Every finding on record at Adaptive Hospice, LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: 1. The identification of each position that is occupied by a volunteer; 2. The work time spent by volunteers occupying those positions; 3. Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. A joint review of the agency report titled "Volunteer PTAN Cost Savings Report" with the Volunteer Coordinator on 02/04/2026 revealed that volunteer utilization for the annual volunteer report for calendar year 01/01/2024, through 01/01/2025 revealed volunteer utilization was 0.65%. The annual volunteer report for calendar year 01/01/2025 through 12/31/2025 revealed volunteer utilization of 0.71%. Utilization for ADS (alternate delivery site) 1 starting September 2025 through December 2025 was 0.0%. The annual volunteer report for ADS 2 for November 2024 through December 2025 was 0.0%. For calendar year 01/01/2026, through the current date of review, 02/04/2026, volunteer utilization was 1.89%. During an interview on 02/04/2026, the Regional Volunteer Coordinator stated, "We have had challenges recruiting volunteers; since last year, we have not been able to recruit enough volunteers, and we did not meet the 5% requirement. We are currently in the process of recruiting more volunteers. A new Volunteer Manager was hired. An active volunteer recruitment and retention program is in progress." No further information was provided. A joint review of the agency report titled "Volunteer PTAN Cost Savings Report," with the Volunteer Coordinator on 02/04/2026 revealed that volunteer utilization for the parent location was 1.4% for the period 01/01/2023 through 01/01/2024. The annual volunteer report for calendar year 01/01/2024, through 01/01/2025, revealed volunteer utilization was 0.65%. The annual volunteer report for calendar year 01/01/2025, through 12/31/2025, revealed volunteer utilization of 0.71%. Utilization for ADS 1 starting September 2025 through December 2025 was 0.0%. The annual volunteer report for ADS 2 for November 2024 through December 2025 was 0.0%, for calendar year 01/01/2025, through 12/31/2025, revealed volunteer utilization of 1.89%.

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: 1. The hospice discharge summary described in HCDT 40.I; and 2. The patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients who transferred to a Medicare/Medicaid certified facility to seek aggressive treatment, the agency did not ensure that a copy of the discharge summary was forwarded to the receiving facility. CLINICAL RECORD 15: The patient was elected the hospice benefit and was admitted on 06/24/2025. The patient revoked the benefit and transferred to a Medicare/Medicaid certified facility to seek aggressive treatment on 06/28/2025. A discharge summary was completed and present in the record, however, there was no documented evidence that the discharge summary was forwarded to the receiving facility for continuity of care. During an interview with the Manager of Clinical Services of the parent location on 02/05/2026, she confirmed that a discharge summary was not forwarded to the receiving facility. No further information was provided.

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, anther alternative treatments that could affect drug therapy. 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 clinical record review and interview. 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the medication profile contained the current prescriptions, over the counter drugs and supplements. Clinical Record 10: The start of care occurred on 3/16/2023. The medication profile did not contain tube feeding supplements. Oxygen was added to the medication profile on 3/20/23. In an interview on 4/13/2023, the Manager of Accreditation stated, "You are right it's not on there." 1 of 19 (5%) of clinical records reviewed revealed that the agency did not ensure that the medication profile contained the current prescriptions, over the counter drugs and supplements.

