Every finding on record at Sante Hospice, 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, in accordance with CMS §418.24–the elements of the hospice care election statement. (L523) This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected hospice care 07/30/2025 with a diagnosis of senile Degeneration of Brain. The initial plan of care dated 07/30/2025 included an order for social worker visit 1 time for initial evaluation. The Social Worker's initial assessment was not completed until 08/05/2025. This was 6 days after the election of hospice care. There was no documented reason why the initial psychosocial assessment was not completed by the social worker within 5 calendar days and no explanation or a missed visit within the 5 days. During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the social worker's initial assessment was not completed within 5 calendar days.

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 clinical record review and interview. In 6 of 18 (33%) clinical records of patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide was completing tasks as ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 2: The patient elected hospice care on 02/25/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral hygiene and nail care every visit. On 03/11/2026 the aide documented that these tasks were not completed. CLINICAL RECORD 3: The patient elected hospice care on 02/21/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral care, ROM and nail care every visit. On 02/23/2026 the aide documented that these tasks were not completed. CLINICAL RECORD 4: The patient elected hospice care on 07/30/2025 with a diagnosis of Atherosclerotic Heart Disease Without Angina. The aide care plan created by the RN included oral hygiene and nail care every visit. On 02/26/2026, the aide documented on 02/26/2026 that these tasks were not completed. CLINICAL RECORD 5: The patient elected hospice care on 03/31/2026 with a diagnosis of Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung. The aide care plan created by the RN included denture care, shave, trim, and nail care every visit. On 04/02/2026 and 04/06/2026, the aide documented that these tasks were not completed. CLINICAL RECORD 8: The patient elected hospice care on 02/05/2026 with a diagnosis of COPD. The aide care plan created by the RN included shampoo every visit. On 02/06/2026, aide documented that this tasks were not completed. CLINICAL RECORD 10: The patient elected hospice care on 01/22/2026 with a diagnosis of Hepatic Encephalopathy. The aide care plan created by the RN on 01/22/2026 included complete shower every visit. On 01/26/2026 the aide documented " Bed bath was given." During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the aide did not follow the aide plan of care. No further information was provided.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) clinical record reviewed of patient receiving hospice aide services revealed that the agency did not ensure that the hospice aide reported changes to the aide plan of care regarding tasks not completed. CLINICAL RECORD 3: The patient elected hospice care on 02/21/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral care, ROM and nail care every visit. The aide documented on 02/23/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 5: The patient elected hospice care on 03/31/2026 with a diagnosis of Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung. The aide care plan created by the RN included denture care, shave and trim, and nail care every visit. The aide documented on 04/02/2026 and 04/06/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 4: The patient elected hospice care on 07/30/2025 with a diagnosis of Atherosclerotic Heart Disease Without Angina. The aide care plan created by the RN included oral hygiene, and nail care every visit. The aide documented on 02/26/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 2: The patient elected hospice care on 02/25/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral hygiene, and nail care every visit. The aide documented on 03/11/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 8: The patient elected hospice care on 02/05/2026 with a diagnosis of COPD. The aide care plan created by the RN 0n 02/05/2026 included shampoo every visit. The aide documented on 02/06/2026 that this tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 10: The patient elected hospice care on 01/22/2026 with a diagnosis of Hepatic Encephalopathy. The aide care plan created by the RN on 01/22/2026 included complete shower every visit. The aide documented on 01/26/2026 " Bed bath was given." There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the aide did not inform the RN of tasks not completed and changes in the plan of care. No further information was provided.

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 need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical record reviewed for patients receiving aide services revealed the agency did not ensure that the RN made an onsite visit to do a supervisory visit no less than 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 7: The patient elected hospice care on 01/09/2026 with Parkinson’s Disease. The aide's first visit was on 01/14/2026. A supervisory visit was not complete until 02/05/2026 (21 days after the first aide visit). During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that an RN supervisory visit was not completed on time. No further information was provided.

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 described in HCDT 40.I; 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%) clinical record reviewed, in which the patient was admitted to a Medicare/Medicaid certified hospital, revealed that the agency did not ensure that a discharge summary was forwarded to the receiving facility. CLINICAL RECORD 15: The patient elected hospice care on 07/04/2025 with the diagnosis of Atherosclerotic Heart Disease. The registered nurse documented on 01/19/2026 that the patient revoked and was admitted to a hospital to seek aggressive treatment. A discharge summary was completed. A review of clinical records revealed no evidence that the completed discharge summary was forwarded to the receiving hospital. On 04/07/2026 a joint record review and interview was conducted with the RN/ Administrator (Personnel Record 3) who confirmed that a discharge summary was not forwarded to the receiving hospital. No further information was provided.

