Every finding on record at Mi Casa Healthcare, 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 14 (7%) clinical records reviewed, the hospice did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/22/2025 with a diagnosis of Alzheimer’s disease. The comprehensive assessment did not include documentation of an initial bereavement assessment that included the needs for the patient's family, and focused on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. During a joint review of records and interview on 02/12/2026, the Director of Nursing agreed that there was no documentation of a bereavement risk assessment.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical records reviewed, it was revealed that the agency did not ensure that the patients' medication profiles were complete and/or updated as changes were made based on the patients' updated comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 12/6/2022. On the RN "Initial/Comprehensive Assessment" dated 12/6/2022, the RN documented "Patient has more dyspnea during ADLs requiring frequent breaks and oxygen administration of 2 Liters as needed. Patient's oxygen saturation at 90% while caregiver and patient changed incontinence brief. Patient refused oxygen administration. Patient reports needing more oxygen while sleeping, stating that when she is having a bad night and having difficulty breathing..." The "Skilled Nurse Visit" dated 3/23/2023, the nurse documented oxygen saturation 98% "on oxygen". “Patient sitting on sofa upon arrival, supplemental oxygen in use due to SOB.” The patient's Medication Profile for dates: 12/6/2022 to 3/5/2023 or on the updated Medication Profile for dates: 3/6/2023 to 6/3/2023, did not list oxygen. Clinical Record 2: The patient elected the hospice benefit on 11/16/2022. In the "Skilled Nurse Visit" dated 3/7/2023, the nurse first documented the use of oxygen stating, "Patient verbalized agreement to use of supplemental oxygen, ordered at this time pending delivery.” On the "Skilled Nurse Visit" dated 3/24/2023, the nurse documented in the narrative, “Requires use of supplemental oxygen, due to SOB.” Oxygen was not listed on the patient's Medication Profile from the dates 3/7/2023 to 4/6/2023. Clinical Record 5: The patient elected the hospice benefit on 1/17/2023. During the "Skilled Nurse Visit" on 2/2/2023, the nurse first documented the use of oxygen at 1 liter per minute (LPM) per nasal cannula. Then on the "Skilled Nurse Visit" on 2/6/2023, the nurse documented that the patient's oxygen flow was increased to 3 LPM. The Medication Profile dated 1/7/2023 - 4/16/2023 did not include oxygen. Document 1: The agency's policy PC.M55 "Medication Profile" (effective date 2022) read, "The patient's medication profile review includes, but is not limited to determining accuracy and completeness of the profile." Interview: In an interview with the Alternate Director of Nurses on 4/6/2023, it was confirmed that oxygen was not listed on the Medication Profiles.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 and interview. In 1 of 9 (11%) clinical records reviewed, it was revealed that the hospice did not ensure that the patient's plan of care was updated to reflect new respiratory issues identified in the patient's updated comprehensive assessments. Clinical Record 5: The patient elected the hospice benefit on 1/17/2023. On 1/23/2023, the nurse documented in the "Skilled Nurse PRN Visit", that a visit needed to be made due to the patient experiencing an increase in chest congestion and a tight feeling in the chest. The nurse obtained a new order for Levaquin for a suspected respiratory infection. On 1/26/2023, the nurse documented in the "Skilled Nurse Visit" that the patient was experiencing decreased oxygen saturations to 80's% with increased dyspnea. An order was obtained for albuterol nebulizer treatments. On 1/31/2023, the nurse documented in the "Skilled Nurse Visit" that the patient's lungs still had crackles upon auscultation, and the nurse administered an albuterol nebulizer treatment. On 2/2/2023, in the "Skilled Nurse Visit," the first mention of oxygen was documented with the patient receiving oxygen at 1 liter per minute (LPM) via nasal cannula (NC). The nurse received a new order for Tessalon Pearls. And then, on 2/6/2023, the nurse documented in the "Skilled Nurse Visit" that the patient's oxygen had been increased from 1 LPM per NC to 3 LPM. There was no update to the problems and planned interventions based on the identification of new respiratory symptoms, new medications for the treatment of suspected respiratory infection (Levaquin), new orders for medications to treat the patient's cough and increased chest congestion (Albuterol nebulizer treatments, Mucinex, and Tesselon Pearls), or the use of oxygen. Interview: In an interview with the Alternate Director of Nurses on 4/5/2023, it was confirmed that the patient's problems and interventions were not updated to include the new respiratory issues identified by the nurse.

