Every finding on record at Lhcg Clxx, LLC

Based on record review and interview, the hospice failed to ensure it completed an evaluation for services within 48 hours of referral for one (Patient #12) of 19 patients. --- Findings: Patient #12A review of the clinical record showed a referral date of 11/07/24 with initial evaluation and election of the hospice benefit on 11/13/24 (6 days). The clinical record showed no declined visits, no physician notifications, and no changes in orders.  On 06/12/26 at 10:51 a.m., Staff A stated the initial evaluation was not completed within two days of referral.

Based on record review and interviews, the hospice failed to ensure completion of initial comprehensive assessments for plans of care no later than five calendar days after election of the hospice benefits for five (Patients # 8, 9, 11, 13 and #18) of 19 patients. --- Findings: Patient #8A review of the clinical record showed an election of the hospice benefit on 03/28/25 with a current POC from 05/22/26 to 07/20/26. The clinical record showed no medical social worker psychosocial assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of the psychosocial assessment and showed no communication or notifications to the physician.      On 06/12/26 at 10:35 a.m., Staff B stated the initial psychosocial assessment was not completed within the first five days after the election of the hospice benefit. Patient #9A review of the clinical record showed an election of the hospice benefit on 01/30/26 with a current POC from 05/22/26 to 07/20/26. The clinical record showed no medical social worker psychosocial assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of the psychosocial assessment and showed no communication or notifications to the physician.      On 06/12/26 at 10:37 a.m., Staff B stated the initial psychosocial assessment was not completed within the first five days after the election of the hospice benefit. Patient #11A review of the clinical record showed an election of the hospice benefit on 04/01/25 with a current POC from 05/26/26 to 07/24/26. The clinical record showed no medical social worker psychosocial assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of the psychosocial assessment and showed no communication or notifications to the physician.      On 06/12/26 at 10:49 a.m., Staff B stated the initial psychosocial assessment was not completed within the first five days after the election of the hospice benefit. Patient #13A review of the clinical record showed an election of the hospice benefit on 01/23/26 with a current POC from 04/23/26 to 06/21/26. The clinical record showed no medical social worker psychosocial assessment after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of the psychosocial assessment and showed no communication or notifications to the physician.      On 06/12/26 at 10:52 a.m., Staff B stated the initial psychosocial assessment was not completed within the first five days after the election of the hospice benefit. Patient #18A review of the clinical record showed an election of the hospice benefit on 11/19/25 with a last POC from 12/23/25 to 03/22/26. The clinical record showed a chaplain spiritual assessment dated 11/25/25 (6 days) after the initial comprehensive assessment (election of benefits) and development of the POC. The clinical record showed no patient or caregiver refusal of the chaplain spiritual assessment and showed no communications or notifications to the physician.      On 06/12/26 at 11:05 a.m., Staff B stated the chaplain spiritual assessment was not completed within the first five days after the election of the hospice benefit.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC at the time of initial assessment for 19 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and #19) of 19 patients. --- Findings: Patient #1A review of the clinical record showed an initial bereavement assessment dated 06/12/25 and a current POC date of 04/06/26 to 06/04/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 06/12/25.  Patient #2A review of the clinical record showed an initial bereavement assessment dated 03/18/26 and a current POC date of 03/16/26 to 06/13/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 03/18/26. Patient #3A review of the clinical record showed an initial bereavement assessment dated 12/16/25 and a current POC date of 04/15/26 to 06/14/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 12/16/25.  