Every finding on record at Journey Hospice Care Inc

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 and 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 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide was supervised by the Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/13/2024 and was recertified for multiple episodes of care. For the episode of care dated 05/11/2025 to 07/10/2025 hospice aide services were ordered twice a week. The Registered Nure (RN) documented an aide supervisory visit on 05/12/2025 and the next aide supervisory visit was dated 05/27/2025, a total of 15 days and 1 day outstanding. The RN documented an aide supervisory visit on 06/26/2025 and the next aide supervisory visit was dated 07/11/2025, a total of 15 days and 1 day outstanding. During a joint review of the record and interview on 08/20/2025, the Director of Patient Care Services (Personnel Record 2) stated the reason the hospice aide supervisory visit was done on the 15th day was due to the patient rescheduling the nursing visit. She stated that they would be looking at the scheduling and working on a new process.

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 records reviewed of patients who were discharged from hospice services, the agency did not ensure the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/05/2025 and revoked hospice services on 04/13/2025. There was no documented evidence in the clinical record that the discharge summary was sent to the patient's attending physician. During a joint review of the records and interview on 08/20/2025, the Director of Patient Care Services (Personnel Record 2) stated they sent the information to the hospital the patient entered when they revoked hospice care, but they did not send it to the attending physician. The Director of Patient Care Services stated that additional education will be given to the staff on the discharge process.

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 interviews. 2 of 13 (15%) records reviewed revealed that the hospice did not ensure that comprehensive assessment was completed timely. Clinical Record 11: The patient was admitted to hospice care on 7/30/22. The social worker assessment was completed on 8/11/22. There was no documented evidence that the patient or family declined the visit or requested that this visit be rescheduled. Clinical Record 1: The patient was admitted to hospice care on 7/9/22. The initial chaplain assessment was completed on 9/13/22. There was no documented evidence that the patient or family declined a visit or requested that this visit be rescheduled. The Director of Patient Care Services acknowledge in an interview on 10/25/22 that the assessments were not completed or documented timely.

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 and interviews. 2 of 13 (15%) clinical record review revealed the hospice did not ensure that a bereavement assessment was completed as a part of the comprehensive assessment. Clinical Record 1 The patient elected hospice services on 7/9/2022 and the comprehensive assessment was completed on 7/9/22. The record lacked evidence of a completed bereavement assessment. Clinical Record 13 The patient elected hospice services on 12/24/2022 and the comprehensive assessment was completed on 12/24/22. The record lacked evidence of a completed bereavement assessment. The Director of Patient Care Services acknowledged in an interview on 10/25/22 that there was no documentation of an initial bereavement assessment completed at the time of the comprehensive assessment.

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, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 7 of 13 (54%) records reviewed for patients receiving hospice services revealed that the agency did not ensure that the services as ordered on the plan of care (POC) were being provided to patients. Clinical Record 6: The patient elected hospice care on 4/5/2022. The POC dated 4/5/2022 ordered chaplain services one time a month. A missed chaplain visit was identified the month of September 2022. The record lacked documentation of why the visit was not provided as ordered and that the physician was notified. Clinical Record 11: The patient elected hospice care on 7/30/2022. The POC dated 7/30/2022 ordered chaplain services one time a month. A missed chaplain visit was identified the month of September 2022. The record lacked documentation of why the visit was not provided as ordered and that the Physician was notified. Clinical Record 7: The patient elected hospice care on 4/4/2022. The POC dated 4/4/2022 ordered social worker services one time a month. A missed social worker visit was identified the month of August 2022. The record lacked documentation of why the visit was not provided as ordered and that the physician was notified. Clinical Record 8: The patient elected hospice care on 5/13/2021. The POC dated 5/13/2021 ordered skilled nursing services two times per week. One missed skilled nursing visit was identified the weeks ending 9/10/22, 9/17/22, 9/24/22, 10/1/11, 10/8/22, 10/15/22. The record lacked documentation of why the visits were not provided as ordered and that the physician was notified. Clinical Record 9: The patient elected hospice care on 3/8/2021. The POC dated 3/8/2021 ordered skilled nursing services two times per week. One missed skilled nursing visit was identified the weeks ending 9/10/22 and 10/1/22. The record lacked documentation of why the visits were not provided as ordered and that the Physician was notified. Clinical Record 3: The patient elected hospice care on 5/19/22. The POC dated 5/19/22 ordered skilled nursing services two times per week. One missed skilled nursing visit was identified the weeks ending 8/13/22, 8/20/22, 8/27/22, 10/1/22 and 10/8/22. The record lacked documentation of why the visits were not provided as ordered and that the physician was notified. Clinical Record 4: The patient elected hospice care on 4/5/22. The POC dated 4/5/22 ordered skilled nursing services two times per week. One missed skilled nursing visit was identified the week ending 9/24/22. The record lacked documentation of why the visit was not provided as ordered and that the physician was notified. Clinical Record 11: The patient elected hospice care on 7/30/2022. The POC dated 7/30/2022 ordered social worker services one time a month. A missed social worker visit was identified the month of August 2022. The record lacked documentation of why the visit was not provided as ordered and that the Physician was notified. Clinical Record 7: The patient elected hospice care on 4/4/2022. The POC dated 4/4/2022 ordered chaplain services one time a month. A missed chaplain visit was identified the month of August 2022. The record lacked documentation of why the visit was not provided as ordered and that the physician was notified. Clinical Record 9: The patient elected hospice care on 3/8/2021. The POC dated 3/8/2021 ordered chaplain services one time a month. A missed chaplain visit was identified the month of September 2022. The same POC ordered social work services one time a month. A missed social work visit was identified the month of September 2022. The record lacked documentation of why the visit was not provided as ordered and that the physician was notified. The Director of Patient Care Services was interviewed during a joint review of the clinical record on 10/25/2022. She explained, "during a time of staffing issues the IDT reviews visit frequency, and if they determine a change can be made a new order needs to be written and updated on the POC." The social worker and chaplain visit frequencies/orders were not updated and the agency did not have documentation of missed visits or why the visits was not provided.

