Every finding on record at Accord Health Group, LLC

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 needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 11 (9%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that hospice aide supervision occurred by a registered nurse in the patient's home at least every fourteen days. CLINICAL RECORD 6: The patient elected hospice on January 22, 2026. The patient's plan of care dated January 26, 2026, ordered an aide visit twice a week for twelve weeks. The aide visited on January 26, 2026, January 29, 2026, February 2, 2026, and February 5, 2026. The nurse visits were daily from January 26 to February 9, 2026, and did not include documentation of supervision of the aide during those visits. On February 11, 2026, an interview was conducted with the VP Clinical Services and Executive Director, during which the findings were reviewed. They reviewed the clinical record six and agreed with the finding.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by clinical record review, document review and interview. In 7 of 7 (100%) clinical records in which controlled medication was ordered in the home setting revealed that the agency did not ensure that a copy of the hospice's written policies and procedures for the management and disposal of controlled medication was provided to the patient, family, or the patient's legal representative. DOCUMENT 1: The agency's policy 8.10.1 titled Medication Disposal, dated February 2022, stated in part, "At the time when controlled drugs are first ordered, Hospice will provide a copy of Hospice policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family." CLINICAL RECORD 3: The controlled medication Morphine 20 milligrams/1 milliliter oral solution; 0.5 ml - 1ml orally every six hours for moderate pain was ordered on June 6, 2024. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 4: The controlled medication Morphine 20 milligrams/1 milliliter (ml) oral solution; 0.25 ml - 0.5 ml orally every four hours for pain or air hunger was ordered on October 6, 2025. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 5: The controlled medication Morphine 20 milligrams/1 milliliter (ml) oral solution: 0.25 ml to 0.50 ml orally every four hours for pain or air hunger was ordered on October 5, 2025. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 6: The controlled medication Morphine 20 milligrams/1 milliliter (ml) oral solution; 0.25 ml - 0.5 ml orally every four hours for pain or air hunger was ordered on January 22, 2026. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 11: The controlled medication acetaminophen-hydrocodone 325 mg-5mg oral tablet every four hours as needed for breakthrough pain was ordered on August 13, 2024. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 13: The controlled medication Morphine 20 milligrams/1 milliliter (ml) oral solution; 0.25 ml - 0.5 ml orally every four hours for pain or air hunger was ordered on July 24, 2025. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." CLINICAL RECORD 14: The controlled medication Morphine 20 milligrams/1 milliliter (ml) oral solution; 0.25 ml - 0.5 ml orally every four hours as needed for pain/dyspnea patient was ordered on October 25, 2024. The clinical record reviewed revealed no evidence that the patient, family, or the patient's legal representative received a copy of the agency's policy 8.10.1 titled "Medication Disposal." On February 12, 2026, an interview was conducted with the VP Clinical Services. The agency felt they were fulfilling the requirement by having the patient/family/or patient representative sign a document titled "Medication Information Acknowledgement". The document does not include the agency's policy 8.10.1, titled "Medication Disposal." She acknowledged the agency did not provide the policy to the patient/family/ or representative.

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 clinical record review and interview. 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that an initial bereavement assessment was completed as part of the initial comprehensive assessment. Clinical Record 9: The patient elected hospice care on 11/30/22. The initial comprehensive assessment was completed by the registered nurse on 12/01/22. The chaplain completed the initial bereavement assessment on 12/15/22, 15 days after the patient elected hospice care. The Administrator stated during a joint review of the clinical records and interview on 4/7/23 that the initial bereavement assessment was not completed with the initial comprehensive assessment.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) records reviewed revealed the agency did not ensure the plan of care included the scope and frequency of chaplain services. Clinical Record 6: The patient elected hospice care on 12/06/22. The initial assessment completed by the chaplain on 12/13/22 identified the family and patient requesting chaplain services for spiritual support "once a month." The plan of care did not include the frequency of visits for the chaplain. During an interview and a joint record review on 04/07/23, the Administrator confirmed that there was no frequency in the record for the chaplain visits.

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. 1 of 10 (10%) records reviewed in which the hospice aide was accepted revealed the agency did not ensure the Registered Nurse (RN) provided written patient care instructions for the hospice aide. Clinical Record 9: The patient elected hospice care on 11/30/22. The plan of care ordered hospice aide services "2 times per week." The hospice aide completed a visit on 12/15/22. There was no evidence that the hospice aide was assigned and provided written patient care instructions by the RN. The Administrator stated during an interview and a joint review of the clinical records on 04/07/2023 that the aide's care plan was not in the clinical record and could not be located.