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 and interview. In 1 of 9 (11%) clinical records reviewed, it was revealed that the agency failed to ensure that the hospice documented that the patient and the patient's care plan was reviewed during the Interdisciplinary Group (IDG) at least every 15 days. Clinical Record 5: The patient elected the hospice benefit on 1/17/2023. In a review of the agency's Interdisciplinary Group (IDG) Meetings from 1/17/2023 to 3/22/2023, there was no documentation that this patient who elected the hospice benefit on 1/17/2023 was reviewed and discussed until 3/8/2023. Interview: In an interview on 4/6/2023 with the Alternate Director of Nurses/Alternate Administrator and Administrator, it was confirmed that there was no Interdisciplinary Meeting Review for this patient documented until 3/8/2023.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 2 (100%) Hospice Aide personnel records reviewed, it was revealed that the hospice did not ensure the initial Hospice Aide skills competency evaluation was completed by direct observation with a patient or a pseudo-patient. Personnel Record 12: The hospice aide's date of hire was 3/29/2023. The Initial "Competency Skills Checklist Hospice Aide" form dated 3/29/223 did not include evidence that the skills performed by the Hospice Aide were observed directly with a patient or a pseudo-patient. The skills form included "Method: Observation with a patient (PT), in a lab (L), or Verbal (V) for the skills of "bed bath, sponge bath, tub bath, shower, shampoo hair (sink), shampoo hair (tub), shampoo hair (bed), nail care, skin care, oral hygiene, toileting (toilet), toileting (bedpan/urinal), toileting (brief), catheter care, safe transfer techniques, safe ambulation, normal range of motion, positioning (body alignment and pressure relief), and massage." There was no method of how the evaluation of skills was determined - if the aide was observed with a patient or a pseudo-patient. Personnel Record 10: The hospice aide's date of hire was 12/13/2022. The Initial "Competency Skills Checklist Hospice Aide" form dated 12/13/2022 did not include evidence that some of the required competency skills performed by the Hospice Aide were observed directly with a patient or a pseudo-patient. The skills form included "Method: Observation with a patient (PT), in a lab (L), or Verbal (V) for the skills of "bed bath, sponge bath, tub bath, shower, shampoo hair (sink), shampoo hair (tub), shampoo hair (bed), nail care, skin care, oral hygiene, toileting (toilet), toileting (bedpan/urinal), toileting (brief), catheter care, safe transfer techniques, safe ambulation, normal range of motion, positioning (body alignment and pressure relief), and massage." The following skills were marked as "V," that the hospice aide had not performed the skill but only verbalized the process to the RN: "bed bath, sponge bath, tub bath, shampoo hair (sink), shampoo hair (bed), nail care, toileting (bedpad/urinal), toileting (briefs), catheter care, normal range of motion, positioning (body alignment and pressure relief), and massage." Document 1: The agency's policy HR.C10 "Competency Assessment" (effective date 2022) read. "Clinical supervisors and/or peer reviewers assess the performance of employees during joint visits in the clinical practice setting, in a lab setting to demonstrate a skill on a 'pseudo-patient' and through oral presentation, knowledge-based tests, case studies, self-assessment of a combination of any of the above." The policy also specifies, "Any skill which is technical must be observed." Interview: In an interview on 4/6/2023 with the Administrator, the Alternate Director of Nursing (DON), as well as with the Office Manager who is in charge of the Personnel Records, they confirmed that the Hospice Aides were not observed with a patient or a pseudo-patient performing all of the required skills on the "Competency Skills Hospice Aide" form.

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. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the clinical record was accurate and complete as the patient's hospice election statement was missing the effective date of the election of the hospice benefit. Clinical Record 1: The patient elected the hospice benefit on 11/3/2022. On the "Hospice Election, Informed Consent, & Acknowledgement" form, the effective date for when the Medicare Hospice Benefit would begin was left blank (no effective date for beginning hospice care). Interview: In an interview with the Alternate Director of Nurses/Alternate Administrator on 4/5/2023, it was confirmed that the hospice election effective date was left blank on the Hospice Election Form. Document 1: The agency's policy PC. D25 "Documentation Requirements" (effective date 2022) read, "No spaces are left blank on documentation tools and forms...". The agency's policy PC. E10, "Election of the Medicare Hospice Benefit" (effective date 2022) read, "...Includes the effective date of the election ....".