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. 1 of 19 (5%) clinical records reviewed, the agency did not ensure that an initial comprehensive bereavement assessment was conducted. Clinical Record 3: The start of care (SOC) occurred on 2/23/2023. There was no documented evidence that an initial bereavement assessment was completed. The Manager of Accreditation stated in an interview, " I am sure the reason it didn't get documented is that the patient had just been discharged two days prior for hospitalization, so they didn't think of it as a new admission." 1 of 19 (5%) of clinical records reviewed revealed that the agency did not ensure that an initial comprehensive bereavement assessment was conducted.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 5 of 19 (29%) clinical records reviewed, the agency did not ensure that all drugs and treatment necessary were included in the plan. Clinical Record 4: The start of care occurred on 12/9/2022 with plan of care episodes 12-9-2022 through 3-8-2023 and 3-9-2023 through 6/6/2023. The initial skilled nurse assessment revealed that the patient was incontinent. A physician order was documented on 12/11/2022 "Irrigate Foley catheter with 30 cc sterile water daily and PRN to keep patent." There was no physician order to insert a Foley catheter. No physician order was documented on the plan of care for managing the Foley catheter. A Foley catheter was observed during a home visit on 4/11/2023. The recertification plan of care does not contain orders or interventions for the management of Foley catheter. Clinical Record 10: The start of care (SOC) occurred on 3/16/2023. The Skilled Nurse (SN) initial assessment revealed that the patient utilizes continuous oxygen via Bipap and is dependent on g-tube feedings. The plan of care dated 3/16/2023 does not document oxygen as supplied or listed on the medication profile. The plan of care does not include tube feedings on the medication list. Physician orders were written on 3/20/2023 for Oxygen use via Bipap and did not transfer to the plan of care. The Plan of care documents “Tube feeds every 6 hours” under the Nutritional Requirements section, but there are no specific orders for the type of feeding and amount to be administered on the medication list or in the interventions section. Clinical Record 5: The start of care occurred on 7/7/2022. A skilled nurse visit note documented on 2/15/2023 reads in part, "More trouble breathing at night and using oxygen more." The plan of care dated 1/3/2023 – 3/3/2023 did not include interventions related to oxygen use, safety, or oxygen education. Oxygen was listed on the medication list. Clinical Record 11: The start of care occurred on 1/20/2023 with a primary diagnosis of COPD. The Skilled Nurse start of care assessment documented that the patient is oxygen dependent. The care plan includes an oxygen concentrator on the supply list and lists an intervention on the use of oxygen but does not document an order for the specified amount of oxygen to be used. A physician order was written for oxygen on 1/22/2023 but was not included in the care plan. Clinical Record 12: The start of care assessment by the skilled nurse on 12/17/2022 revealed that the patient is Short of Breath upon exertion. Oxygen was ordered and is included in the plan of care. There are no interventions related to educating the patient about when and how to use oxygen and safety considerations related to oxygen. Clinical Record 13: The start of care assessment by the skilled nurse on 12/17/2022 revealed that the patient is oxygen dependent at 2 Liters with a primary diagnosis is COPD, and O2 stats drop too low 80's if oxygen is off. The plan of care dated 12/17/2022 does not include any respiratory interventions or interventions related to oxygen. In an interview on 4/13/2023 the Manager of Accreditation stated, " I have reviewed all of the charts with findings, and I do not see anything different than what you are seeing." 2 of 19 (11%) of clinical records reviewed revealed that the agency did not ensure that all drugs and treatment necessary were included on the plan.

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, observations, and interview. 2 of 12 (16%) clinical records reviewed where home health aide services were provided, the agency did not ensure that written care instructions were provided to the home health aide in a manner that was clear enough to allow the aide to care for the patient within the scope of practice. Clinical Record 1: The Aide care plan dated 12/9/2022 with no revisions through 4/11/2023 did not include any mention of Foley catheter care. Observed Foley catheter presence during home visit on 4/11/2023. Clinical Record 9: The Aide care plan developed 9/26/2022 with an update on 1/10/2023. New orders were received for wound care on the coccyx on 2/16/2023. The physician orders included non-adhesive dressing and kerlix to heels. The aide care plan was not updated after change in condition, wound care orders received and there were no instructions provided to the aide related to wound areas and dressings and personnel care. The Manager of Accreditation reviewed records and confirmed with statement, "No, It's not there." 2 of 12 (16%) of clinical records with a home health aide reviewed revealed that the agency did not ensure that written care instructions were provided to the home health aide in a manner that was clear enough to allow the aide to care for the patient within the scope of practice.

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, Physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. 3 of 19 ((16%) clinical records reviewed, the agency did not ensure that the clinical record included required physician orders. Clinical Record 5: The start of care dated 3/23/2023 documented a lung cancer diagnosis. The plan of care dated 3/23/23 included supplies for oxygen and oxygen safety measures. Interventions included "Instruct in the safe use of oxygen and monitor its effectiveness." There are no physician orders for oxygen, which was not on the medication list. The Administrator stated in an interview related to record #5, "She has oxygen, they just forgot to put it on the med list as an order." Clinical Record 1: During a home visit observation on 4/11/2023, a Foley catheter was place. At the start of care initial assessment on 12/09/2022, the skilled nurse did not document that a Foley catheter was in place. The documentation revealed that the patient was incontinent. Physician Orders were received on 12/11/2022 to irrigate a Foley catheter, but there were no orders to insert a Foley catheter. The plan of care for episodes 12/09/2022-3/08/2023 and 3/9/2023- 6/6/2023 did not document orders for the management of a Foley catheter. In relation to record #1, Administrator stated in part, " I looked, there is no order for the Foley itself." Clinical Record 10: The Initial start of care assessment on 3/16/2023 revealed that this patient is dependent on oxygen via a Bipap and dependent on tube feeding via a peg tube. The plan of care dated 3/16/2023 -5/16/2023 does not include orders for Bipap or peg tube, and Oxygen and Tube feedings are not on the medication profile. A physician order dated 3/17/2023 read, "Add oxygen 1-12 Liters, PRN via oxygen concentrator for SOB or SPO2 88% or less." There is no physician order documenting the use of BIPAP. The plan of care was updated on 3/20/2023 but did not include orders for peg tube feeding or oxygen via BIpap. A skilled nursing note documented on 4/8/2023 reveals that the caregiver reported respiratory difficulty. The Caregiver said that "suctioning helped, but patient is exhausted." The plan of care did not include orders for suctioning. The Manager of Accreditation stated in an interview on 4/13/2023 related to Record #10, 'Your right, there are no orders (for those items.)." 3 of 19 ((16%) of clinical records reviewed revealed that the agency did not ensure that the clinical record included required physician orders.