the interview with the Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services no explanation provided. On 2/18/25 at 4:50 PM findings were reviewed with the Hospice team.

Based on clinical record reviews and staff interview the Governing Authority failed to ensure the review of all medications the patient is currently using in order to identify any potential adverse effects and drug interaction is being conducted. This was evident in one (1) of three (3) clinical records reviewed (Patient #1). Failure to review all medications the patient is currently using to identify any potential adverse effects and drug interaction has the potential for negative patient outcomes. --- Patient #1 has a start of care date of 1/6/2025 and expired on 1/8/2025. The ";Physician Orders" dated 1/6/2025 documents the active medications but lacks documented evidence of the start of care date, certification period, patient diagnoses, services/frequency/duration, interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information. The Referral/Discharge instructions dated 1/6/2025 documents, "Patient will continue with IV (Intravenous) Solu-Medrol 60 milligrams every 6 hourly". There is no documented evidence of Solu-Medrol/Methylprednisolone in the assessment. The comprehensive assessment lacks documented evidence of a review of all of the patient's current/active medications and other alternative treatments that could affect drug therapy. There is no documented evidence medication reconciliation was conducted during the assessment. On 2/18/25 at 2:50 PM during the interview with the Vice President of Mission Quality, the Vice President of Mission Quality states, "the agency does not have a current workflow process to double check medication order entry". On 2/18/25 at 4:50 PM the findings were reviewed with the Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services.

Based on record reviews and staff interviews, the hospice failed to develop complete individualized Plans of Care and ensure the provision of care in accordance with written Patient Plans of Care to address all Patient needs. This was evident for two (2) of three (3) patient care records reviewed. (Patients #1, and #2). Failure to develop complete individualized Plans Of Care to address all patient needs has the potential for negative patient outcomes. --- 1.Patient #1 has a start of care date of 1/6/2025 and expired on 1/8/2025. The Hospice Physician Certification of Terminal Illness dated 1/6/2025 documents the following diagnoses, "Acute Respiratory Failure with Hypoxia, COVID-19, Viral Pneumonia, unspecified, and Interstitial Pulmonary Disease, unspecified". The Plan of Care titled ";Physician Orders" dated 1/6/2025 lacks documented evidence of: The start of care date. Certification period. The patient diagnoses, the nature and condition causing admission. Services such as Skilled Nursing, Medical Social Service, Pastoral Care, and hospice aide Services including frequency /duration necessary for the palliation and management of the terminal illness, and Interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information to meet the patient care needs. 2. Patient #2 has a start of care date 10/1/24. The Plan of Care titled "Physician Orders" dated 2/12/2025 lacks documented evidence of the start of care date, certification period, patient diagnoses, services/frequency/duration, interventions/goals, prognosis, activity, medical supplies, allergy and other pertinent information. There is no documented evidence of a written individualized plan of care to meet the patients care need. On 2/18/25 at 3:50 PM Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services were interviewed. No explanation provided. On 2/18/25 at 4:50 PM the findings were reviewed with the Vice President of Mission Quality, Executive Director, and Coordinator of Patient Services

Observed in Infection Control Tracer. In a review of the HCO’s Emergency Management Plan, there were several requirements that were not addresses. For example, the surveyor noted there was no program evaluation for the past two years. These findings were reviewed, discussed and confirmed with the EM Coordinator, the VP Mission Quality and the CEO.

Observed in Environment of Care Session. In a review of the HCO’s Emergency Preparedness Plan, there were several requirements that were not addressed. For example, the surveyor noted that the organization had not identified in writing the potential emergencies that could affect its ability to provide services and the likely consequences of those emergencies (HVA). These findings were reviewed, discussed, and confirmed with the EM Coordinator, the VP Mission Quality and the CEO.

Observed in Emergency Management Session. In a review of the HCO’s Emergency Management Plan, there were several requirements that were not addressed. For example, the surveyor noted the organization did not have documentation to show that staff were trained on emergency management at least every two years. These findings were reviewed, discussed, and confirmed with the EM Coordinator, the VP Mission Quality and the CEO.