Patient #4A review of the clinical record showed an initial bereavement assessment dated 05/26/26 and a current POC date of 05/22/26 to 08/19/26 with IDG updates on 06/04/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 05/26/26. Patient #5A review of the clinical record showed an initial bereavement assessment dated 12/19/25 and a current POC date of 05/17/26 to 07/15/26 with IDG updates on 05/14/26 and on 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 12/19/25. Patient #6A review of the clinical record showed an initial bereavement assessment dated 07/11/25 and a current POC date of 05/05/26 to 07/03/26 with IDG updates on 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 07/11/25. Patient #7A review of the clinical record showed an initial bereavement risk assessment by the SN dated 03/04/26 and by the Chaplain on 03/13/26 and a current POC date of 03/04/26 to 06/01/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26, 05/07/26 and 05/21/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 03/04/26 and 03/13/26. Patient #8A review of the clinical record showed an initial bereavement risk assessment by the SN dated 03/28/25 and by the Chaplain on 03/31/25 and a current POC date of 05/22/26 to 07/20/26 with IDG updates on 05/07/26 and 05/21/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 03/28/25 and 03/31/25. Patient #9A review of the clinical record showed an initial bereavement risk assessment by the SN dated 01/30/26 and by the Chaplain on 02/03/26 and a current POC date of 04/30/26 to 07/28/26 with IDG updates on 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 01/30/26 and 02/03/26. Patient #10A review of the clinical record showed an initial bereavement assessment dated 09/11/24 and a current POC date of 04/29/26 to 06/27/26 with IDG updates on 04/23/26, 05/07/26 and 05/21/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 09/11/24. Patient #11A review of the clinical record showed an initial bereavement risk assessment by the SN dated 04/01/25 and by the Chaplain on 04/04/25 and a current POC date of 05/26/26 to 07/24/26 with IDG updates on 04/23/26, 05/07/26 and 05/21/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 04/01/25 and 04/04/25. Patient #12A review of the clinical record showed an initial bereavement assessment dated 11/18/24 and a current POC date of 05/07/26 to 07/05/26 with IDG updates on 04/23/26, 05/07/26 and 05/21/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 11/18/24. Patient #13A review of the clinical record showed an initial bereavement risk assessment by the SN dated 01/23/26 and by the Chaplain on 01/27/26 and a current POC date of 04/23/26 to 06/21/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 01/23/26 and 01/27/26. Patient #14A review of the clinical record showed an initial bereavement assessment dated 03/02/26 and a current POC date of 05/28/26 to 08/25/26 with IDG updates on 05/14/26 and 05/28/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 03/02/26. Patient #15A review of the clinical record showed an initial bereavement risk assessment by the SN dated 01/06/26 and by the Chaplain on 01/09/26 and a last POC date of 01/06/26 to 04/05/26 with IDG updates on 01/17/26 and 02/11/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC until the patient’s death on 01/16/26. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement risk assessments dated 01/06/26 and 01/09/26. Patient #16A review of the clinical record showed an initial bereavement assessment dated 07/28/25 and a last POC date of 10/23/25 to 01/20/26 with IDG updates on 10/30/25, 11/13/25, 11/28/25, 12/11/25 and 01/08/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC until the patient’s death on 01/12/26.  The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 07/28/25. Patient #17A review of the clinical record showed an initial bereavement assessment dated 09/19/25 and a last POC date of 12/15/25 to 03/14/26 with IDG updates on 12/11/25, 12/24/25 and 01/08/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC until the patient’s death on 01/10/26. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 09/19/25. Patient #18A review of the clinical record showed an initial bereavement assessment dated 11/20/25 and a last POC date of 12/23/25 to 03/22/26 with IDG updates on 12/11/25, 12/24/25 and 01/08/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 11/20/25. Patient #19A review of the clinical record showed an initial bereavement assessment dated 11/18/25 and a last POC date of 11/13/25 to 02/10/26 with IDG updates on 11/20/25, 12/04/25, 12/18/25, 12/31/25 and 01/03/26. The clinical record showed no bereavement POC and no bereavement interventions and goals in the overall POC. The clinical record showed no patient or caregiver refusal of a bereavement POC since the bereavement assessment dated 11/18/25.   On 06/11/26 from 1:15 to 1:45 p.m., Staff E stated:A bereavement POC is put into place after a patient’s death.The patients (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18 and #19) had no bereavement POC and showed no bereavement interventions and goals in their overall POCs.Patients #15, 16, 17 had bereavement POCs which consisted of eMR system generated mail-outs and telephone calls put into place after their deaths.

