Every finding on record at Mclaren Health Management Group

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 7 of 23 (30%) clinical records reviewed it was revealed that the agency did not ensure that all medical supplies and appliances necessary to meet the needs of the patient were included in the patient's individualized written plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/19/2024. The plan of care dated 02/13/2025-04/13/2025 included orders for "Oxygen 2.5 liters via nasal cannula as needed for dyspnea." The plan of care did not include the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/31/2023. A physician's order dated 06/04/2023 included orders for "Oxygen 2 liters via nasal cannula as needed for dyspnea.” The plans of care dated 08/29/2023-11/26/2023, 11/27/2023-01/25/2024, 01/26/2024-03/25/2024, 03/26/2024-05/24/2024, 05/25/2024-07/23/2024, 07/24/2024-09/21/2024, 09/22/2024-11/20/2024, 11/21/2024-01/19/2025, and 01/20/2025-03/20/2025 did not include the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/28/2024. The plan of care dated 10/28/2024-01/25/2025 included orders to "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including continuous oxygen.” The plan of care did not include the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/27/2024. The initial nursing assessment dated 12/27/2024 read in part "patient is on intermittent oxygen at 2 liters via nasal cannula.” The plan of care dated 12/27/2024-03/26/2025 did not include the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/02/2025. The plan of care dated 01/02/2025-04/01/2025 included orders to "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including oxygen.” The plan of care did not include the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 18: The patient elected the hospice benefit on 11/23/2024. The plan of care dated 02/21/2025-05/21/2025 included orders to "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including oxygen.” The plan of care did not include the patient's oxygen concentrator or oxygen supplies. CLINICAL RECORD 19: The patient elected the hospice benefit on 01/26/2024. The plan of care dated 01/26/2024-03/03/2024 included orders for "Oxygen 1-6 liters via nasal cannula as needed for shortness of breath.” The plan of care did not include the patient's oxygen concentrator or oxygen supplies. In an interview on 03/13/2025, the Hospice Clinical Manager reviewed the records, confirmed the above findings, and stated "The oxygen supplies are not listed on any of these plans 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 4 of 16 (25%) clinical records reviewed with hospice aide services provided it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/21/2024. The nursing visit note dated 01/31/2025 read in part, "Patient has a foley catheter in place after hospitalization." The plan of care dated 01/19/2025-04/18/2025 ordered "Aide 1x/week.” The aide care plan dated 10/21/2024 lacked updated patient care instructions for the foley catheter. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/14/2025. A physician's order dated 02/24/2025 ordered, "Oxygen 2-6 liters via nasal cannula as needed for dyspnea.” The plan of care dated 02/14/2025-05/14/2025 ordered "Aide 1x/week.” The aide care plan dated 02/15/2025 did not include instructions regarding the oxygen. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/28/2024. A physician's order dated 11/21/2024 ordered, "Place Foley catheter 18Fr, with 10ml balloon.” The plan of care dated 10/28/2024-01/25/2025 ordered "Aide 2x/week.” The aide care plan dated 11/22/2024 did not include instructions regarding foley catheter care. CLINICAL RECORD 23: The patient elected the hospice benefit on 10/16/2024. A physician's order dated 10/16/2024 included orders for wound care with a wound dressing to a wound on the patient's coccyx. The plan of care dated 10/16/2024-11/15/2024 ordered "Aide 2x/week.” The aide care plan dated 10/16/2024 included relevant instructions of "shower at every visit.” The aide care plan did not include instructions regarding the wound dressing should it become wet or dislodged during the shower. On 03/13/2025, the Hospice Clinical Manager reviewed the records and confirmed the findings that the aide care plans did not include foley catheter care, wound dressing or oxygen instructions.