Observed in Record Review. In 3 of 9 patient records reviewed, The chaplain and social worker failed to complete their initial assessments within five days after the patient election of hospice. On HV #5/RR 5, RR #6 and RR #9, the surveyor noted there was no chaplain and/or social work assessment as a part of the initial comprehensive assessment, nor was there communication documentation, addressing the delay reason. This is required, per the organization policy. These findings were reviewed, discussed and confirmed by the VF, Mission Quality and RN VP, Patient Services

Observed in Record Review. In 3 of 9 patient records reviewed, The bereavement risk assessment was not completed, as a part of the initial comprehensive assessment. On HV #2/RR #2, HV #3/RR #3 and HV #5/RR #5 the hospice surveyor noted the bereavement risk assessment had not been completed. The HCO’s policy requires the medical social worker to complete the initial bereavement assessment for patients admitted to their hospice program. These findings were reviewed, discussed, and confirmed with the VP Mission Quality and the RN VP of Patient Services.

Observed in Record Review. In 9 of 9 patient records reviewed, The hospice did not ensure patient care plan goals were individualized, measurable, and reassessed at appropriate time frames. Examples include the following: CP goals pt/cg will express feelings and questions openly by 5/5/222, changes in respiratory status will be identified and managed in the next 2 weeks 5/3/22, plan of care will be altered to accommodate prn visits due to concerns for Covid-19 w/in 2 weeks start 12/29/21, pt/pg. will identify spiritual needs, Pt to exhibit fewer episodes of agitation/behavioral outbursts with/in 2 weeks. Start effective date: 06/20/2022, pt will have at least 1 bm every 3 days over the next 2 weeks. These stated goals do not contain information specific to the individual patients’ diseases and consistently were not updated between interdisciplinary group meetings and certification periods, hindering the organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed and validated with the organizations, VP of Mission Quality and the RN VP of Patient Services..

Observed in Data Session. In a review of the HCO’s Quality Program, the surveyor noted the Hospice QAPI program was not evaluated annually. These findings were reviewed, discussed and confirmed with the VP Mission Quality, the CEO and the Chairperson of the Board.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to use standard infection prevention and control precautions at times required by the organization's policies. For example, with HV #2/RR #2, the surveyor observed the hospice aide making the patient’s bed, examining the patient’s fingernails, and going in and out of her bag, without completing hand hygiene between tasks. The organization policy requires standard precautions to be used, including hand hygiene, to prevent and control infection when conducting direct patient care. These findings were discussed and confirmed with the patient care coordinator.

Observed in Record Review. In 9 of 9 patient records reviewed, The registered nurse did not ensure the hospice aide’s care plan for patient care include the visit frequency, as evidenced by 9 of 9 patient health records, with orders for hospice aides, the aide care plan did not contain a visit frequency. The organization’s policy requires the RN to include the visit frequency as a part of the aide’s care plan. These findings were reviewed, discussed and confirmed with the VP mission quality and the RN VP of Patient Services.

Observed in Record Review. In 2 of 9 patient records reviewed, The registered nurse did not complete hospice aide supervisory visits every 14 days. On HV #3/RR #3 and RR #8 the surveyor noticed there was at least a 30-day space between documentation of hospice aide supervisory visits by a registered nurse. Regulations require a registered nurse to conduct supervisory visits at a time frame of every 14 days, to ensure ordered aide services meet the patient’s needs. These findings were reviewed, discussed and confirmed with the organization’s VP Mission Quality.

Observed in Patient Home. In 1 of 1 home visits conducted, The HCO did not ensure the patient’s facility record contain documentation pertinent to hospice care, for example, the surveyor noticed in the facility health record for HV #2/RR #2, multiple documents were missing, including copies of the patient’s hospice consent for treatment, the hospice plan of care, the hospice aide plan of care, and the patient’s hospice medication administration record. The organization’s policy/procedure for patients admitted to healthcare facilities is for copies of hospice documents to be placed behind the “hospice” tab in the patient’s hard chart. Findings were discussed and confirmed with the patient care coordinator and director of facility care.