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 and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the individualized plan of care included specific interventions based on the problems identified in the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 12/12/2023 with terminal diagnoses of protein-calorie malnutrition and senile degeneration of the brain. The initial comprehensive assessment dated 12/12/2023 included documentation that the patient had a Foley catheter in place. On the Skilled Nurse visit notes dated 12/14/23 and 12/15/23 the Skilled Nurse documented that the Foley catheter was patent and draining yellow urine. The plan of care dated 12/12/2023 did not include problems, goals, or interventions related to the genitourinary system or Foley catheter. During the joint record review and interview on 12/18/2023, the Administrator confirmed that the plan of care did not include goals or interventions related to the Foley catheter.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and the reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed revealed the agency did not ensure the IDG completed updated comprehensive assessments no less frequently than every 15 days to consider patients' changes that have taken place since the initial assessment. In an interview with the Administrator about both of these clinical records she stated that there were IDG meetings, and these patients were on the agenda. She stated it was the Director of Nursing responsibility to enter the IDG notes for these patients. No other explanations were given. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of the pancreatic duct. During review of the clinical record, it was found that the agency failed to provide updated comprehensive assessments or information on the patient's progress toward outcomes or change in patient condition. No RN visits were documented on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023. There were no documented IDG meetings with evidence of information on patients decline or progression towards goals. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. During the clinical record review, it was found that the agency failed to provide updated comprehensive assessments or information on the patient's progress toward outcomes or change in patient condition. This is by evidence of no documented RN visits on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3. There was no input by the RN in the IDG meeting notes that were recorded in September and no IDG meetings recorded for the month of October. In an interview with the Administrator about both of these clinical records she stated that there were IDG meetings, and these patients were on the agenda. She stated it was the Director of Nursing responsibility to enter the IDG notes for these patients. No other explanations were given.

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. 2 of 4 (50%) clinical records reviewed revealed the agency did not ensure that IDG meetings to review, revise and document the patient's plan of care were held at least every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. There was no documented IDG meetings in the month of October and no other evidence that the plan of care was reviewed or revised at least every 15 calendar days. The Administrator had no explanation for why there were no IDG meetings documented. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. There was no documented evidence of collaboration with the interdisciplinary team and no evidence the plan of care was reviewed or revised since the patient's admission. The Administrator had no explanation for why there were no IDG meetings documented.

Is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure that spiritual counseling services were provided to meet the needs of the patient's and family's acceptance of the service. Clinical Record 2: The patient elected the hospice benefit on 9/1/2023 with a diagnosis of Hypertensive Heart Disease & Chronic Kidney Disease. On admission the patient and family accepted Chaplain services and they were ordered on the plan of care for 1 time every month. The Chaplain made an initial visit within 5 days of the admission. There was no other evidence or documentation of any other Chaplain visits or contact with the patient or family. In an interview with the Administrator, she stated that the patient had declined further chaplain services. There was no evidence to support this statement. There was no order to discontinue chaplain services and no changes were made to the plan of care.

is required that a hospice aide provides services ordered by the Interdisciplinary group. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure that the aide provide services ordered by the interdisciplinary group. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. Aide services were elected by the patient and were ordered on the plan of care 1 time a week. The aide plan of care was in place and ordered that the aide assist with all activities of daily living. Visits made by the aide on 9/21/2023 and 9/29/2023 revealed that the aide did not complete any of the ordered tasks. In an interview with the administrator, she agreed that the aide did not complete all tasks on the aide care plan.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Physician orders. This CONDITION was not met as evidenced by clinical record review and interview. The hospice failed as follows: To maintain clinical records containing current clinical information including updated comprehensive assessments; updated plans of care, and clinical visit notes which included the care and services provided to patients [HSIM.3.I/L672]; To maintain physician's orders for care and services provided HSIM.3.I/L678. The cumulative effect of these systemic issues resulted in the potential for compromised quality health care and patient safety. This is a CMS CONDITION DEFICIENCY at 418.104.