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; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) clinical records reviewed with hospice aide services provided it was revealed that the agency did not ensure that hospice aide supervisory visits were completed no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/18/2024. The plans of care dated 10/15/2024-12/13/2024 and 12/14/2024-02/11/2025 ordered, "Aide 1 time per week." A hospice aide supervisory visit was dated 12/06/2024 and the next hospice aide supervisory visit was dated 12/27/2024, 21 days later and 7 days outstanding. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/19/2024. The plans of care dated 07/18/2024-10/15/2024, 10/16/2024-12/14/2024, and 12/15/2024-02/12/2025 ordered, "Aide 1 time per week." A hospice aide supervisory visit was dated 09/19/2024 and the next hospice aide supervisory visit was dated 01/02/2025, 105 days later and 91 days outstanding. The next hospice aide supervisory visit was dated 02/04/2025, 33 days later and 19 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/09/2024. The plans of care dated 10/07/2024-01/04/2025 and 01/05/2025-03/05/2025 ordered, "Aide 1 time per week." A hospice aide supervisory visit was dated 10/09/2024 and the next hospice aide supervisory visit was dated 10/30/2024, 21 days later and 7 days outstanding. A hospice aide supervisory visit was dated 11/27/2024 and the next hospice aide supervisory visit was dated 01/17/2025, 50 days later and 36 days outstanding. CLINICAL RECORD 14: The patient elected the hospice benefit on 11/20/2024. The plan of care dated 11/20/2024-02/17/2025 ordered, "Aide 1 time per week starting 11/27/2024." The first hospice aide visit was dated 11/27/2024. The first hospice aide supervisory visit was dated 02/05/2025, 70 days later and 56 days outstanding. CLINICAL RECORD 22: The patient elected the hospice benefit on 05/03/2024. The plan of care dated 05/03/2024-07/31/2024 ordered, "Aide 2 times per week.” A hospice aide supervisory visit was dated 05/22/2024. The next hospice aide supervisory visit was dated 06/12/2024, 21 days later and 7 days outstanding. In an interview on 03/13/2025, the Hospice Clinical Manager reviewed the records, confirmed the above findings, and stated "There are no other supervisory visits in these patient charts.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 6 of 23 (26%) clinical records reviewed it was revealed that the agency did not ensure that the patient's clinical record included all physician orders. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/21/2024. The nursing visit note dated 01/31/2025 read in part "Patient has a foley catheter in place after hospitalization." The record lacked documentation of physician orders for the size, care and maintenance of the foley catheter. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/24/2025. The nursing visit note dated 01/27/2025 read in part "RN placed an 18 Fr, 10ml balloon foley catheter." The record lacked documentation of physician orders for the size, care and maintenance of the foley catheter. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/28/2024. The initial nursing assessment dated 10/28/2024 read in part "Patient is utilizing continuous oxygen.” The plan of care dated 10/28/2024-01/25/2025 included orders to, "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including continuous oxygen.” The clinical record did not include a physician order for the dose and route of the oxygen. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/27/2024. The initial nursing assessment dated 12/27/2024 read in part "Patient is on intermittent oxygen at 2 liters via nasal cannula.” The clinical record did not include physician orders for the dosage, route and frequency of the oxygen. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/02/2025. The initial nursing assessment dated 01/02/2025 read in part "Patient is on continuous oxygen.” The plan of care dated 01/02/2025-04/01/2025 included orders to "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including oxygen.” The plan of care did not include a physician order for the dose, route, and frequency of the oxygen. CLINICAL RECORD 18: The patient elected the hospice benefit on 11/23/2024. The plan of care dated 02/21/2025-05/21/2025 included orders to "Train patient in pharmacological and non-pharmacological measures to manage/relieve respiratory symptoms including oxygen.” The clinical record did not include a physician order for the dose, route, and frequency of the oxygen. On 03/12/2025, the Hospice Clinical Manager reviewed the records and confirmed the finding that the records did not contain physician's orders for the size, care and maintenance of the foley catheter nor physician's orders for the dosage, route and frequency of oxygen.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility 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 2 (50%) live discharge clinical records reviewed it was revealed that the agency did not ensure that a hospice discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 22: The patient elected the hospice benefit on 05/03/2024. A hospice discharge visit was dated 08/02/2024 and read in part "Patient transferred to another hospice.” The record lacked documentation of a hospice discharge summary being sent to the receiving hospice. On 3/14/2025 the Hospice Clinical Manager reviewed the record and confirmed the finding, stating "We do not have any documentation of a summary being sent. Our computer system was down at that time and a discharge summary was hand delivered to the receiving hospice.”

