Every finding on record at All Care Hospice and Palliative Care Inc

It is required that the documented comprehensive assessment include 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; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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, observation, and interview. In 3 of 14 (21 %) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1/CLINICAL RECORD 9: The patient was admitted to hospice on 02/27/2025 with a terminal diagnosis of hypertensive heart disease without heart failure. During a home visit observation with the social worker (Personnel Record 3), a medication review was completed by comparing the patient's current home medications to the hospice medication profile dated 03/16/2026. The following medication was listed on the medication profile but was not available in the home: Senna S 8.6-50 mg tablet, one tablet by mouth daily, start date 02/27/2025, Albuterol sulfate inhalation nebulization solution (2.5 mg/3 ml) 0.083%, Take one vial per inhalation every six hours as needed for congestion/shortness of breath, start date 02/27/2026. HOME VISIT 2/CLINICAL RECORD 8: The patient was admitted to hospice on 12/17/2025 with a terminal diagnosis of vascular dementia. During a home visit observation with the chaplain (Personnel Record 4), a medication review was completed by comparing the patient's current home medications to the hospice medication profile dated 03/16/2026. The patient had the following medications available in the home, but they were not on the medication profile: Quetiapine 25 mg, one tablet by mouth twice a day, dated 02/12/2026, Quetiapine 50 mg, one tablet by mouth twice a day, dated 02/26/2026, and Loperamide 2 mg, one capsule by mouth after first loose stool and one capsule after each stool not to exceed 4 capsules, dated 09/04/2025. The following medication was listed on the drug profile but was not available in the home: Geodon 40 mg, one capsule by mouth daily. It was empty, with the last filled date 02/26/2026. HOME VISIT 3/CLINICAL RECORD 6: The patient was admitted to hospice on 01/14/2026 with a terminal diagnosis of cerebral infarction. During a home visit observation with the registered nurse (Personnel Record 1), a medication review was completed by comparing the patient's current home medications to the hospice medication profile dated 03/16/2026. The patient had the following medications available in the home, but they were not on the medication profile: Tamsulosin HCL 0.4 mg, one capsule by mouth daily, dated 03/11/2026, and Cipro 500 mg, one tablet by mouth twice a day for UTI, dated 03/11/2026. During an interview with the alternate administrator/Director of Nursing (Personnel Record 7) on 03/19/2026, she stated, “This is one of the ongoing educations that they have been providing to the clinical staff. They are documenting the information in the visits, and orders for the medications are being updated, but they have also identified that medication lists have not been updated with changes, but they will continue to provide education and monitor.”

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 and 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 and interview. In 1 of 3 (33%) clinical record review of patients who elected hospice aide services revealed that the agency did not ensure 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. CLINICAL RECORD 9: The patient was admitted to hospice on 02/27/2025. The nurse documented an on-site supervisory visit of the hospice aide on 10/20/2025, and the next supervisory visit was documented on 11/10/2025, a total of 21 days and 7 days outstanding. The nurse also documented an aide supervisory visit on 12/22/2025, and no other hospice aide supervisory visits were noted prior to the discontinuation of hospice aide services on 01/12/2026, a total of 21 days and 7 days outstanding. The clinical record lacked evidence that the agency provided supervision by a registered nurse to the hospice aides, as evidenced by 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. During an interview with the Alternate Administrator/Director of Nursing (Personnel Record 7) on 03/19/2026, she stated that she did not know how that was missed, but they are now supervising the hospice aides by the registered nurse weekly.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met, as evidenced by personnel record review and interview. In 1 of 10 (10%) personnel record review revealed the agency did not ensure to assess the skills and competencies of all individuals providing care, including volunteers providing services. Personnel Record 2: The Certified Nursing Assistant was hired on 02/25/2025. The personnel record contained a competency dated 02/25/2025; however, it did not include documentation that a shower, tub, and sponge bath were observed, nor did it document that the hospice aide was competent in this area. The personnel record review lacked documented evidence of the completion of an initial competency. During an interview with the alternate administrator/Director of Nursing (Personnel Record 7) on 03/19/2026, she stated, “They were confused about how to document all three tasks as completed, but that they now understand that all three must be observed and documented.”

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family, and maintained by the hospice. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 2 of 5 (40%) clinical records reviewed revealed the hospice did not ensure the documented discussion of the emergency plan provided to the patient/family included evacuation or shelter in place plans as per the agency's policy. The agency's policy "Emergency Preparedness Policy and Plan" (revised 5/03/2021), stated in part, "Patient Care and Communication... The patient admission packet information provided and discussed with patient or caregiver will include, but not limited to, the following.. Materials that describe survival tips and plans for evacuation and sheltering in place." Clinical Record #5 was reviewed and identified that the patient elected the hospice benefit on 3/2/2022. Review of the clinical record revealed there was no documented evidence that the discussion of the emergency plan with the patient/caregiver included plans for the patient's evacuation if needed. The agency's form "Emergency Preparedness" completed during the patient's admission was missing information on evacuation and sheltering in place. Clinical Record 4 was reviewed and identified that the patient elected the hospice benefit on 3/2/2022. Review of the clinical record revealed there was no documented evidence that the discussion of the emergency plan with the patient/caregiver included plans for the patient's evacuation if needed. The agency's form "Emergency Preparedness" completed during the patient's admission was missing information on evacuation and sheltering in place. During an interview on 10/4/2022, the Alternate Administrator agreed that the form was completed but did not include the evacuation information. She had no additional information to provide.