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 the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed revealed that the agency did not ensure clinical records contained updated comprehensive assessments, updated plans of care, and clinical notes of the care and services provided to patients. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse (RN) visits were ordered on the plan of care 1 time a week. The RN case manager made visits on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3/2023. There were no clinical notes to represent the care/service provided on these dates. There were no updated comprehensive assessments since the patient's admission and no updated plan of care. In an interview with the Director, she stated that she has had problems with the RN not putting in her visit notes in a timely manner. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. On the plan of care RN visits were ordered 1 time a week. The RN made patient visits on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023. There was no documented evidence of the care/services provided to the patient on these dates. There was no updated comprehensive assessment since the patient's admission and no updated plan of care. In an interview with the Administrator, she agreed that the visits were not documented in a timely manner.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review. 2 of 4 (50%) records revealed skilled nurse visits beyond the ordered frequency in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse (RN) visits were ordered on the plan of care 1 time a week. During the weeks on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3/2023 biweekly visits were made. There were no physician's orders in the record to cover these extra visits. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. On the plan of care RN visits were ordered 1 time a week. During the weeks on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023 biweekly visits were made. There were no physician's orders in the record to cover these visits.

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 clinical record review, document review, and interview. In 3 of 19 (16%) records reviewed it was revealed the hospice agency did not ensure the initial comprehensive assessments were completed within five (5) days of the patients' election of their hospice benefit. The agency's policy, "9-017 The Plan of Care" (revised May 2022), stated in part at sub-section five (5): "The rest of the interdisciplinary group will review the individualized plan of care within two (2) days of the start of care". Clinical Record 1: The record for this patient with a hospice benefit election date of 3/23/2023 had an initial MSW (Medical Social Worker) psychosocial assessment documented as completed on 3/29/2023, which was 1 day past due. The record did not contain evidence of an attempted visit prior to 3/29/2023, and there was no evidence that the RN completed the psychosocial assessment during their visit on 3/23/2023. Clinical Record 3: The record for this patient with a hospice benefit election date of 4/11/2023 had an initial MSW (Medical Social Worker) psychosocial assessment documented as completed on 4/21/2023, which was 5 days past due. The record did not contain evidence of communication or of an attempted visit before 4/21/2023, and there was no evidence that the RN completed the psychosocial assessment during their visit on 4/11/2023. Clinical Record 8: The record for this patient with a hospice benefit election date of 4/17/2023 contained documented evidence of a telephone communication dated 4/26/2023, which was 9 days after the patient's hospice benefit election. The documentation stated, "patient requested to reschedule visit until next week." Joint record review and interview with the Director of Nursing (DON) on 6/6/2023 confirmed the record did not contain any documented evidence that the Social Worker attempted to complete the initial comprehensive assessment prior to the 4/26/2023 documented telephone call. An interview with the Administrator on 6/5/2023 confirmed the hospice agency did not consistently complete the comprehensive assessments within five (5) days of the patients electing the hospice benefit.

