Every finding on record at Legacy Family Hospice, 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. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/15/2025 with diagnoses of malignant neoplasm of bilateral ovaries, colostomy (a surgical procedure that involves creating an opening in the large intestine through the abdominal wall), and pure wick urinary catheter. The nurse documented on the initial comprehensive assessment dated 11/15/2025 that the patient had a colostomy and a pure wick catheter. The plan of care dated 11/15/2025 to 02/12/2025 did not include planned interventions related to the patient’s colostomy and pure wick catheter. During an interview on 11/20/2025, the Clinical Director/Alternate Administrator (Personnel Record 5) stated they would be providing additional education and training to the clinical staff regarding the plan of care.

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 and interview. In 3 of 19 (16%) clinical records reviewed with hospice aide services provided, the agency did not ensure the registered nurse provided patient specific written care instructions for the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/30/2025 with diagnosis of malignant neoplasm of the brain. The Registered Nurse documented on the initial comprehensive assessment dated 08/30/2025 a wound assessment of an area on the top of the scalp. The clinical record included an order dated 09/01/2025 for daily wound care to the scalp wound. The hospice aide plan of care completed by the Registered Nurse dated 08/30/2025 did not include patient specific care instructions for the aide related to the patient’s scalp wound and how to care for the wound while providing a bath and shampoo of the hair. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/15/2025 with diagnoses of malignant neoplasm of bilateral ovaries, colostomy (a surgical procedure that involves creating an opening in the large intestine through the abdominal wall), and pure wick urinary catheter. The hospice aide plan of care dated 11/15/2025 did not include patient specific care instructions for the hospice aide related to the patient’s colostomy and pure wick catheter. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/12/2023 with diagnoses of unspecified severe protein-calorie malnutrition and colostomy. The hospice aide plan of care dated 10/01/2025 did not include patient specific care instructions for the hospice aide related to the patient’s colostomy. During an interview on 11/19/2025, the Clinical Director/Alternate Administrator (Personnel Record 5) stated they would be providing additional training to the clinical staff regarding the hospice aide plan of care.

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 19 (26%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide documented the care provided as required by agency policy. Agency policy No. 9-020 Hospice Aide Services, revised May 2022, required in part, "Hospice aides will document care provided in accordance with the hospice aide assignment." CLINICAL RECORD 4: The hospice aide assignment date 02/11/2025 to 05/11/2025 assigned the hospice aide the task of document the last BM (bowel movement) every visit, report to RNCM (Registered Nurse Case Manager) if no BM x 3 days. The hospice aid did not document the date of the last BM on the aide visit note dated 04/15/2025. CLINICAL RECORD 5: The hospice aide assignment date 06/03/2025 to 08/01/2025 assigned the hospice aide the task of document the last BM every visit, report to RNCM if no BM x 3 days. The hospice aid did not document the date of the last BM on the aide visit note dated 06/18/2025. CLINICAL RECORD 6: The hospice aide assignment date 08/21/2025 to 10/19/2025 assigned the hospice aide the task of document the last BM every visit, report to RNCM if no BM x 3 days. The hospice aid did not document the date of the last BM on the aide visit notes dated 09/23/2025, 10/01/2025, and 10/14/2025. CLINICAL RECORD 7: The hospice aide assignment date 08/12/2025 to 11/09/2025 assigned the hospice aide the task of document the last BM every visit, report to RNCM if no BM x 3 days. The hospice aid did not document the date of the last BM on the aide visit note dated 09/09/2025. CLINICAL RECORD 10: The hospice aide assignment date 08/24/2024 to 10/22/2024 assigned the hospice aide the task of document the last BM every visit, report to RNCM if no BM x 3 days. The hospice aid did not document the date of the last BM on the aide visit note dated 08/08/2024. During an interview on 11/19/2025, the Clinical Director/Alternate Administrator (Personnel Record 5) stated that they would be providing additional training to the clinical staff regarding the hospice aide plan of care and education would be provided to the nursing and hospice aide staff.

