Every finding on record at Inhouse Hospice LLC

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment and records 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 2 of 6 (33%) clinical records reviewed with revision to the plan of care, the agency did not ensure the revised plan of care included the patient’s progress towards outcomes and goals specified in the plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/21/2024 with diagnosis of cerebral vascular accident. Clinical record review revealed the Volunteer was ordered on 11/12/2024 to provide services of companionship and socialization. The Volunteer documented visits were provided on 11/06/2024, 11/22/2024, and 01/15/2025. The IDG (interdisciplinary group meeting) documented during meetings dated 11/14/2024, 11/27/2024, and 01/20/2025 that the plan of care was reviewed, but there was no documented evidence of the patient’s progress towards the volunteer goals for companionship and socialization. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/12/2024 with diagnosis of cerebral vascular disease. Clinical record review revealed the Volunteer was ordered on 09/23/2024 to provide services of companionship and socialization. The Volunteer documented visits were provided on 09/26/2024, 10/09/2024, 10/22/2024, and 11/06/2024. The IDG documented during meetings dated 10/06/2024, 10/30/2024, and 11/13/2024 that the plan of care was reviewed, but there was no documented evidence of the patient’s progress towards the volunteer goals for companionship and socialization. During an interview and review of records on 05/29/2025, the Administrator stated that the agency is in the process of interviewing for the position of Volunteer Coordinator and that person will attend IDG meetings to update the plans of care as needed.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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, observation, and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared patient specific care instructions for the hospice aide. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 01/15/2025 with diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the patient had a Foley catheter connect to a large drainage bag placed on 03/31/2025. The updated hospice aide care plan assignments dated 04/25/2025, 05/07/2025, and 05/28/2025 did not include the Foley catheter. During the home visit observation on 05/28/2025, with the Registered Nurse (RN) (Personnel Record 2), the patient was observed to still have the Foley catheter with large drainage bag in place. During an interview on 05/29/2025, the Administrator and the Director of Quality stated that they had reviewed the record, and the Foley catheter was not on the aide plan and should have been.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/15/2025 with diagnosis of chronic obstructive pulmonary disease. The hospice aide care plan dated 01/15/2025 and updated on 03/24/2025 assigned the aide the task of shower every visit. The Hospice Aide (HA) documented on aide visit notes dated 02/10/2025, 02/21/2025, 02/25/2025, and 03/21/2025 that the patient was provided with a bed bath. The hospice aide did provide services as ordered in the plan of care and there was no documentation in the clinical record as to why the patient was given a bed bath instead of a shower. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/31/2024 with diagnosis of cerebral vascular accident. The hospice aide care plan updated on 02/03/2025 assigned the aide the tasks of shower and shampoo every visit. The Hospice Aide documented on the aide visit notes dated 02/06/2025 and 03/19/2025 that a shower and shampoo were not required and, on the aide visit notes dated 02/26/2025, 03/18/2025, 03/27/2025 the HA documented shampoo not required. The hospice aide did provide services as ordered in the plan of care and there was no documentation in the clinical record as to why the tasks were not provided to the patient. During an interview and joint review of records on 05/29/2025, the Administrator and the Director of Quality stated that the aide had not provided care as ordered and had not documented why the care was not provided.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed with aide services provided, the agency did not ensure the aide documented reporting changes in the patient’s care to the Registered Nurse. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/15/2025 with diagnosis of chronic obstructive pulmonary disease. The hospice aide care plan dated 01/15/2025 and updated on 03/24/2025 assigned the aide the task of shower every visit. The Hospice Aide (HA) documented on aide visit notes dated 02/10/2025, 02/21/2025, 02/25/2025, and 03/21/2025 that the patient was provided with a bed bath. There was no documentation in the clinical record that the HA reported the change in the patient’s care to the Registered Nurse. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/21/2024 with diagnosis of protein calorie malnutrition. The plan of care dated 08/21/2024 to 11/18/2024 included an order for hospice aide services twice a week. The HA was assigned to provide the patient a shower and shampoo at each visit. The HA documented on the aide visit notes dated 09/03/2024 and 09/05/2024 that the patient refused the shower and shampoo. There was no documentation in the clinical record that the HA reported the change in the patient’s care to the Registered Nurse. During an interview and joint review of records on 05/29/2025, the Administrator and the Director of Quality stated that they have been working on this process and have a process improvement in place.