Based on record review and interview, the hospice failed to ensure POCs included interventions and goals for the hospice diagnoses for seven (Patients #2, 8, 9, 13, 14, 16 and #17) of 19 patients. --- Findings: Patient #2A review of the plan of care dated 03/16/26 to 06/13/26 with POC updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for the hospice diagnosis of hypertensive heart disease with chronic kidney failure and congestive heart failure.  Patient #8A review of the plan of care dated 04/30/26 to 07/28/26 with POC updates dated 05/07/26 and 05/21/26 showed no interventions and goals for the hospice diagnosis of coronary artery disease.  Patient #9A review of the plan of care dated 05/22/26 to 07/20/26 with POC updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for the hospice diagnosis of dysphagia. Patient #13A review of the plan of care dated 04/23/26 to 06/21/26 with POC updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for the hospice diagnosis of B cell lymphoma. Patient #14A review of the plan of care dated 05/28/26 to 08/25/26 with POC updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for the hospice diagnosis of metabolic encephalopathy. Patient #16A review of the plan of care dated 10/23/25 to 01/20/26 with POC updates dated 10/30/25, 11/13/25, 11/28/25, 12/11/25 and 01/08/26 showed no interventions and goals for the hospice diagnosis of cerebral ischemia. Patient #17A review of the plan of care dated 12/15/25 to 03/14/26 with POC updates on 12/11/25, 12/24/25 and 01/08/26 showed no interventions and goals for the hospice diagnosis of atherosclerotic heart disease. On 06/12/26 at 10:13 a.m. to 11:04 a.m., Staff B stated the plans of care should have included interventions and goals for the hospice diagnoses for patients #2, 8, 9, 13, 14, 16 and #17.

Based on record review and interview, the hospice failed to ensure care was coordinated between the IDG members and the physician for three (Patients #1, 7 and #19) of 19 patients. --- Findings: Patient #1A review of the POC dated 04/06/26 to 06/04/26 showed a SN narrative note dated 04/14/26 that showed the patient had sustained a right hip fracture and was experiencing signs and symptoms of unrelieved pain and a 30-50% loss of appetite and nutritional intake.  The SN and MSW notes from 04/17/26 to 06/03/26 showed the patient’s family member had declined all pain medications except non-prescription strength acetaminophen despite the patient’s continued signs and symptoms of unrelieved pain and loss of appetite. The IDG plan of care updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no discussion by the IDG and no IDG requested intervention by the physician to discuss the patient’s continued unrelieved pain symptoms with the family member and showed no recommendations or ordered interventions to address the 30-50 % loss of appetite and nutritional intake.  On 06/12/26 at 10:00 a.m., Staff B stated the IDG team members did not discuss or recommend interventions for the patient’s unrelieved pain symptoms or the loss of appetite and nutritional intake.  Patient #7A review of the POC dated 03/04/26 to 06/01/26 showed a hospice aide visit frequency of two times a week for 12 weeks. The clinical record showed hospice aide missed visits for patient refusal of service on: 03/06/26, 03/13/26, 03/17/26, 03/27/26, 04/06/26, 04/17/26, 04/21/26, 05/15/26 and on 05/19/26. Plan of care updates dated 03/12/26, 03/26/26, 04/09/26, 04/23/26, 05/07/26 and 05/21/26 showed no discussion of the hospice aide missed visits by the IDG and showed no orders for a decrease in the hospice aide visit frequency.  On 06/12/26 at 10:30 a.m., Staff B stated the IDG team members should have discussed the patient’s continued refusal of aide visits and reduced the aide visit frequency. Patient #19A review of the POC dated 11/13/25 to 02/10/26 showed a hospice aide visit frequency of two times a week for 12 weeks. The clinical record showed one hospice aide visit on 12/02/26 and showed no other hospice aide visit attempts (14 visits ordered, one visit conducted) and showed no missed visit notes. Plan of care updates dated 11/20/25, 12/04/25, 12/18/25, 12/31/25 and 01/08/26 showed no discussion of the hospice aide visits by the IDG and showed no orders to discontinue the hospice aide visit frequency.  On 06/12/26 at 11:10 a.m., Staff B stated the IDG team members should have discussed the aide visit frequency and discontinued the aide visits.

