Every finding on record at Love & Faith Hospice Services Inc

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 clinical record review, document review, and interview. In 6 of 14 (43%) clinical records reviewed revealed the agency did not ensure the interdisciplinary group reviewed the patient's plan of care no less than every fifteen calendar days. DOCUMENT 1: The agency's policy 1-036, titled "Interdisciplinary Group," dated November 2021, stated in part, "A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the comprehensive assessment." CLINICAL RECORD 2: The patient’s election of benefit was dated 06/16/2025. The patient's last Interdisciplinary Group (IDG) meeting and updated plan of care was documented on November 28, 2025. As of January 7, 2026, there was no evidence that plan of care had been updated. CLINICAL RECORD 3: The patient’s election of benefit was dated 07/21/2025. The patient's last IDG meeting and updated plan of care was documented on November 14, 2025. As of January 7, 2026, there was no evidence that plan of care had been updated. CLINICAL RECORD 5: The patient’s election of benefit was dated 09/07/2024. The patient's last IDG meeting and updated plan of care was documented on August 8, 2025. As of January 8, 2026, there was no evidence that plan of care had been updated. CLINICAL RECORD 6: The patient’s election of benefit was dated 07/02/2025. The patient's last IDG meeting and updated plan of care was documented on December 12, 2025. As of January 7, 2026, there was no evidence that plan of care had been updated. CLINICAL RECORD 8: The patient’s election of benefit was 03/24/2025. The patient resides in his home. The patient's last IDG meeting and updated plan of care was documented on October 14, 2025. As of January 7, 2026, there was no evidence that plan of care had been updated. CLINICAL RECORD 10: The patient’s election of benefit was dated 03/07/2025. The patient's last IDG meeting and updated plan of care was documented on September 2, 2025. As of January 7, 2026, there was no evidence that plan of care had been updated. An interview was conducted with the Director of Patient Care Services (DPCS) on January 8, 2026. The DPCS stated that for clinical records five, eight, and ten, the electronic medical records platform had malfunctioned, resulting in data loss and that the vendor was working on recovering the data. The DPCS acknowledged that no alternative form of documentation was utilized and that all findings were accurate.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that nursing care and services were provided by a registered nurse (RN), as required by agency policy. DOCUMENT 3: The agency's policy 9-019 titled Nursing Care, dated November 2021, stated in part, " The hospice registered nurse performs ongoing updates of the comprehensive assessment to assess the impact of the terminal diagnosis." CLINICAL RECORD 5: The patient’s election of benefit was dated 09/07/2024. The patient resided in an assisted living facility (ALF). The patient’s current benefit period was dated 12/06/2025 - 02/03/2026. The patient's plan of care, dated August 8, 2025, included skilled nursing services that were ordered three times per week. The clinical record review found no evidence of RN visits documented after August 15, 2025. CLINICAL RECORD 9: The patient’s election of benefit was dated 03/23/2025. The patient resided in an ALF. The patient's plan of care, dated December 12, 2025, included skilled nursing services that were ordered twice a week, and included three as-needed visits. The patient’s current benefit period was dated 11/18/2025-11/01/2026. The clinical record review found no evidence of RN visits documented for December 2025 and the first week of January 2026. CLINICAL RECORD 10: The patient’s election of benefit was 03/07/2025. The patient resides in an ALF. The patient's plan of care, dated December 9, 2025, included Skilled Nursing services ordered twice a week, plus three as-needed visits. The patient’s current benefit period was dated 12/29/2025 - 02/26/2026. The clinical record review found no evidence of RN visits documented for December 2025 and the first week of January 2026. An interview was conducted on January 8, 2026, with the Director of Patient Care Services (DPCS). The DPCS provided evidence found in the facility's hospice binders documenting the hospice RN visits (for CR #5 and CR #10). The documentation in the binder was a communication note that the visit had taken place. There was no documentation to indicate a comprehensive assessment was completed. The DPCS also acknowledged the RN visit documentation (for CR #9) was missing.