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 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the patient's attending physician was forwarded a copy of the hospice discharge summary. CLINICAL RECORD 18: The patient elected the hospice benefit on 02/28/2025 and revoked the hospice benefit on 03/24/2025. The discharge summary dated 03/24/2025 included the question “Patient attending physician notified.” The answer was documented as “No.” There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 19: The patient elected the hospice benefit on 07/25/2025. The patient was discharged on 10/16/2025. The discharge summary dated 10/16/2025 included the question “Patient attending physician notified.” The answer was documented as “No.” There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient’s attending physician. During an interview on11/20/2025, the Clinical Director/Alternate Administrator (Personnel Record 5) stated they would be providing additional education and training to the clinical staff regarding the discharge process.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 7 (71%) records reviewed, revealed the agency did not ensure the nursing visits followed the physician orders on the Plan of Care (POC). Record 1: The patient's POC had documented orders for skilled nursing 2 times a week effective 11/21/22. During the week of 12/25/22, there were 5 nursing visits made. During the week of 1/1/23, there were 3 nursing visits made. During the week of 1/8/23, there were 5 visits made with no order change in visit frequency. Record 3: The patient's POC had documented orders to increase skilled nursing visits on 1/20/23 to daily. There were 2 extra visits on 1/20 and 1/21 before the patient's death visit on 1/21/23 for a total of 3 each day. There was no documented change of frequency orders. Record 5: The patient had orders for skilled nursing visits 2 times a week effective 11/23/22. During the week of 12/4/22, there were 3 skilled nursing visits made, during the week of 1/8/23 there was 1 skilled nursing visit made, and during the week of 1/22/23, there were 3 skilled nursing visits made. The nursing frequency did not match the orders on the hospice POC. Record 6: The patient had orders for skilled nursing effective 11/18/22, 2 times a week with no PRN visits ordered. During the week of 11/27/22, there were 4 skilled nursing visits made, the week of 12/4/22 there were 3 skilled nursing visits made and the week of 01/01/23 there were 3 skilled nursing visits made. The nursing frequency did not match the orders on the hospice POC. Record 7:The care plan was updated on 1/15/23, for skilled nursing visits 3 times a week. That same week there were 4 skilled nursing visits made. There was no documented evidence or orders for the fourth visit that week. During an interview with the RN Patient Care Coordinator on 2/8/23 and agreed the visit frequencies that were made did not match the orders in the POC.

It is required that each patient’s individualized written plan of care: reflects patient and family goals. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 7 (29%) records reviewed, revealed the agency did not ensure the Plan of Care (POC) specified the needs of the patient and family reflected patient and family goals as identified in the comprehensive assessment. Record 1: The initial assessment dated 11/25/22, identified that the patient was taking Acetaminophen for pain and Lorazepam for anxiety. The POC did not include the identified problems and goals. Record 7: The initial assessment dated 11/25/22, identified that the patient was taking Acetaminophen and Morphine for pain. The POC did not include the identified problems and goals. During an interview with the RN Patient Care Coordinator on 2/8/23, agreed there were no problems, patient or family goals for the pain and/or anxiety medications that were ordered.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 7 (29%) records reviewed, revealed the agency did not ensure the Plan of Care (POC) included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Record 3: The Registered Nurse (RN) initial comprehensive assessment dated 1/6/23, identified the need for aide services and an aide care plan was developed. There were no orders on the hospice plan of care with a frequency for aide visits. The aide made 2 visits the week of 1/8/23 and 1 visit the week of 1/15/23. Record 7: The patient had orders for registered nursing (RN) visits in the POC for 1 time every 14 days effective 12/07/22 and the RN made comprehensive supervisory visits every 14 days. However, the licensed practical nurse (LPN) made visits with no documentation of orders on the POC. The LPN made one visit on 12/8/22, to the patient on week one of the elections to hospice. The following week 12/11/22 the LPN made 2 visits. During the week of 12/18/22, there was 1 LPN visit made. Two LPN visits were made during the week of 12/25/22. During the week of 01/01/23, there was 1 LPN visit made. During the week of 1/8/23, there were 4 LPN visits. During an interview with the RN Patient Care Coordinator on 2/8/23, agreed there were orders missing on the POC for all visits provided.

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; Consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 7 (14%) records reviewed, revealed the agency did not ensure the aide followed the visit frequency in the hospice plan of care. Record 6: The aide services were ordered three times a week effective 11/18/2022. During the week of 01/01/2023, only two aide visits were made to the patients without any documentation or notification to the RN of why the visit was missed. During an interview with the RN Patient Care Coordinator on 2/8/23, agreed there was no documentation from the aide to the RN of the missed visit in record 6.