Every finding on record at Nurses & Company Hospice LLC

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) applicable clinical records reviewed revealed that the agency did not ensure a registered nurse supervised a licensed practical nurse in accordance with agency policy. Policy No. 1-031 (Responsibilities/Supervision of Clinical Services) states in part: " A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services." CLINICAL RECORD 8: The patient elected the hospice benefit on 07/22/2023 with diagnoses of Malignant neoplasm of the anterior surface of epiglottis, secondary malignant neoplasm of nodes of multiple regions, Systemic Lupus Erythematosus, HTN, and Type 2 DM. A review of the benefit periods 03/18/2024 - 05/16/2024 and 05/17/2024 - 07/15/2024 included a skilled nurse frequency of one time a week (1xw). The licensed practical nurse documented visits on 05/14/2024 and 06/03/2024. The clinical record review on 08/06/2025 included a registered nurse supervisory visit on 03/18/2024. There were no other documented LPN supervisory visits as of 08/06/2025 in accordance with agency policy of monthly supervision by the registered nurse. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/11/2025 with diagnoses of Alzheimer's, malignant neoplasm of right breast, tachycardia, restlessness and agitation, severe protein-calorie malnutrition, and incontinence. A review of the benefit period 02/11/2025 - 05/11/2025 included skilled nurse frequency of one time a week(1xw). The licensed practical nurse (LPN) documented visits on 02/13/2025 and 03/11/2025. The clinical record review on 08/05/2025 revealed no documented evidence of LPN supervisory visits for February or March in accordance with agency policy of monthly supervision by the registered nurse. The patient was discharged on 04/03/2025. During an interview with the Regional Quality Specialist on 08/06/2025, she confirmed the records did not have an RN Supervisory visit documented.

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. This standard was not met as evidenced by document review and interview. The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the 2024 Hospice Volunteer Requirement Report revealed the volunteer percentage of hours worked for January 2024 through December 2024 was 0.7%. The Administrator/Director of Nursing (DON) stated in an interview on 08/06/2025 that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. They stated, "they are getting more volunteer hours, and the percentage is up to 1.1% in 2025." The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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. This standard was not met as evidenced by a review of clinical records, document review, and interviews. Agency policy no. 1-021 titled Bereavement Assessment stated in part, "(1) on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the bereavement coordinator." 3 of 11 (27%) clinical records reviewed revealed the initial bereavement assessment was not completed. Clinical Record 7 Patient with hospice election of benefit dated 8/9/2022 did not have a documented initial bereavement assessment as of review on 10/21/2022. Clinical Record 6: The patient with hospice election of benefit dated 5/31/2022 did not have a documented initial bereavement assessment as of review on 10/21/2022. Clinical Record 8: The patient with hospice election of benefit dated 5/26/2022 did not have a documented initial bereavement assessment as of review on 10/21/2022. An interview with Director of Accreditation on 10/21/2022 confirmed the initial bereavement assessments were missing for Records 6, 7, and 8 during the joint record review.

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 a review of clinical records, interviews, and observations. 1 of 10 (10%) clinical records reviewed where hospice aide services were accepted, the Registered Nurse failed to update the hospice aide care plan after the hospice aide reported the functional decline of the patient and the nurse completed a re-assessment visit. Clinical Record 11: Patient with hospice election of benefit dated 11/11/2021 had a documented aide care plan dated 11/17/2021 with the assigned task of shower bath every visit. Aide visit dated 9/23/2022 documented “Y” to completed shower bath with a note bed bath given instead and RN notified. Aide visit dated 9/20/2022 documented ‘Y” to completed shower bath with the note "bed bath given due to the patient not feeling well. The patient took some medication before my visit and was not steady. I did assist to the toilet and was having problems walking there." Aide visit dated 10/4/2022 documented shower bath not completed with a note bed bath given and RN notified. Aide visit dated 10/7/2022 documented bath shower completed and assigned task transfer assist not completed with note patient did not get out of bed, placed pillow under the left side to reduce pressure on buttocks. Aide visit dated 10/11/2022 documented shower bath not completed with a note that bed bath given. Aide visit dated 10/14/2022 documented the assigned task of shower completed with a note bed bath due to weakness. Aide visit dated 10/18/2022 documented a bed bath given with the help of the patient's daughter. An interview with the hospice aide revealed she called the RN on 9/20/2022 to notify the RN case manager of the patient's decline. PRN RN visit dated 9/21/2022 and routine RN visit dated 9/22/2022 documented under the Aide Orientation section documented "no" to the question “were changes made to the aide care plan at the current visit?” PRN RN Visit dated 10/4/2022 documented under Aide Orientation section, documented "no" to question “were changes made to the aide care plan at the current visit?” The hospice aide plan of care had not been updated since 11/17/2021. Home Visit 3: During the home visit (Clinical Record 11) on 10/19/2022, the daughter described the events of the patient's functional decline, and that the patient had been bedbound for the last month. An interview on 10/19/2022 with the Clinical Manager (Staff 4) and Director of Accreditation confirmed the hospice aide care plan should have been updated. Clinical manager updated the aide care plan to bed bath on 10/20/2022.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 2 of 10 (20%) clinical records reviewed of patients that accepted hospice aides, the aide failed to provide the services in accordance with the documented plan of care. Clinical Record 2: The patient with hospice election of benefit dated 11/6/2021 had a documented aide care plan dated 4/11/2022. The care plan documented two types of baths: bed bath to be completed on the last visit of the week and shower bath to be completed on the first visit of the week. Hospice aide frequency was twice weekly. Aide visit notes dated 5/3/2022, 4/29/2022, 4/19/2022, 4/15/2022, and 4/12/2022 documented "Y" for completion of both bed bath and shower bath at each visit. Clinical Record 10: Patient with hospice election of benefit dated 6/30/2021 had documented aide care plan dated 3/24/2022. The aide care plan contained documented assigned tasks of light housekeeping to be completed at every visit. Instructions under the details section are documented to assist one person with dirty dishes, assist with soiled clothing from the room, wipe down soiled tables and straighten clothes. The tasks for changing bed linens, and making bed or laundry clothes were not assigned or documented on the aide care plan. Home Visit 1: During a home visit on 10/19/2022, the hospice aide was interviewed to review verbally all tasks performed for the patient (Clinical Record 10). The aide stated completing tasks of laundry, changing linens, and making bed which was not included in the aide plan of care. Interview with the Clinical Manager (Staff 4) and Director of Accreditation confirmed the hospice aide care plan needed to be updated for Record 10, and the hospice aide documented Record 2 incorrectly.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by observations and interview. 1 of 2 (50%) observed inspections of the agency's medical supply rooms revealed expired supplies. Inspection of the medical supply room at the Alternate Delivery Site (ADS) on 10/21/2022 revealed four (4) expired Abbott BinaxNOW™ COVID-19 Ag Cards with lot number 145147R expired 2/8/2022. Because the manufacturer Abbott on January 2022 sent out a notification explaining that some BinaxNOW™ COVID-19 Ag Cards may have a longer than the labeled product expiration date, the lot number 145147R was verified on the BinaxNOW™ COVID-19 Test Lot Expiry Lookup website (https://binaxnowlookup.abbott.com). Lot number 145147R was not found. Abbott Technical Services was called (1-800-257 9525) to confirm if items were included in the extended expiration date. The Abbott representative confirmed if the lot number was not found on the lookup website, they were not extended and were expired. ADS Clinical Manager (Staff 3) witnessed the inspection of the medical supply room on 10/21/2022 and heard what the Abbott representative stated regarding items not included in the extended expiry date. Clinical manager confirmed the items were expired and were discarded from circulation.