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; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that hospice aide supervision occurred by a registered nurse in the patient's home at least every fourteen days. DOCUMENT 4: The agency's policy 1-037 titled Hospice Aide Supervisory Visits, stated in part, "The frequency of supervisory visits must be conducted no less frequently than every 14 days." CLINICAL RECORD 8: The patient's plan of care dated November 28, 2025, ordered hospice aide services two times per week. The hospice aide visited on December 1, 2025, December 3, 2025, and December 8, 2025. December 10, 2025, December 15, 2025, December 17, 2025, December 22, 2025, December 24, 2025, December 29, 2025, and December 31, 2025. There was no documented evidence that the RN completed a supervisory visit of the hospice aide for December 2025. CLINICAL RECORD 10: The patient's plan of care dated December 9, 2025, ordered hospice aide services three times per week. The hospice aide documented visits on December 1, 2025, December 4, 2025, December 9, 2025, December 11, 2025, December 16, 2025, December 18, 2025, December 23, 2025, and December 30, 2025. There was no documented evidence that the RN completed a supervisory visit of the hospice aide for December 2025. CLINICAL RECORD 11: The patient's plan of care dated February 28, 2025, ordered hospice aide services three times a week. The hospice aide documented visits on March 5, 2025, March 10, 2025, March 12, 2025, and March 14, 2025. There was no documented evidence that the RN completed a supervisory visit of the hospice aide for March 2025. CLINICAL RECORD 5: The patient's plan of care dated August 8.2025, ordered hospice aide services three times a week. The hospice aide documented visits on August 11, 2025, August 13, 2025, August 15, 2025, August 18, 2025, August 20, 2025, and August 22, 2025. There was no documented evidence that the RN completed a supervisory visit of the hospice aide from August 11, 2025, to August 25, 2025. An interview was conducted with the Director of Patient Care Services (DPCS) on January 8, 2026. The DPCS acknowledged the supervision of aide services did not occur within the frequency noted in the agency's policy.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed the agency did not ensure recertification was completed no later than two calendar days after the first day of each benefit period. DOCUMENT 2: The agency's policy 1-007 titled Certification of Terminal Illness, dated November 2021, stated in part, "A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period". CLINICAL RECORD 2: The patient’s election of benefit was dated 06/16/2025. The patient's third benefit period began on December 13, 2025. There was no evidence of a documented physician's recertification. The Medical Director's name was electronically present on a blank recertification form that lacked a dated narrative statement and documentation of a face-to-face visit. CLINICAL RECORD 5: The patient’s election of benefit was dated 09/07/2024. The patient's eighteenth benefit period began on December 2, 2025. There was no evidence of a documented physician's recertification. The Medical Director's name was electronically present on a blank recertification form that lacked a dated narrative statement and documentation of a face-to-face visit. CLINICAL RECORD 6: The patient’s election of benefit was dated 07/02/2025. The patient's third benefit period began on December 29, 2025. There was no evidence of a documented physician's recertification. The Medical Director's name was electronically present on a blank recertification form that lacked a dated narrative statement and documentation of a face-to-face visit. CLINICAL RECORD 9: The patient’s election of benefit was dated 03/23/2025. The patient's fourth benefit period began on November 11, 2025.There was no evidence of a documented physician's recertification. The Medical Director's name was electronically present on a blank recertification form that lacked a dated narrative statement and documentation of a face-to-face visit. CLINICAL RECORD 10: The patient’s election of benefit was dated 03/07/2025. The patient's fifth benefit period began on December 29, 2025.There was no evidence of a documented physician's recertification. The Medical Director's name was electronically present on a blank recertification form that lacked a dated narrative statement and documentation of a face-to-face visit. An interview with the Director of Patient Care Services (DPCS) was conducted on January 8, 2026. The DPCS stated he has contacted the Medical Director to complete the recertification documentation.

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 a review of clinical records and interviews. 1 of 3 (33%) clinical records reviewed revealed the agency did not ensure that the hospice aide provided services as ordered on the plan of care (POC). Clinical Record 7: The patient elected hospice services on 10/21/2022. The plan of care dated 10/21/2022 included an order for Aide services three times weekly. For the weeks ending 10/22/2022 and 10/29/22 there were no documented aide visits. The clinical record did not include documentation that the aide reported the missed visits to the physician and registered nurse (RN), or the reason(s) for the missed visits. This finding was discussed with the Administrator/Director of Patient Care Services (DPCS) in an interview on 1/31/2023. The Administrator/DPCS confirmed there were no documented aide visits for the weeks ending 10/22/2022 and 10/29/2022 and no missed visit documentation or documentation of the reason the aide visits were not provided as ordered.

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 a copy of the discharge summary to the patient's attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) clinical records reviewed for a patient that revoked hospice care revealed that the agency did not ensure that a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 4: The patient revoked the election of hospice care on 1/24/2023. The clinical record did not include documentation that a discharge summary was completed and sent to the patient's attending physician. Administrator/Director Patient Care Services was interviewed during a joint review of the clinical record on 1/31/23 who confirmed there was no documentation validating that a discharge summary was forwarded to the patient's attending physician.