Every finding on record at Lorian Health Hospice Inc

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 clinical record review and interview. In 4 of 9 (44%) clinical records reviewed for start of care, the organization did not ensure the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 02/24/2025. Clinical record review revealed the Chaplain’s initial spiritual assessment completed as part of the initial comprehensive assessment was dated 03/06/2025, 10 days after the patient’s election of hospice care, and 5 days outstanding. The clinical record contained no documentation of the patient’s refusal of spiritual care or a reason for delay in providing the spiritual assessment. Clinical Record 5: The patient elected the hospice benefit on 01/25/2025. Clinical record review revealed the Chaplain’s initial spiritual assessment completed as part of the initial comprehensive assessment was dated 02/04/2025, 10 days after the patient’s election of hospice care, and 5 days outstanding. The clinical record contained no documentation of the patient’s refusal of spiritual care or a reason for delay in providing the spiritual assessment. Clinical Record 6: The patient elected the hospice benefit on 01/28/2025. Clinical record review revealed the Chaplain’s initial spiritual assessment completed as part of the initial comprehensive assessment was dated 02/04/2025, 7 days after the patient’s election of hospice care, and 2 days outstanding. The clinical record contained no documentation of the patient’s refusal of spiritual care or a reason for delay in providing the spiritual assessment. Clinical Record 14: The patient elected the hospice benefit on 02/21/2025. Clinical record review revealed the Medical Social Worker’s initial psychosocial assessment completed as part of the initial comprehensive assessment was dated 02/27/2025, 6 days after the patient’s election of hospice care, and 1 day outstanding. The clinical record contained no documentation of the patient’s refusal of medical social services or a reason for delay in providing the psychosocial assessment. During an interview and joint clinical record reviews on 04/10/2025, the Director of Patient Care Services (DPCS) and the Alternate DPCS confirmed the Chaplain’s initial spiritual assessments and the MSW’s initial psychosocial assessment were not completed in the required timeframe.

It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served; represent the internal needs of the organization; and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. The organization did not ensure performance improvement projects (PIPs) were conducted annually. During an interview and review of the agency’s QAPI [quality assurance performance improvement] binder with the Director of Patient Care Services, it was revealed that a PIP was documented in the first quarter of 2024, which stated that the organization's governing board was notified that there was no documented evidence of PIPs that had been conducted in 2023. The QAPI binder reflected data collection and analysis according to the organization's governing board-approved QAPI program plan from January 2024 through Quarter 1, 2025, including PIPs which represented the needs of the hospice population served, internal needs of the organization, and reflected the scope, complexity, and performance of the hospice services and operations. However, there was no documented evidence that the agency had conducted performance improvement projects annually, as required. The organization did not ensure that performance improvement projects (PIPs) were conducted annually. During the review of the binder containing QAPI meeting minutes and Performance Improvement Projects, and during the interview with the DPCS/Alternate Administrator, it was revealed that a PIP was documented in the first quarter of 2024, which stated that the organization's governing board was notified that there was no documented evidence of PIPs that had been conducted in 2023. The QAPI binder reflected data collection and analysis according to the organization's governing board-approved QAPI program plan from January 2024 through Quarter 1, 2025, including PIPs which represented the needs of the hospice population served, internal needs of the organization, and reflected the scope, complexity, and performance of the hospice services and operations.