Based on record review and interview, the hospice failed to ensure: Chaplain visits were provided in accordance with the plan of care for two (Patients #1 and #3) of 19 patients.Aide visits were provided in accordance with the plan of care for six (Patients #2, 6, 7, 14, 15 and #19) of 19 patients.SN visits were provided in accordance with the plan of care for one (Patient #6) of 19 patients. --- Findings: Patient #1A review of a POC dated 04/06/26 to 06/04/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed a chaplain visit frequency of two times a month for one month, then one time a month for one month effective 04/21/26.  The clinical record showed from:04/21/26 to 05/02/26 no chaplain visits were conducted (two visits ordered, no visits conducted).05/03/26 to 06/04/26 no chaplain visits were conducted (one visit ordered, no visits conducted). The clinical record showed no communication between the IDG and showed no changes in the ordered chaplain visit frequency.  On 06/12/26 at 10:00 a.m., Staff B stated no chaplain visits were conducted as ordered. Patient #3A review of a POC dated 04/15/26 to 06/14/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed a chaplain visit frequency of one time a month for one month, two times a month for one month, then one time a month for one month.  The clinical record showed from:04/16/26 to 05/02/26 no chaplain visits were conducted (one visit ordered, no visit conducted).05/03/26 to 06/04/26 no chaplain visits were conducted (two visits ordered, no visits conducted). The clinical record showed no communication between the IDG and showed no changes in the ordered chaplain visit frequency.  On 06/12/26 at 10:18 a.m., Staff B stated no chaplain visits were conducted as ordered. Patient #2A review of a POC dated 03/16/26 to 06/13/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed a hospice aide visit frequency of two times a week for 13 weeks. A POC update on 05/08/26 changed the hospice aide visit frequency to two aides two times a week.  The clinical record shown during the week of:05/10/26 to 05/16/26 a two-person aide visit was conducted on 05/11/26 but only a one-person aide visit was conducted on 05/15/26 (two-person visits ordered, one person visit conducted). 05/17/26 to 05/23/26 a one-person aide visit was conducted on 05/21/26 and 05/22/26 (two-person visits ordered, one person visits conducted). 05/24/26 to 05/30/26 a one-person aide visit was conducted on 05/27/26 and 05/29/26 (two-person visits ordered, one person visits conducted).05/31/26 to 06/06/26 a one-person aide visit was conducted on 06/01/26 (two-person visits ordered, one person visit conducted) and a two-person aide visit was conducted on 06/05/26.  The clinical record showed no communication between the IDG and showed no changes in the ordered aide.  Patient #6A review of a POC dated 05/05/26 to 07/03/26 with IDG updates on 04/30/26, 05/14/26 and 05/28/26 showed a hospice aide visit frequency of three times a week and a SN visit frequency of two times a week.  The clinical record shown during the week of:05/10/26 to 05/16/26 a SN visit was conducted on 05/12/26 (two visits ordered, one visit conducted).05/24/26 to 05/30/26 aide visits were conducted on 05/27/26 and 05/29/26 (three visits ordered, two visits conducted).  The clinical record showed no missed visit notes, no communication between the IDG and showed no changes in the ordered aide visit frequency.  Patient #7A review of a POC dated 03/04/26 to 06/01/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26, 05/07/26 and 05/21/26 showed a hospice aide visit frequency of two times a week.  The clinical record shown during the week of:03/29/26 to 04/04/26 an aide visit was conducted on 04/03/26 (two visits ordered, one visit conducted). 05/03/26 to 05/09/26 an aide visit was conducted on 05/08/26 (two visits ordered, one visit conducted).  The clinical record showed no missed visit notes, no communication between the IDG and showed no changes in the ordered aide visit frequency.  Patient #14A review of a POC dated 05/28/26 to 08/25/26 with IDG updates on 05/14/26 and 05/28/26 showed a hospice aide visit frequency of three times a week.  The clinical record shown during the week of:05/31/26 to 06/06/26 aide visits were conducted on 06/02/26 and 06/05/26 (three visits ordered, two visits conducted).  The clinical record showed no missed visit notes, no communication between the IDG and showed no changes in the ordered aide visit frequency.  Patient #19A review of a POC dated 11/13/25 to 02/10/26 with IDG updates on 11/20/25, 12/04/25, 12/18/25, 12/31/25 and 01/03/26 showed a hospice aide visit frequency of two times a week.  The clinical record shown during the week of:11/16/25 to 11/21/25 no aide visits were conducted (two visits ordered, no visits conducted). 11/22/25 to 11/29/25 no aide visits were conducted (two visits ordered, no visits conducted).11/30/25 to 12/06/25 one aide visit was conducted on 12/02/25 (two visits ordered, one visit conducted).12/07/25 to 12/13/25 no aide visits were conducted (two visits ordered, no visits conducted).12/14/25 to 12/20/25 no aide visits were conducted (two visits ordered, no visits conducted).12/21/25 to 12/27/25 no aide visits were conducted (two visits ordered, no visits conducted).12/28/25 to 01/03/26 no aide visits were conducted (two visits ordered, no visits conducted). The clinical record showed no missed visit notes, no communication between the IDG and showed no changes in the ordered aide visit frequency.  On 06/12/26 from 10:13 a.m. to 11:10 a.m., Staff B stated:The chaplain visits were not conducted as ordered on patients #1 and #3.The aide visits were not conducted as ordered on patients #2, 6, 7, 14 and #19.The SN visits were not conducted as ordered on patient #6.