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 medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; and Actual or potential drug interactions. 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 interview and observation. In 3 of 4 (75%) home visits conducted in which a medication reconciliation was performed, it was revealed the hospice did not ensure all the medications the patients were taking were updated and/or documented in the clinical records and included in the full review of the patients' medication regimens. Home Visit 1: A home visit was conducted with a Registered Nurse (RN) (Staff 2) on 6/6/2023 at the private residence of the patient with a hospice benefit election date of 4/11/2023 (Record 3). The Director of Nursing (DON) was also present during the home visit. The patient reported that they were taking the following medications: Immodium, 2 mg. Take two (2) tablets orally (PO) with the first loose stool. May take two (2) more tablets with each additional loose stool. Do not exceed eight (8) tablets daily; Furosemide 40 mg. Take one (1) tablet daily; and Vitamin D3, 2,000 IU. Take one (1) tablet daily. The hospice agency's medication profile did not contain documentation of the medications Immodium, Furosemide, and Vitamin D3, and they were not included in review of the patient's medication regimen. A joint medication record review and interview with the DON confirmed the hospice medication profile was not updated to contain documentation of all the medications currently being taken by the patient. Home Visit 3: A home visit was conducted with a Social Worker (Staff 6) on 6/6/2023 at the group home where the patient with a hospice benefit election date of 3/27/2023 (Record 4) resided. The Director of Nursing (DON) was also present during the home visit. The patient reported they were taking the following medications: Amitriptyline 25 mg. Take one (1) capsule daily; Tramadol 50 mg. Take one (1) tablet every eight (8) hours for pain; and Eliquis 5 mg. Take one (1) tablet two times daily (BID). The hospice agency's medication profile did not contain documentation of the medications Amitriptyline, Tramadol, and Eliquis. A joint medication record review and interview with the DON confirmed the hospice medication profile was not updated to contain documentation of all the medications currently being taken by the patient. Home Visit 4: A home visit was conducted with a Chaplain (Staff 7) at the group home where the patient with a hospice benefit election date of 11/8/2019 (Record 9) resided. The Director of Nursing (DON) was also present during the home visit. The hospice agency medication profile included documentation of the medication order, "Loperamide capsule two (2) mg. Take on (1) capsule every six (6) hours as needed (PRN) for diarrhea". However, the patient's medication profile in the home stated, "Loperamide capsule two (2) mg. Take on (1) capsule daily as needed (PRN) for diarrhea". The hospice agency medication profile stated, "Omeprazole delayed-release twenty (20) mg capsule. Take one (1) capsule two times daily (BID)", and the medication profile in the home stated, "Omeprazole twenty (20) mg. Take one (1) capsule daily. The hospice agency medication profile stated, "Ipratropium-Albuterol Inhalation 0.5-2.5 (3) mg/3ML. Take one (1) vial every four (4) hours as needed (PRN) for shortness of breath and cough". The medication profile in the home stated, "Ipratropium-Albuterol Inhalation 0.5-2.5 (3) mg/3ML. Take one (1) vial two times daily (BID) for shortness of breath. A joint medication record review and interview with the DON confirmed the hospice medication profile was not updated to contain documentation of the orders for all the medications currently being taken by the patient.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 19 (21%) records it was revealed that the agency did not provide hospice service visits in accordance with the orders for visit frequency documented on the plans of care. The agency's policy, "9-001, Scope of Services", (revised May 2022), stated in part in sub-section four (4): "Home visits will be provided according to the plan of care including scope and frequency." Clinical Record 9: This patient with a hospice benefit election date of 11/8/2019 had a care plan for the certification period of 4/21/2023-6/19/2023. The visit frequency order dated 4/21/2023 for the Social Worker was one (1) time (X) monthly. The chart did not contain any evidence of Social Work visits being completed, or missed visits, in the months of April and May. A joint record review and interview with the Director of Nursing (DON) on 6/7/2023 confirmed there were missed Social Worker visits in April and May. The interview also confirmed the record did not contain evidence the physician or interdisciplinary group (IDT) was notified of the missed Social Work visits. Clinical Record 15: This patient with a hospice benefit election date of 7/25/2022 had a care plan for the certification period of 3/22/2023-5/21/2023. The visit frequency order dated 3/22/2023 for the Social Worker was one (1) time (X) monthly. The chart did not contain any evidence of Social Work visits being completed, or missed visits, in the months of March, April, or May. In addition, the visit frequency order dated 3/22/2023 for the Chaplain was one (1) time (X) monthly. The chart did not contain any evidence of Chaplain visits completed, or missed visits, during the months of March, April, and May. A joint record review and interview with the Director of Nursing (DON) on 6/7/2023 confirmed there were missed Social Worker visits in March, April, and May, and a missed Chaplain visit in May. The interview also confirmed the record did not contain evidence the physician or interdisciplinary group (IDT) was notified of the missed Social Work and Chaplain visits. Clinical Record 5: This patient with a hospice benefit election date of 11/23/2022 had a plan of care (POC) dated 2/15/2023 for the certification period of 2/21/2023-5/21/2023. The visit frequency order dated 2/21/2023 for the Chaplain was one (1) time (X) monthly. The chart did not contain any evidence of Chaplain visits being completed, or missed visits, during the months of February, March, April, or May. A joint record review and interview with the Director of Nursing (DON) on 6/7/2023 confirmed there were missed Chaplain visits in February, March, April, and May. The interview also confirmed the record did not contain evidence the physician or interdisciplinary group (IDT) was notified of the missed Chaplain visits. Clinical Record 7: This patient with a hospice benefit election date of 4/3/2023 had a plan of care dated 4/3/2023 for the certification period of 4/3/ 2023-7/1/2023. The visit frequency order dated 4/3/2023 for the Chaplain was one (1) time (X) monthly. A Chaplain visit was documented as completed on 4/3/2023 but here was no evidence of a Chaplain visit completed, or missed, in the month of May. A joint record review and interview with the Director of Nursing (DON) on 6/7/2023 confirmed there was a missed Chaplain visit in May. The interview also confirmed the record did not contain evidence the physician or interdisciplinary group (IDT) was notified of the missed Chaplain visit.