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 10 of 11 (91%) clinical records reviewed with aide services provided, the organization did not ensure the Registered Nurse prepared patient specific written patient care instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 07/08/2024 and was a live discharge for no longer terminally ill on 03/24/2025. The plan of care for the benefit period dated 01/24/2025 to 03/24/2025 included patient diagnoses of chronic obstructive pulmonary disease, dependence on 9 liters of continuous supplemental oxygen per nasal cannula, and history of peripheral vascular disease with bilateral lower extremity wounds requiring daily dressing changes. The hospice aide care plan assignment dated 01/27/2025 did not provide the aide with instructions related to oxygen management and management of the bilateral lower extremity dressings while providing a bath and personal cares to the patient. Clinical Record 2: The patient elected the hospice benefit on 02/24/2024. The plan of care dated 02/24/2024 included patient diagnoses of chronic obstructive pulmonary disease, heart failure, history of falls, dependence on 2 liters of supplemental oxygen, and dependence on a wheelchair for mobility. The hospice aide care plan assignment dated 02/24/2024 did not provide the aide with instructions related to oxygen management during cares provided and the patient’s wheelchair dependence for mobility. Clinical Record 4: The patient elected the hospice benefit on 10/01/2024. The plan of care dated 10/01/2024 included patient diagnoses of pulmonary fibrosis, three pressure ulcers on the patient’s buttocks receiving daily wound care treatments, history of recurrent pneumonia post-COVID, congestive heart failure, and a dependence on 4.5 liters of supplemental oxygen. The hospice aide care plan assignment dated 10/01/2024 did not provide the aide with instructions related to oxygen management and management of the three buttocks wound dressings while providing a bath and personal cares to the patient. Clinical Record 5: The patient elected the hospice benefit on 01/25/2025. The plan of care dated 01/25/2025 included patient diagnoses of multiple sclerosis, bedbound status, foley catheter, and dependence on 2 liters of supplemental oxygen. The hospice aide care plan assignment dated 01/25/2025 did not provide the aide with instructions related to oxygen management while providing a bath and personal cares to the patient. Clinical Record 6: The patient elected the hospice benefit on 01/28/2025. The plan of care dated 01/28/2025 included patient diagnoses of Parkinson’s disease, a sacral region stage 2 pressure ulcer, dependence on 2 liters of supplemental oxygen, presence of a neurostimulator, and dependence on a wheelchair. The hospice aide care plan assignment dated 03/26/2025 did not provide the aide with instructions related to management of the sacral pressure ulcer wound dressings while providing a bath and personal cares to the patient. Clinical Record 9: The patient elected the hospice benefit on 12/15/2024. The plan of care dated 03/15/2025 to 06/12/2025 included patient diagnoses of Alzheimer's disease, dementia, congestive heart failure, dependence on a wheelchair for mobility, and oxygen ordered on 03/28/2025 at 2 liters per nasal cannula. The hospice aide care plan assignment last updated on 01/27/2025 did not provide the aide with instructions related to the patient’s wheelchair dependence for mobility and was not updated to include instructions related to oxygen management while providing a bath and personal cares to the patient. Clinical Record 10: The patient elected the hospice benefit on 09/25/2024. The plan of care for the episode of care dated 03/24/2025 to 05/22/2025 included patient diagnoses of Parkinson’s disease, spinal stenosis, dependence on 2 liters of supplemental oxygen, walker use for mobility, and syncopal episodes with falls. The hospice aide care plan assignment last updated on 01/29/2025 did not provide the aide with instructions related to the patient’s use of a walker for mobility and oxygen management while providing a bath and personal cares to the patient. Clinical Record 11: The patient elected the hospice benefit on 12/05/2024. The clinical record was reviewed for the episode of care dated 02/03/2025 to 04/03/2025 and the benefit period that started on 04/04/2025. The patient’s diagnoses included atherosclerotic heart disease of native coronary artery, bedbound status, Foley catheter, a stage 2 pressure ulcer of the left knee lateral femoral condyle, and a venous stasis ulcer of the front lower leg with wound dressings. The hospice aide care plan assignment last updated on 12/06/2024 did not provide the aide with instructions related to management of the left knee pressure ulcer and the front lower leg venous ulcer wound dressings while providing a bath and personal cares to the patient. Clinical Record 12: The patient elected the hospice benefit on 02/13/2025. The plan of care for the benefit period dated 02/13/2025 to 05/13/2025 included patient diagnoses of traumatic subdural hematoma without loss of consciousness, dependence on 2 liters of supplemental oxygen, colostomy status, and a healed pressure ulcer of the sacrum. The hospice aide care plan assignment last updated on 04/08/2025 did not provide the aide with instructions related to the management of the patient’s colostomy while providing a bath and personnel cares to the patient. Clinical Record 14: The patient elected the hospice benefit on 02/21/2025. The plan of care dated 02/21/2025 to 05/21/2025 included patient diagnoses of Parkinson’s disease, Alzheimer’s disease, dementia, a history of falls, and wheelchair dependence for mobility. The hospice aide care plan assignment last updated on 04/03/2025 did not provide the aide with instructions related to the patient’s use of a wheelchair for mobility and fall precautions. During a joint clinical record review and interview on 04/10/2025, the Director of Patient Care Services and Alternate Director of Patient Care Services confirmed that the aide plan of care assignments did not include instructions to the aide(s) related to oxygen management, management of wound dressings during cares, and safety instructions related to mobility issues.