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 clinical record review and interview. In 3 of 9 (33%) clinical records reviewed, it was revealed that the hospice did not ensure that the patients' plans of care reflected accurate discipline visit frequency orders. Clinical Record 3: The patient elected the hospice benefit on 12/1/2022. The first aide visit was performed on 12/2/2022. The patient had been receiving aide visits three times a week since the day after admission. The first order for aide visits was for dates effective 2/1/2023 to 2/28/2023. Another order was entered for aide visits three times a week, effective for dates 3/1/2023 to 5/20/2023. Aide visits made from 12/2/2022 until 1/31/2023 were not included in the frequency of services ordered in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 12/6/2022. The plan of care for effective dates 12/6/2022 to 2/25/2023, included an order for the frequency of nursing visits two times a week. With the updated plan of care for benefit period 2, the plan of care order for nurse visits was revised for the nurse to begin nursing visits three times a week with the effective dates 3/8/2023 to 3/18/2023. . There was a gap in orders for nursing visits from 2/26/2023 to 3/7/2023, and there was one nurse visit that was performed on 3/6/2023 without an order. Another order was documented to continue nursing visits three times a week with effective dates from 3/23/2023 to 4/1/2023. There was another gap in orders for nursing visits from 3/19/2023 to 3/22/2023. There were nursing visits performed on 3/20/2023 and 3/22/2023 without an order. Clinical Record 5: The patient elected the hospice benefit on 1/17/2023. Several visits were made to address changes in the patient's respiratory status. On 2/2/2023, in the "Skilled Nurse Visit," the first mention of oxygen was documented with the patient receiving oxygen at 1 liter per minute (LPM) via nasal cannula (NC). On 2/6/2023, the nurse documented in the "Skilled Nurse Visit" that the patient's oxygen had been increased from 1 LPM per NC to 3 LPM. There was no update to the patient's plan of care to include the oxygen concentrator or order for oxygen use. Interview: In an interview with the Alternate Director of Nurses on 4/5/2023, it was confirmed that there were no orders in the patient's record for an oxygen concentrator or for oxygen use and confirmed that visits were made without an order.

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%) applicable clinical records reviewed in which there was a live discharge from the hospice, it was revealed that the agency did not ensure that the discharge summary included the plan of care and physician orders or a summary of the patient's hospice stay. Clinical Record 7: The patient elected the hospice benefit on 2/14/2023. Then on 2/16/2023, the patient was discharged due to moving out of the hospice's service area. The nurse documented in the Discharge Visit dated 2/16/2023, "Discharge instructions reviewed with daughter. Daughter has current medications list, medications and directions reviewed verbalized understanding. Weekly pill box last filled on 2/15/23. Patient has enough medications to last for at least 2 weeks, recently filled at local pharmacy by daughter. Daughter instructed to have patient follow up with PCP in 1-2 weeks, verbalized understanding." The form had boxes that were checked for the following: Physician in Agreement with Plan to Discharge for Stated Reason Patient/Caregiver in Agreement with Plan to Discharge for Stated Reason PatientLegal Representative in agreement with Plan to discharge for Stated Reason Notified Patient/Caregiver/Legal Representative: Notified IDG Staff Notified Pharmacy/Pharmacy BenefitManager Notified DME Company: Copy of Discharge Summary sent to Attending Physician Patient/Caregiver is Safe With Medication Administration Patient/Caregiver Can IdentifyandManage Symptoms Patient/Caregiver Can Verbalize who to Follow-up With Post Discharge Patient/Caregiver Can Verbalize Emergency Preparedness Response Discharge Order Received Medication List Provided to Patient/Caregiver Other: Patient has enough medication to last for at least 2 weeks. Weekly pill box filled 2/15/2023. While the box was checked that the Discharge Summary was sent to the receiving attending physician, the form did not include the patient's plan of care, physician orders, or summary of the hospice stay to facilitate continuity of care for the patient. Document 1: The agency's policy PC.D20 "Discharge from the Hospice" (effective date 2022), the policy reads, "This discharge summary is filed in the clinical record and includes the date and reason for discharge, any instructions or referral information given to the patient or family, hospice diagnosis, significant health history, discharge orders, instructions, medication profile, and allergies...., the client's latest physician orders, status of the patient at time of discharge, a summary of the client's stay, brief description of services provided and ongoing needs that cannot be met, a copy of the patient's current plan of care, ...presence of advance directives..." Personnel Record 7: In an interview on 4/6/2023 with the Alternate Director of Nurses (DON) and the Administrator and reviewing the CHAP Standard and Medicare Regulation for the required components of a Discharge Summary, they confirmed that the documented Discharge Summary was missing the elements of the plan of care, physician orders, medication profile, and summary of the patient's hospice stay.