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 following: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by document review, interview, and observation. In 2 of 19 (11%) records reviewed it was revealed the hospice did not document the supplies being used for the management of the patients' care on the plans of care. Clinical Record 1: This patient with a hospice benefit election date of 3/23/2023 had a plan of care dated 4/12/2023 that did not list any supplies being used for the palliation and management of the patient. During clinical record review with the Office Administrator, it was confirmed through the agency's online supply ordering system that the patient receives underpads, foam cleanser, gloves, and wipes. An interview with the Adminstrator on 6/5/2023 confirmed the agency does not put supplies on the Plan of Care (POC) due to the scope of the EMR. The Administrator reported the supplies should be listed in the Initial RN summary at the bottom of the Initial RN assessment page. The Office Administrator confirmed that the supplies were not listed in the RN summary note dated 3/23/2023. During a subsequent interview with the Administrator on 6/5/2023 they confirmed the initial RN assessment did not list any supplies at the bottom of the summary. Clinical Record 2: The record for this patient, with a hospice benefit election date of 11/8/2022, was conducted with the Office Administrator on 6/5/2023. The clinical record had an initial RN assessment note that stated, "pt is incontinent of urine at times, and the patient has a colostomy." The plan of care dated 11/8/2022-1/6/2023 did not list any supplies needed for the management of the patient. During review of the record the Office Administrator confirmed the supplies were not listed on the plan of care. The online supply management system was accessed, and the following supplies were being provided to the patient: ostomy bags; ostomy barrier wafers; ostomy paste; size large gloves; wipes; skin prep; and zinc barrier cream. During a home visit (Home Visit 2) conducted on 6/6/2023 with a Home Health Aide (Staff 4) in the presence of the Director of Nursing, and it was confirmed that ostomy bags, ostomy barrier wafers, ostomy paste, size large gloves, wipes, skin prep, and zinc barrier cream were in the home and provided by the hospice agency. An interview with the Administrator on 6/5/2023 confirmed the agency does not put supplies in the Plan of Care (POC) due to the scope of the EMR. The Administrator reported the supplies should be listed in the Initial RN summary at the bottom of the page. The Office Administrator confirmed during review of the record that RN's initial summary stated in part, "patient wears pull-ups" and there was no documentation of ostomy supplies. The joint home visit and record review with the DON on 6/6/2023 confirmed the supplies provided by the hospice agency in the home were not listed on the plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visits it was revealed that the hospice agency did not ensure the use of standard precautions and safe handling of soiled items during care provided to the hospice patient. The agency's policy, "7-009 Hand Hygiene" (revised May 2022), stated in part in sub-section three (3): "Hand decontamination using an alcohol-based hand rub should be performed: ... (D) After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated. (E) When moving from a contaminated body site to a clean body site during patient care". Home Visit 2: A home visit was conducted on 6/6/2023, in the presence of the Director of Nursing (Staff 10), observing a hospice aide (Staff 4) to a patient who elected their hospice benefit on 11/8/2022 (Record 2). The hospice aide performed hand hygiene when entering the patient's home and was observed gathering the supplies necessary for a shower and donned one (1) pair of gloves. The hospice aide removed the patient's clothes, including a pull-up brief, and placed the worn brief on the floor. The hospice aide then started and completed the entire shower, including peri-care, while wearing the same pair of gloves that were donned at the beginning of the personal care session. The hospice aide did not remove gloves or perform hand hygiene following the completion of the shower. The hospice aide then dried the clean patient with a clean towel and dressed the patient while continuing to wear the same pair of gloves. While dressing the patient, the hospice aide asked the patient if they would like a clean pull-up brief applied. The patient declined to have a clean pull-up and stated: "I only had that pull-up on for three hours. Just put that one back on me." The hospice aide placed the previously worn pullup back on the patient. When the patient was completely dressed, the hospice aide removed their gloves and performed hand hygiene. During interview, the Director of Nursing confirmed the hospice aide wore one (1) pair of gloves while providing a shower and did not change the gloves following the completion of the shower and before dressing the patient. The Director of Nursing also confirmed the reapplication of the used pull-up was not in compliance to prevent disease transmission. The Director of Nursing stated that the hospice aide should have placed a clean pull-up on the patient instead of asking if she wanted the previously worn brief back on.