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 observation and interview. In 1 of 11 (9%) clinical records reviewed with aide services provided, the organization did not ensure the hospice aide provided services as ordered in the plan of care. Home visit 1: During the home visit observation on 04/09/2025 with the Hospice Certified Home Health Aide, the aide stated that she applied barrier cream to the patient’s bottom after every bath. The hospice aide care plan assignment last updated on 04/08/2025 did not include instructions to the aide for application of barrier cream. During a joint record review and interview on 04/10/2025, the Director of Patient Care Services and the Alternate Director of Patient Care Services confirmed that barrier cream was not included in the aide instructions on the aide plan of care assignment.

It is required that volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with volunteer services provided, the agency did not ensure volunteer services were included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 07/08/2024. The plan of care dated 01/24/2025 to 03/24/2025 included the statement, “Volunteer services as needed.” The clinical record contained no documented evidence of a volunteer plan of care and no documented evidence of a physician order for the frequency of volunteer visits. During an interview on 04/09/2025, the Medical Social Worker/Volunteer Coordinator explained that the patient had received volunteer services during the episode of care dated 01/24/2025 to 03/24/2025. The Volunteer Coordinator confirmed he was unable to locate the volunteer plan of care and physician order for volunteer services.

It is required that orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed for contracted staff, the organization did not ensure contracted staff were oriented to hospice philosophy. Personnel Record 3: Hospice Medical Director, contracted, date of contract 12/01/2024. Personnel record review revealed no documented evidence of orientation to the organization’s hospice philosophy including addressing the needs and concerns of patients and families coping with a terminal illness. Personnel Record 5: Physical Therapist, contracted, date of contract 10/01/2024. Personnel record review revealed no documented evidence of orientation to the organization’s hospice philosophy including addressing the needs and concerns of patients and families coping with a terminal illness. During a review of personnel records and interview on 04/09/2025, the Human Resources Director and the Director of Patient Care Services both confirmed the Medical Director, and the Physical Therapist were not provided with this training.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by personnel record review and interview. In 1 of 2 (50%) personnel records reviewed for contracted staff, the organization did not ensure a criminal background check was obtained before contracted personnel had direct patient contact or access to patient records. Personnel Record 3: Hospice Medical Director date of contract 12/01/2024. Personnel record review revealed no documented evidence that a criminal background check was obtained prior to direct patient contact or access to patient records. During a review of personnel records and interview on 04/09/2025, the Human Resources Director and the Director of Patient Care Services both confirmed that the personnel file for the Hospice Medical Director did not include documentation of a criminal background check obtained before the Medical Director had direct patient contact or access to patient records.

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 record review and interview. 1 of 7 (14%) records revealed the agency did not ensure that the spiritual assessment component of the initial comprehensive assessment was completed within 5 days of admission to the hospice as required. Record #25091: The patient was admitted to hospice on 11/2/2021. The Initial Spiritual Assessment was not documented in the clinical record or documentation that the Chaplain contacted the family/patient within 5 days of admission to hospice. An interview was conducted on 5/25/22 with the Director of Nursing (DON) (Staff ID:91533) who stated after review, that there was no documentation explaining the reason the chaplain assessment was delayed.

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, document review and interview. 2 of 3 (66%) clinical records revealed the agency failed to ensure the patient’s attending physician was notified of patients discharge from hospice services. Record # 25091: The patient was admitted to hospice on 11/5/2021 and requested discharge from hospice on 11/9/2021. No discharge summary was provided to the patient’s primary care practitioner or other health care professional within five (5) business days of the patient discharge (Policy No. 2-043.1 Discharge Summary). Record #65076: The patient was admitted to hospice on 1/20/2022 and requested discharge from hospice on 1/25/2022 to seek aggressive treatment. No discharge summary was provided to the patient’s primary care practitioner or other health care professional within five (5) business days of the patient discharge (Policy No. 2-043.1 Discharge Summary). An interview was conducted on 5/25/2022 with the Director of Nursing (Staff ID: 91533) who stated after review, that there was no documentation the physician was notified of hospice discharge.