Every finding on record at Sd Hospice, Inc.

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 2 of 3 (67%) clinical records reviewed that received hospice services for at least five (5) days revealed the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/26/2025. The record lacked evidence that the spiritual counselor (SC) completed an initial assessment within the five (5) day window. There was evidence of a phone call to the patient on 04/30/2025 (Day 4) to set up a visit to complete the initial SC assessment; voicemail was left. The record lacked evidence of follow-up by the spiritual counselor. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/25/2025. The record lacked evidence that the spiritual counselor (SC) completed an initial assessment within the five (5) day window. There was evidence of a phone call to the patient on 03/29/2025 (Day 4) to set up a visit to complete the initial SC assessment; voicemail was left. The record lacked evidence of follow-up by the spiritual counselor. The Administrator, Director of Patient Care Services (DPCS), and DPCS Designee stated in an interview on 06/12/2025 that the agency did not ensure that the IDG completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care.

It is required that each patient’s individualized written plan of care reflects patient and family goals 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 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included goals and interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The initial nursing assessment narrative dated 04/26/2025 stated, "Appetite remains fair, consumes 50% of meals per served as tolerated with Ensure strawberry 3 bottles per day and as needed for natural supplement". The Nutrition assessment stated, "Swallowing - Dysphagia and Aspiration precautions" and "Diet type - Mechanical Soft". The interdisciplinary group (IDG) POC dated 04/26/2025 lacked an intervention that included supplemental nutrition for the Goal - Altered Nutrition. The IDG POC lacked goal(s) and intervention(s) for Dysphagia. CLINICAL RECORD 3: The initial nursing assessment narrative dated 05/01/2025 stated, "Patient has dysphagia, thus makes her high risk for aspiration pneumonia, malnutrition and choking and airway obstruction." The initial spiritual assessment was completed on 05/01/2025 and reported a frequency of one (1) time per month with two (2) as needed (PRN) visits for spiritual support. The IDG POC dated 05/01/2025 lacked evidence of goal(s) and intervention(s) for dysphasia and spiritual care, respectively. The Administrator, Director of Patient Care Services (DPCS), and DPCS Designee stated in an interview on 06/12/2025 that the agency did not ensure the POC included goals and interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure skilled nursing frequencies were provided per the patient plan of care (POC). CLINICAL RECORD 2: The interdisciplinary group (IDG) POC dated 03/25/2025 ordered: the registered nurse (RN) and licensed vocational nurse (LVN) both to have a frequency of "One (1) time per every two (2) weeks with two (2), as needed (PRN), times two (2) for "Symptom management". There was evidence of RN visits completed on 04/01/2025, 04/22/2025 (21 days apart), 05/06/2025, 05/16/2025, and 06/04/2025 (19 days apart). The record lacked evidence of an RN visit at least once every two (2) weeks on two (2) occasions, 21 days apart, and 19 days apart respectively. There was evidence of LVN visits completed on 04/07/2025, 04/15/2025, 04/28/2025, 05/16/2025 (18 days apart), and 05/28/2025. The record lacked evidence of an LVN visit at least once every two (2) weeks on one (1) occasion, 18 days apart. The Administrator, Director of Patient Care Services (DPCS), and DPCS Designee stated in an interview on 06/12/2025 that the agency did not ensure skilled nursing frequencies were provided per the patient POC.

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 1 (100%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the registered nurse (RN) provided the aide with clear and accurate patient-specific written care instructions. CLINICAL RECORD 3: The RN initial skin impairment assessment dated 05/01/2025 stated, "Stage 2 pressure injury on left buttock". The interdisciplinary group (IDG) POC dated 05/01/2025 stated for the RN to, "Cleanse wound to left buttock with saline spray pat dry apply zinc oxide and leave open to air daily or as needed during diaper change". The aide care plan dated 05/01/2025 lacked evidence of clear patient-specific written instructions for how to manage and what to report related to the wound area on the patient's "Left buttock" while providing the assigned task: "Bed bath". The aide visit frequency ordered was two (2) times per week. The aide visit notes dated 05/06/2025, 05/09/2025, 05/13/2025, and 05/17.2025 lacked evidence of how the aide managed the "Left buttock" wound while performing the assigned task: "bed bath". The Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 06/11/2025 that the agency did not ensure the RN provided the aide with clear and accurate patient-specific written care instructions regarding how to manage and what to report related to the wound area on the patient's "Left buttock".

It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician 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 2 of 2 (100%) clinical records reviewed in which the patient revoked the hospice benefit revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 5: The patient revoked the hospice benefit on 03/26/2025 to pursue aggressive treatment. The record lacked evidence that the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 4: The patient revoked the hospice benefit on 03/26/2025 to pursue aggressive treatment. The record lacked evidence that the discharge summary was forwarded to the patient's attending physician. The Administrator, Director of Patient Care Services (DPCS), and DPCS Designee stated in an interview on 06/12/2025 that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. The DPCS stated that the above patients were husband and wife.

Upon patient record review, 2 of 5 (Patient #4, 5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 4, 5: The medication profile did not indicate medications were reviewed for side effects and potential drug interactions at the time of hospice admission.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The plan of care does not indicate DME the patient utilizes for palliation of the terminal illness. The patient requires a walker and shower chair. (corrected on site)

Upon patient record review, 1 of 1 applicable (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 5: The aide care plan, dated 12.22.2021, indicated shampoo should be provided by the aide as needed. The aide care plan cannot utilize PRN, as needed, or per patient choice when designating the frequency of tasks for the aide; the care plan must specify how frequently each task is to be performed.