Based on record reviews and interview, the hospice failed to ensure a completed discharge summary was provided to the receiving service provider for one (Patient #18) of 19 patients. --- Findings: Patient #18 A review of the clinical record showed the patient was discharged from the hospice on 01/03/26 for hospital care services. The clinical record showed no coordination of care, and no discharge summary of care was provided to the hospital provider. On 06/12/26 at 11:05 a.m., Staff B stated the discharge summary was not sent to the hospital.

Based on record review and interview, the hospice failed to ensure review and update of hospice aide care plans for two (Patients #2 and #15) of 19 patients. --- Findings: Patient #2A review of the plan of care dated 03/16/26 to 06/13/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/30/26, 05/14/26 and 05/28/26 ordered hospice aide visits two times a week. On 05/08/26 a physician’s order was added to increase the aide services to two-person aide visits. The POC showed no update to the hospice aide care plan last dated 04/03/26. On 06/12/26 at 10:13 a.m., Staff B stated the hospice aide care plan was not reviewed and updated after the 05/08/26 order to increase the aide services to two-person aide visits. Patient #15A review of the plan of care dated 01/06/26 to 04/05/26 with IDG updates on 01/17/26 and 02/11/26 ordered hospice aide visits two times a week. On 01/08/26 a physician’s order was added to increase the aide services to two-person aide visits. The POC showed no update to the hospice aide care plan last dated 01/06/26. On 06/12/26 at 10:55 a.m., Staff B stated the hospice aide care plan was not reviewed and updated after the 01/08/26 order to increase the aide services to two-person aide visits.

Based on record reviews and interviews, the hospice failed to ensure POCs included hospice aide visit interventions and goals for 11 (Patients #1, 3, 4, 5, 6, 7, 9, 10, 13, 14 and #19) of 19 patients. --- Findings: Patient #1A review of a plan of care dated 04/06/26 to 06/04/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services. A review of the clinical record showed visits were conducted on:04/06/26, 04/08/26, 04/10/2604/13/26, 04/15/26, 04/17/2604/27/26, 05/01/2605/04/26, 05/06/26, 05/08/2605/11/26, 05/13/26, 05/15/2605/18/26, 05/20/26, 05/21/2605/25/26, 05/27/26, 05/29/2606/01/26, 06/03/26  On 06/12/26 from 10:00 a.m. to 11:10 a.m., Staff B stated the plans of care did not include interventions and goals for hospice aide services for patients #1, 3, 4, 5, 6, 7, 9, 10, 13, 14, 17, 18 and #19. Patient #3A review of the plan of care dated 04/15/26 to 06/14/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed visits conducted on:04/17/2604/21/26, 05/01/2605/06/26, 05/08/2605/12/26, 05/15/2605/19/26, 05/22/2605/26/26, 05/29/2606/02/2606/09/26 Patient #4A review of the plan of care dated 05/22/26 to 08/19/26 with IDG updates on 06/04/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed visits conducted on:05/27/26, 05/28/2606/03/26   Patient #5A review of the plan of care dated 05/17/26 to 07/15/26 with IDG updates on 05/14/26 and on 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed visits conducted on:05/18/26, 05/22/2605/29/2606/01/26, 06/04/26.Patient #6A review of the plan of care dated 05/05/26 to 07/03/26 with IDG updates on 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:05/06/26, 05/08/2605/13/26, 05/15/2605/18/26, 05/20/26, 05/22/2605/27/26, 05/29/2606/01/26, 06/03/26, 06/05/26 Patient #7A review of a plan of care dated 03/04/26 to 06/01/26 with IDG updates on 03/12/26, 03/26/26, 04/09/26, 04/23/26, 05/07/26 and 05/21/26 showed no interventions and goals for hospice aide services. A review of the clinical record showed visits were conducted on:03/10/2603/20/2603/24/2604/03/2604/10/2604/14/2604/24/2605/01/2605/22/2605/29/26 Patient #9A review of the plan of care dated 05/22/26 to 07/20/26 with POC updates dated 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:05/06/26, 05/08/2605/13/26, 05/15/2605/20/26, 05/22/2605/27/26, 05/29/2606/03/26, 06/05/26 Patient #10A review of the plan of care dated 04/29/26 to 06/27/26 with IDG updates on 04/23/26, 05/07/26 and 05/21/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:04/30/2605/04/2605/14/2605/21/2606/01/26, 06/04/26 Patient #13A review of the plan of care dated 04/23/26 to 06/21/26 with IDG updates on 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:04/24/2604/27/26, 05/01/2605/04/26, 05/08/2605/11/26, 05/15/2605/18/26, 05/22/2605/27/26, 05/29/2606/02/26, 06/05/26 Patient #14A review of the plan of care dated 05/28/26 to 08/25/26 with IDG updates on 05/14/26 and 05/28/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:06/02/26, 06/05/26 Patient #19A review of the plan of care dated 11/13/25 to 02/10/26 with IDG updates on 11/20/25, 12/04/25, 12/18/25, 12/31/25 and 01/03/26 showed no interventions and goals for hospice aide services.  A review of the clinical record showed for visits conducted on:12/02/25 On 06/12/26 from 10:00 a.m. to 11:10 a.m., Staff B stated the plans of care should have included interventions and goals for the aide services for patients #1, 3, 4, 5, 6, 7, 9, 10, 13, 14 and #19.

