Every finding on record at Limitless Hospice LLC

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 clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure the comprehensive assessment included 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. Clinical Record 3: The date of hospice election was 03/05/2024. The record lacked evidence of an initial bereavement assessment. During a joint clinical record review and interview on 04/17/2024, the Director of Clinical Services confirmed that the record lacked 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.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers. During a volunteer program review and interview on 04/17/2024, the Alternate Administrator/Volunteer Coordinator/Bereavement Coordinator/Volunteer confirmed that the retention efforts from January 2024 through April 2024 were not documented. The Alternate Administrator/Volunteer Coordinator/Bereavement Coordinator/Volunteer was also the volunteer. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers.

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. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 through April 2024. There were no documented volunteer hours for 2024. Direct patient hours for January 2024 were 13 hours, and February 2024 was 12 hours. There were no patients on service during 2023. During a joint review of the volunteer program records and interview on 04/17/2024, the Alternate Administrator/Volunteer Coordinator/Bereavement Coordinator/Volunteer confirmed that the agency did not document any volunteer hours from January 2024 through April 2024. The Alternate Administrator/Volunteer Coordinator/Bereavement Coordinator/Volunteer stated that she was available for patient volunteer requests. There have not been any requests from the five patients they have had for services. There was no volunteer for administrative needs available. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 through April 2024. There were no documented volunteer hours for 2024. Direct patient hours for January 2024 were 13 hours, and February 2024 was 12 hours. There were no patients on service during 2023.

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. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that all entries in the patient record were 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. Clinical Record 1: The patient's date of hospice election was 03/06/2024. The benefit period was 03/06/2024-06/03/2024. The social worker assessment was dated 3/5/2024, and the benefit period was listed as 03/05/2024-06/02/2024. The benefit period on the spiritual visit note was listed as 02/09/2024-04/08/2024. During a joint clinical record review and interview on 03/06/2024, the Director of Clinical Services/Supervising Registered Nurse confirmed that the listed entries were not dated correctly or contained the correct benefit period.

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 1 (100%) clinical record for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 4: The date of revocation was dated 02/02/2024. The record lacked evidence of a discharge summary and documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 04/18/2024, the Alternate Administrator and Director of Clinical Services confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 4: The date of the revocation was 02/02/2024. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. During a joint record review and interview on 04/18/2024, the Alternate Administrator and the Director of Clinical Services confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.