Every finding on record at Woodlake Healthcare LLC

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 11 (45%) clinical record review revealed that the agency did not ensure aide services were provided as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 07/23/2024. Hospice aide services were ordered three (3) times per week starting on 07/29/2024. The clinical record revealed that the week of 09/01/2024 and 09/22/2024, the hospice aide only saw the patient twice a week. A review of the documentation lacked evidence of a missed visit being documented. Clinical Record 2: The patient elected the hospice benefit on 02/29/2024. Hospice aide services were ordered three (3) times per week starting on 03/03/2024. The clinical record revealed that the week of 09/01/2024, 11/24/2024, and 12/08/2024 the hospice aide only saw the patient twice a week. A review of the documentation lacked evidence of a missed visit being documented. Clinical Record 3: The patient elected the hospice benefit on 03/12/2024. Hospice aide services were ordered three (3) times per week starting on 03/17/2024. The clinical record revealed the week of 11/24/2024, the hospice aide only saw the patient twice a week. A review of the documentation lacked evidence of a missed visit being documented. Clinical Record 9: The patient elected the hospice benefit on 10/18/2023. Hospice aide services were ordered three (3) times per week starting on 06/30/2024. The clinical record revealed the week of 07/04/2024, the hospice aide only saw the patient twice a week. A review of the documentation lacked evidence of a missed visit being documented. Clinical Record 10: The patient elected the hospice benefit on 09/17/2024. Hospice aide services were ordered three (3) times per week starting on 09/22/2024. The clinical record revealed the week of 11/24/2024, the hospice aide only saw the patient twice a week. A review of the documentation lacked evidence of a missed visit being documented. During an interview with the Administrator/Executive Director on 12/18/2024, she stated that she did not know why those missed visits were not documented, but they are primarily around the holidays when patients and/or their families refuse a visit.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary. 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 was a live discharge revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. Clinical Record 13: The patient elected hospice on 05/16/2024 and was a live discharge on 11/08/2024 due to no longer meeting criteria. The clinical record review revealed no documented evidence of a discharge summary sent to the attending physician. Clinical Record 14: The patient elected hospice on 05/29/2024 and signed a revocation of hospice services on 06/15/2024. A review of the clinical record revealed no documented evidence of a summary, a discharge summary sent to the attending physician. During an interview with the Administrator/Executive Director on 12/18/2024 she stated that she would be sure that the staff was given education on the discharge process so that the discharge summary will be sent to the attending physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: Physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 2 of 3 (67%) home visit observation revealed the agency did not ensure the SNF/NF was provided the physician certification and/or recertification of terminal illness. Home Visit 1: The patient elected the hospice benefit on 07/23/2024 and resides in a nursing facility. During home visit 1 (Home Visit 1) with the aide (Personnel Record 2) on 12/18/2024 a review of documentation provided to the nursing facility by the hospice agency revealed no documented evidence that the physician certification and/or recertification of terminal illness was provided. Home Visit 3: The patient elected the hospice benefit on 03/12/2024 and resides in a nursing facility. During the home visit (Home Visit 3) with the registered nurse (RN) (Personnel Record 1) on 12/18/2024, a review of the documentation provided to the nursing facility by the hospice agency revealed no documented evidence that the physician certification (CTI) and/or recertification of terminal illness was provided. During the interview with the RN stated that she was unaware that the CTIs needed to be provided to the facility, but she would be sure that they were printed so that she could provide them in the future. During an interview with the Administrator/Executive Director on 12/18/2024 she stated that she would be sure that education was provided to 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. 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. 2 of 11 (18%) of clinical records reviewed revealed that an initial bereavement assessment was not completed. There was no documented evidence as to why the assessment had not been completed. Clinical record #48587 was reviewed and identified that the patient elected the hospice benefit on 1/27/2022. The bereavement risk level (bereavement low) was noted in the chart on 3/9/2022 and 5/4/2022. There was no documented evidence the bereavement assessment was completed. Clinical record # 77476 was reviewed and identified that the patient elected the hospice benefit on 9/24/2021. The patient accepted SW and declined Chaplain services. There was no bereavement assessment in the documented clinical record. The Director of Clinical Services was interviewed on 4/6/2021 and agreed that there was no bereavement assessment completed on the identified patients. She stated that these patients did not have identified family to complete a bereavement assessment. She had no additional information to provide.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (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. 2 of 2 (100%) applicable clinical records reviewed of patients who were discharged or transferred revealed that the hospice did not forward the discharge summary to the patient's attending physician. Clinical record #57000 was reviewed and identified that the patient revoked hospice services to seek aggressive/curative treatment on 1/10/2022. There was no documentation in the clinical record that the discharge summary was sent to the attending physician . Clinical record #68310 was reviewed and identified that the patient was discharged from hospice services due to hospital admission for treatment for a potential fracture on 2/9/2022. There was no documentation in the clinical record that the discharge summary was sent to the attending physician . The Director of Clinical Services was interviewed on 4/6/2022 and agreed that there was no discharge summary sent to the Attending Physician after discharge. She had no additional information to provide.