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 review of clinical record, document review and interview that in 6 of 12 (50%) records admitted after 01/01/2020, all required disciplines failed to contact patient/family and assess for hospice needs in the required five calendar days. Agency Policy H:2-046.1 Comprehensive Assessment [revised date 10/05/2018] stated in part, "The patient psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation family relationships, social history, source and adequacy of environmental and other resources.....family/caregiver's spiritual orientation, including as appropriate, any involvement in a religious group such as a church or synagogue, or support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffer, guilt, etc." "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care." Record #49736 with benefit of election date 04/11/2021. The physician signed plan of care 04/11/2021 - 07/09/2021 documented frequency for nursing and aide services. The record did not document offering of spiritual services. Interdisciplinary team documented on 04/19/2021, spiritual has not yet evaluated. Interdisciplinary team documented on 04/27/2022 spiritual service declined. This is day 16 and is 11 days late. Record #76955 with benefit of election date 12/03/2021. The admission assessment on 12/03/2021documented acceptance of hospice services. A coordination note, 12/09/2021, documented a missed visit from social work and that the son declined the service. This is day 6 and is 1 day late. The interdisciplinary team documented on 12/07/2021 and 12/21/2021 spiritual not yet evaluated. Interdisciplinary team documented on 01/04/2022 not on chaplains schedule. Interdisciplinary team documented on 01/18/2022 spiritual services offered and declined. This is day 47 and is 42 days late. Record #40935 with benefit of election date 01/20/2022. Interdisciplinary team documented on 01/25/2022 spiritual yet to evaluate and social work not yet assigned. Interdisciplinary team documented 02/08/2022 spiritual declined and social work not yet evaluated, patient then died. This is day 19 and is 14 days late. Record #97435 with benefit of election date 03/24/2022. Interdisciplinary team documented on 03/29/2022 spiritual to evaluate. Interdisciplinary team documented on 04/12/2022 spiritual offered and declined. This is day 19 and is 14 days late. Record # 65297 with benefit of election date 01/17/2022. The physician signed plan of care 01/17/2022 - 04/16/2022 orders social work to evaluate. The medical social work evaluation was documented on 01/24/2022 which is day 7 and is 2 days late. Spiritual care documented on interdisciplinary team 01/25/2022 offered and declined which is day 8 and 3 days late. Record #25252 with benefit of election 12/30/2021. The interdisciplinary team documented on 01/04/2022 that spiritual care not yet evaluated. Interdisciplinary team documented on 01/18/2022 spiritual not on schedule. Interdisciplinary team documented on 02/01/2022 spiritual offered and declined. This is day 33 and is 28 days late. Interview with Clinical Branch Manager on 04/28/2022 stated that services were declined on admission but documentation was unclear.

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, document review and interview that in 3 of 13 (14%) records failed to document all planned intervention and goals from the initial comprehensive assessment and updated from following comprehensive assessment. Agency Policy H:2-030.1 Hospice Plan of Care [revised date 03/04/2019] stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis...." Record #25252 with the initial assessment on 12/30/2021 identified a high fall risk and dementia. No interventions or goals were documented for these identified care issues. The updated assessment on 01/27/2022 identified bilateral leg edema, then 03/03/2022 unna [compression dressing] boots being applied because compression stockings removed by patient. The plan of care was not updated for intervention or goals for care of edema as of discharge 03/16/2022. Record #75048 with an updated assessment on 11/22/2021 documented application of CBD [ primary ingredient from a hemp plant] oil to both knees for pain control. The plan of care was not updated for intervention or goals for this specific pain problem as of review 04/27/2022. Record #76955 with an updated assessment on 03/31/2022 which documented that a Foley catheter was inserted for comfort. No updated intervention or goals documented for this Foley care as of review 04/27/2022. Interview with the Clinical Branch Manager on 04/28/2022 stated that the plans of care are not updated for these cares.

It is required that medical social services are provided:per the plan of care. This standard was not met as evidenced by review of clinical record and interview that in 1 of 11 (09%) records that accepted social work for care, the social work failed to follow the ordered frequency for visits, on the plan of care. Record #22545 with interdisciplinary plans of care from 12/14/2021 thru 01/11/2022 ordered social work visits weekly. The week beginning 12/26/2021 and the next 3 weeks, no visits documented from social worker and no reason for the missed visit documentation. Interview with the Clinical Branch Manager stated that COVID was active at the facility in which the patient resided and the facility did not allow the social worker to visit. Documentation of this request was not in the clinical record and was not documented on the interdisciplinary team plans.