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 4 of 13 (31%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse supervised the Hospice Aide no less frequently than every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/15/2025 with diagnosis of chronic obstructive pulmonary disease. The plans of care dated 01/15/2025 to 04/14/2025 and 04/15/2025 to 07/13/2025 included an order for the Hospice Aide to provide visits twice a week. Clinical record review revealed the Registered Nurse (RN) provided an aide supervisory visit on 04/04/2025 and the next aide supervisory visit was dated 05/03/2025, a total of 29 days and 15 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/21/2024 with diagnosis of protein calorie malnutrition. The plans of care dated 01/18/2025 to 3/18/2025 and 03/19/2025 to 05/17/2025 included an order for the HA to provide visits twice a week. Clinical record review revealed the RN provided an aide supervisory visit on 03/11/2025 and the next aide supervisory visit was dated 03/27/2025, a total of 16 days and 2 days outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/31/2024 with diagnosis of cerebral vascular accident. The plan of care dated 03/31/2025 to 06/28/2025 included an order for the HA to provide visits twice a week. Clinical record review revealed the RN provided an aide supervisory visit on 05/12/2025 and the next aide supervisory visit was dated 05/28/2025, a total of 16 days and 2 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/12/2025 with diagnosis of cerebral vascular accident. The plan of care dated 03/12/2025 to 06/09/2025 included an order for the HA to provide visits once a week for one week, then twice a week for 12 weeks. Clinical record review revealed the RN provided an aide supervisory visit on 03/24/2025 and the next aide supervisory visit was dated 04/12/2025, a total of 19 days and 4 days outstanding. During an interview and review of records on 05/29/2025, the Administrator and the Director of Quality stated that the issue with aide supervision was self-identified, and they are working on a process improvement at this time.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure hospice volunteer services equaled 5% of the total patient care hours of all hospice employees. During an interview with the Administrator and the interim Volunteer Coordinator on 05/29/2025, the cost savings report for the 12 months of 2024 was reviewed. The report showed the agency’s cost saving was 1.20% for 2024. The Administrator and the interim Volunteer Coordinator explained that efforts are in place to increase this percentage and work is being done. They stated 2 volunteer interviews are scheduled for next week. During the interview, the Administrator stated they are preparing to hire a new Volunteer Coordinator and have worked on recruitment processes. Review of volunteer cost savings during interview with the administrator and interim volunteer coordinator on 05/29/2025. The cost savings for the 12 months of 2024 were 1.20%. The cost savings continue with the percentage so far in 2025, and efforts are in place to increase and work on this. There are 2 volunteers coming for interviews next week.

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, herbal remedies, other alternative treatments that could affect drug therapy. 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 of clinical records and interviews. In 1 of 11 (9%) records, review revealed the agency did not ensure the use of oxygen was documented on the medication profile. Clinical Record 5 - The benefit periods dated 5/6/22 and 8/3/22 were reviewed. The initial plan of care dated 5/6/2022 and the physician order documented the patient's use of oxygen. The skilled nurse visit notes documented education of oxygen safety in the home. The medication list did not include oxygen on either plan of care or any updated medication profiles. During joint review of the record and interview with the Vice President of Clinical Services on 8/18/2022, no additional documentation could be found.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 9 (22%) clinical records reviewed revealed the agency did not ensure aide services were provided as ordered on the plan of care. Clinical Record 8 - The SOC was dated 6/7/2022. The aide Plan of Care dated 6/7/22 assigned the aide to shave the patient "weekly". The aide visits were ordered 5 times a week. During the week ending 8/13/22, the aide documented the patient was shaved during the visits dated 8/8/22, 8/9/22, 8/10/22, and 8/11/22, which was completed during the 4 visits completed that week. Clinical Record 3 - The Start of Care (SOC) was dated 6/8/22. The plan of care included orders for aide visits to be provided as "1wk1 and 3wk13". During the week ending 6/11/2022, there was no evidence of aide visit provided, no documentation of a missed aide visit, and no documentation that the nurse was notified. Also, the aide Plan of Care dated 6/8/2022 assigned the aide to complete a shampoo 2 times a week. During the week ending 6/18/2022, the aide provided a shampoo 3 times that week at each visit dated 6/13/2022, 6/15/2022, and 6/17/2022. During the week ending 7/9/2022, the aide provided a shampoo 1 time at the visit dated 7/6/22. There was no documentation on any of the other aide visits provided during the week that the second shampoo was provided. During interview on 8/18/2022, the Vice President of Clinical Services stated, "We have an opportunity to provide additional education".

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 11 (9%) clinical records reviewed the agency did not ensure a physician order included all of the required elements of an order, including identification of the applicable clinical discipline. Clinical Record 2 - The benefit period reviewed was dated 6/8/22-9/5/22. A physician order dated 7/12/22, written by a registered nurse, documented "Increase the visit frequency to 3 times for 1 week". The order did not specify the clinical discipline associated with the visit orders. During interview and joint review of the clinical record with the Vice President of Clinical Services on 8/18/2022, she stated, "The order does not say what discipline the visit frequency was written for."