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; as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 13 (23%) records reviewed revealed that the agency did not ensure that the Interdisciplinary Team (IDT) review the patients individual care plan as required. Clinical Record 1: The patient elected hospice care on 7/9/2022. There was an IDT on 7/28/22 and the next IDT for this patient was on held on 8/25/22. There was no documentation of why the IDT review for the patient's plan of care did not occur less frequently than every 15 calendar days or within 21 days as permitted under the PHE waiver. Clinical Record 3: The patient elected hospice care on 5/19/2022. There was an IDT held on 9/12/22; the next IDT for this patient was on 10/6/22. There was no documentation of why the IDT review for the patient's plan of care did not occur less frequently than every 15 calendar days or within 21 days as permitted under the PHE waiver. Clinical Record 7: The patient elected hospice care on 4/4/2022. There was an IDT held on 9/12/22 the next IDT for this patient was on 10/6/22. There was no documentation of why the IDT review for the patient's plan of care did not occur less frequently than every 15 calendar days or within 21 days as permitted under the PHE waiver. The Director of Patient Care Services was interviewed during a joint review of the clinical record on 10/25/2022. She explained, "that during this time there were challenges with staffing and changes were being made within the management staff."

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 interviews. 6 of 13 (46%) records reviewed for patients receiving aide services revealed that the agency did not ensure that the hospice aide provided services as ordered on the plan of care (POC). Clinical Record 2 The patient elected hospice care on 7/1/2022. The POC dated 7/1/2022 ordered aide services three times weekly. One missed aide visit was identified the week ending 9/17/2022 and the week ending 10/1/22. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician was notified. Clinical Record 4 The patient elected hospice care on 2/26/2022. The POC dated 2/26/2022 ordered aide services three times weekly. One missed aide visit was identified the week ending 10/1/2022. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician was notified. Clinical Record 7 The patient elected hospice care on 4/4/2022. The POC dated 4/4/2022 ordered aide services three times weekly. One missed aide visit was identified the week ending 9/10/2022. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician was notified. Clinical Record 11 The patient elected hospice care on 7/30/2022. The POC dated 7/30/2022 ordered Aide services three times weekly. One missed aide visit was identified the week ending 9/17/2022. The record lacked documentation of why the visit was not provided as ordered and that the RN or Physician was notified. The Director of Patient Care Services was interviewed during a joint review of the clinical record on 10/25/2022 and confirmed that the aide visits were missed. The agency did not have documentation of the missed visits or reason for the missed visits.

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 a review of clinical records and interviews. 1 of 1 (100%) record reviewed for patients discharged from services revealed that the agency did not ensure that a discharge summary was sent to the physician. Clinical Record 13 The patient was discharged from services on 9/30/22. The record lacked evidence that the discharge summary had been forwarded to the patient's physician. The Director of Patient Care Services acknowledged in an Interview on 10/25/22 that there was no documentation validating that the discharge summary was provided to the physician.