It is required that hospice aides are assigned to a specific patient by a registered nurse 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 review of clinical record, observation, document review and interview that in 2 of 9 (22%) records in which a hospice aide was accepted for service, failed to document clear and specific instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide scope of practice. Agency Policy: Aide Plan of Care, H 2-009.1 [Revised day 03/08/2019] stated in part, "The aide plan of care will be individualized to the specific, patient and will include at least: type of services/procedures to be provided,, such as hands on personal care, the performance of simple procedures, ". Record #76955 documented an aide assignment plan developed on 12/03/2021. On 03/31/2022 the nursing visit note documented that a Foley catheter was inserted for comfort and continued in place as of record review 04/26/2022. The hospice aide assignment plan with documented task for bed bath and observed precautions failed to document that catheter care required for a patient residing in the family home. Record #72544 documented an aide assignment plan updated on 08/24/2020, failed to include oxygen safety. Observed during hospice aide visit on 04/25/2022, the aide stated that the patient now wears her oxygen during the shower as she is too short of breath and needs it. The aide demonstrated oxygen safety during the visit but agreed that it was not on the plan of care. The documented face to face on 01/12/2022 documented the need for oxygen continuously. The aide assignment plan failed as of review 04/26/2022 to include oxygen safety. Interview with Clinical Branch Manager on 04/26/2022 stated that the aide plan of care should have been updated.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group. This standard was not met as evidenced by review of clinical record and interview that in 1 of 9 (11%) records in which an aide was accepted for care. Documented aide visits failed to be provided per ordered plan of care. Record #25252 with updated plan of care, 01/04/2022, hospice aide frequency 1 week 1, 2 week 1, 1 week 9. The aide visits documented the week beginning 01/09/2022 delivered 1 visit (no reason for missed second visit) and 0 visits the next 2 weeks (no reason for missed weekly visit). The patient resided in a facility. Interview with the Clinical Branch Manager stated that these weeks several clinical staff tested positive for COVID, including both hospice aides, the facility requested that no staff visit their facility until negative COVID tests received and that the facility would provide the care. An email dated 01/14/2022 documented the positive COVID staff but does not document the phone call with the facility that clarified the care change.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by review of clinical records, document review and interview that in 3 of 13 (23%) records failed to document required physician orders. Agency Policy H:2-032.1, Verification of Physician Orders [revised date 11/12/2020] stated in part, "Orders will be obtained from a licensed physician for care and services to be provided to hospice patients." Record #75048 documented in a nursing visit note on 11/22/2021 that the patient continued to apply CBD {primary ingredient from a hemp plant] oil to knees. As of review 04/26/2022 no physician order documented for this treatment. Record #76955 documented on a nursing visit note on 03/31/2022 that a Foley Catheter placed for comfort and continued in place as of review 04/27/2022. No physician order documented for this treatment. Additionally a physician order written 03/11/2022, "cleanse with soap and water, pat dry, apply Optifoam [ a highly absorbent product] dressing with silver, change weekly and prn." The location of the dressing is absent. This patient had wounds on a right heel, a left foot, and an arm dressing. Nursing visit note on 04/11/2022 documented oxygen prn. No physician order documented as of review 04/27/2022. Nursing visit note on 01/01/2022 documented left elbow wound wrapped with coban [self adhering wrap] over the emulsion dressing. There was a physician order for the emulsion dressing documented 12/10/2021 to cover with gauze but no physician order for coban wrap as of review 04/27/2022. Nursing visit note 01/17/2022 documented Calamazine [a zinc cream to relieve itching and discomfort] cream on bottom. No physician order documented as of review 04/27/2022. Nursing visit note 01/31/2022 documented the patient using Zofran [prevent nausea and vomiting]. No physician order documented as of review 04/27/2022. Record #25252 documented on a nursing visit note 03/03/2022 that unna boot [compression dressing] applied as patient will not leave on compression stockings. Interdisciplinary note update on 03/01/2022 documented unna boot applied as patient will not leave on compression stocking. Nursing visit note on 01/27/2022 documented bilateral edema. No physician order documented for the compression stockings or the unna boot as of review 04/27/2022. Interview with the Clinical Branch Manager on 04/28/2022 stated that some of the information flowed to the interdisciplinary note but physician orders were not documented

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by review of fire drill manual and interview on 04/27.2022 that the agency failed to document fire drills on each shift, every quarter. Review of Fire Drills for the fourth quarter of 2021 documented one fire drill at 1536, which is the morning shift. No other fire drills that quarter. The facility staffs with twelve hour shifts. No fire drill documented for the night shift, fourth quarter. Life Safety Code: " Drills must be conducted quarterly on each shift to familiarize staff with signals and emergency actions required under varied conditions. At least 12 drills shall be held every year. Drills must be held at unexpected times and under varying conditions to simulate an actual fire. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms. The purpose of a fire drill is to test the efficiency, knowledge, and response of staff. Its purpose is not to disturb or excite residents. Documentation of fire drills is required. Documentation shall include the date and time of the drill. " Interview with the Clinical Branch Manager and the Vice President of Hospice and Palliative Care and Manager of Facilities and Maintenance Director on 04/27/2022 stated that the process was missed fourth quarter in 2021. CFR 418.110 (c)