Every finding on record at Pointe of Hope Hospice and Palliative Care LLC

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed it was revealed that the agency did not ensure that the Medical Social Worker's comprehensive assessment was completed within the required 5-day period following the election of hospice care. CLINICAL RECORD 5: The patient was admitted on 08/13/2024. The psychosocial assessment was documented by the Medical Social Worker on 08/20/2024 (day 7). There was no communication documented as to why the visit was not made within the 5-day requirement. During a joint record review and interview on 08/06/2025, Administrator/Clinical Manager (Personnel Record 4) agreed that the Social Worker did not complete her initial comprehensive assessment until 08/20/2025.

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 clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, in which hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse (RN) provided the hospice aide with specific written patient care instructions. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/13/2024 with a primary diagnosis of cerebral vascular accident (CVA). The patient was discharged from services on 08/24/2024. The Interdisciplinary Group (IDG) plan of care, dated 08/16/2024, ordered hospice aide services five times weekly with ordered tasks every visit: bed bath and shower. There was no documented evidence that the RN specified whether the aide should give a bed bath or a shower. The same hospice aide plan of care documented activities ordered by the RN must have specific instructions and that “patient choice (PC) is checked if the patient is functionally cognitive to make the choice,” the PC box was not checked, therefore there was no decision maker identified. During a joint record review and interview on 08/06/2025, the Administrator agreed that the hospice aide was not provided with specific written instructions on whether to give a shower or a bed bath.