Based on record review and interview, the hospice failed to ensure aide supervisory visits were completed every 14 days for one (Patients #2) of 19 patients. --- Findings: Patient #2A review of the plan of care dated 03/16/26 to 06/13/26 with IDG updates on 03/19/26, 04/02/26, 04/16/26, 04/30/26, 05/14/26 and 05/28/26 showed a hospice aide visit frequency of two times a week for 13 weeks. A review of the clinical record showed aide supervisory visits were conducted on 05/18/26 and 06/02/26 (15 days) for aide visits conducted on 05/18/26, 05/21/26, 05/22/26, 05/27/26, 05/29/26 and on 06/01/26. On 06/12/26 from 10:13 a.m., Staff B stated supervisory aide visits were not conducted every 14 days for patients #2.

Based on record review and interview, the hospice failed to ensure clinical SN visit notes were completed in the clinical records per the hospice’s standard of practice for four (Patients # 9, 10, 11 and #13) of 19 patients. --- Findings: Patient #9A review of the plan of care dated 04/30/26 to 07/28/26 showed a skilled nurse visit frequency of one time for one week, two times a week for 12 weeks, then one time a week for one week.   A review of the clinical record showed SN visits on:04/29/26 was completed on 05/04/26 (5 days)05/14/26 was completed on 05/21/26 (7 days)05/18/26 was completed on 05/21/26 (3 days)05/21/26 was completed on 05/26/26 (5 days)06/05/26 was completed on 05/21/26 (5 days) Patient #10A review of the plan of care dated 04/29/26 to 06/27/26 showed a skilled nurse visit frequency of one time for one week, then two times a week for eight weeks. A review of the clinical record showed SN visits on:05/21/26 was completed on 05/27/26 (6 days)05/22/26 was completed on 05/27/26 (5 days) Patient #11A review of the plan of care dated 04/29/26 to 06/27/26 showed a skilled nurse visit frequency of two times for one week, then three times a week for eight weeks. A review of the clinical record showed SN visits on:05/20/26 was completed on 05/28/26 (8 days)   Patient #13A review of the plan of care dated 04/23/26 to 06/21/26 showed a skilled nurse visit frequency of one time for one week, then two times a week for eight weeks.  A review of the clinical record showed SN visits on:04/22/26 was completed on 04/26/26 (4 days)05/15/26 was completed on 05/21/26 (6 days)05/18/26 was completed on 05/21/26 (3 days)06/05/26 was completed on 06/10/26 (5 days) On 06/12/26 from 10:37 a.m. to 10:52 a.m., Staff B stated:The standard for visit notes was they were to be completed and submitted by the next day after a visit.The SN notes were not documented and completed by the nurse within one day of the visits for patients # 9, 10, 11 and #13.

Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for eight (Patients #2, 3, 4, 5, 6, 8, 13 and 14) of 19 patients. --- Patient #2 A review of the Initial Assessment dated 10/03/23 showed no assessment of imminence of death. Patient #3 A review of the Initial Assessment dated 08/09/23 showed no assessment of imminence of death. Patient #4 A review of the Initial Assessment dated 09/06/23 showed no assessment of imminence of death. Patient #5 A review of the Initial Assessment dated 11/14/23 showed no assessment of imminence of death. Patient #6 A review of the Initial Assessment dated 09/16/23 showed no assessment of imminence of death. Patient #8 A review of the Initial Assessment dated 08/11/23 showed no assessment of imminence of death. Patient #13 A review of the Initial Assessment dated 09/07/23 showed no assessment of imminence of death. Patient #14 A review of the Initial Assessment dated 09/01/23 showed no assessment of imminence of death. On 12/14/23 at 1:15 pm, Staff C stated imminence of death was not assessed on the comprehensive assessment for Patients #2, 3, 4, 5, 6, 8, 13 and 14.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include interventions for the palliation and management of the terminal illness for eleven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13 and 14) of 19 patients reviewed. --- Patient #1 A review of the plan of care dated 08/28/23 to 10/26/23 showed a hospice diagnosis of Alzheimer's disease and showed no interventions for the palliation and management of the terminal illness. Patient #2 A review of the plan of care dated 10/03/23 to 12/31/23 showed a hospice diagnosis of cancer of kidney disease and showed no interventions for the palliation and management of the terminal illness. Patient #3 A review of the plan of care dated 08/09/23 to 11/06/23 showed a hospice diagnosis of cerebral atherosclerosis and showed no interventions for the palliation and management of the terminal illness. Patient #4 A review of the plan of care dated 09/06/23 to 12/04/23 showed a hospice diagnosis of atrial fibrillation and showed no interventions for the palliation and management of the terminal illness. Patient #5 A review of the plan of care dated 11/14/23 to 12/14/23 showed a hospice diagnosis of breast cancer and showed no interventions for the palliation and management of the terminal illness. Patient #6 A review of the plan of care dated 09/16/23 to 12/14/23 showed a hospice diagnosis of heart failure and showed no interventions for the palliation and management of the terminal illness. Patient #7 A review of the plan of care dated 08/25/23 to 10/23/23 showed a hospice diagnosis of cerebral atherosclerosis and showed no interventions for the palliation and management of the terminal illness. Patient #8 A review of the plan of care dated 08/11/23 to 11/08/23 showed a hospice diagnosis of hypertension and showed no interventions for the palliation and management of the terminal illness. Patient #9 A review of the plan of care dated 09/24/23 to 11/22/23 showed a hospice diagnosis of Parkinson's disease and showed no interventions for the palliation and management of the terminal illness. Patient #10 A review of the plan of care dated 09/16/23 to 11/14/23 showed a hospice diagnosis of Alzheimer's disease and showed no interventions for the palliation and management of the terminal illness. Patient #12 A review of the plan of care dated 08/29/23 to 11/26/23 showed a hospice diagnosis of hemiplegia and showed no interventions for the palliation and management of the terminal illness. Patient #13 A review of the plan of care dated 09/07/23 to 11/05/23 showed a hospice diagnosis of acute respiratory failure and showed no interventions for the palliation and management of the terminal illness. Patient #14 A review of the plan of care dated 09/01/23 to 11/29/23 showed a hospice diagnosis of alcoholic cirrhosis of the liver and showed no interventions for the palliation and management of the terminal illness. On 12/14/23 at 1:20 pm, Staff C stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13 and 14 failed to include interventions for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect decreased hospice aide services for one (Patient #14) of 19 patients. --- Patient #14 A review of the clinical record showed a plan of care dated 09/01/23 to 11/29/23 and plan of care updates dated 09/15/23, 09/21/23, 09/29/23, 10/13/23, 10/27/23, and 11/10/23 showed a hospice aide frequency of one visit per week for one week, three visits per week for eleven weeks and two visits per week for one week. A physician's order dated 10/17/23 documented a change of hospice aide frequency to one visit per week for 10 weeks. A review of the clinical record showed: A hospice aide missed visit note dated 09/11/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 09/18/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 09/22/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 09/25/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 09/29/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/02/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/06/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/09/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/12/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/13/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/16/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/20/23 due to patient/caregiver refusal. A hospice aide missed visit note dated 10/26/23 due to patient/caregiver refusal. No hospice aide visits were made from 09/18/23 to 10/28/23. Documentation showed no changes in the hospice aide plan of care to reflect the needs of the patient. On 12/14/23 at 1:20 pm, Staff C stated the plan of care should have been updated to reflect the decreased hospice aide services provided for Patient #14.