Every finding on record at All Caring Hospice, LLC

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed it was revealed that the agency did not ensure that medications were provided timely to meet the needs of the patient. DOCUMENT 1: Agency Policy titled, Medication Management, PC.M45, stated in part, "Medications are provided on a timely basis and are available 24 hours a day and seven days a week as needed. The Hospice monitors the medications dispensed to and used by the patient." CLINICAL RECORD 2: The patient elected the hospice benefit on 06/27/2023. The Registered Nurse assessments dated 9/27/2024, 10/04/2024, and 10/10/2024 did not include documented evidence of a medication reconciliation. Additionally, those visits did not include any documented evidence that the RN reviewed the medications to see if the patient needed refills. The patient did not have the medication Alprazolam for 3 1/2 days. During a joint record review and interview on 11/03/2025, the Clinical Director stated, "When the patient ran out, we should have had our hospice doc call in the Alprazolam right away." During a joint record review and interview on 11/03/2025, the Clinical Manager (ADS) stated, "Our Hospice Doc is taking care of the medications now and we have switched her to a different pharmacy. It hasn't been a problem since the changes."

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not complete an initial comprehensive assessment within five days of the election date. Clinical Record 3: The patient elected the hospice benefit on 3/26/2022, with a terminal diagnosis of heart failure. The initial psychosocial assessment completed by the Medical Social Worker was dated 4/1/2022, 6 days after the start of care. The initial psychosocial assessment was not completed within 5 calendar days after the election of hospice care. A joint record review and interview with the Director of Clinical Services on 8/14/2023 confirmed the psychosocial assessment was completed 6 days after the election of benefit date. The Director of Clinical Services also established that the record did not contain evidence of why the psychosocial assessment was not completed within five (5) days. Clinical Record 5: The patient elected the hospice benefit on 1/16/2023, with a terminal diagnosis of chronic kidney disease, stage 5. Clinical record review revealed the Registered Nurse completed the initial comprehensive assessment on 1/16/2023 and the Chaplain completed the initial spiritual assessment on 1/17/2023. The clinical record contained no documented evidence that a psychosocial assessment was completed at the start of care. During joint record review and interview dated 8/14/2023, the Director of Clinical Services confirmed the initial psychosocial assessment was never completed as part of the initial comprehensive assessment.

It is required that 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 document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the patient’s medication profile was updated per agency policy. Agency policy PC.M45 Medication Management (revised 2018) stated in part, "The hospice will maintain a current medication list and current medication administration record. A medication profile is maintained for every patient and includes a listing of the current medication orders for each patient." Home Visit 1/Clinical Record 4: The patient elected the hospice benefit on 6/12/2023, with a terminal diagnosis of intraductal carcinoma of right breast. The patient resided in a Skilled Nursing Facility (SNF). During the home visit observation, a review of the patient’s hospice medication profile revealed the patient was ordered Depakene Solution 250 mg/ml 2.5ml by mouth twice daily. The medication administration record at the SNF ordered Depakene Solution 250mg/ml 2.5ml by mouth daily. The hospice medication profile and the SNF medication administration record were not up to date per agency policy. The Director of Clinical Services interviewed the RN Case Manager (staff 6). The RN Case Manager reported they complete a medication reconciliation with each recertification period every sixty (60) or ninety (90) days. A joint record review and interview with the Director of Clinical Services dated 8/15/2023 confirmed the hospice agency's medication profile did not match the medication profile in the Skilled Nursing Facility. The Director of Clinical Services reported the Skilled Nursing Facility most likely contacted a physician for a medication change and did not update the hospice agency. Home Visit 2/ Clinical Record 2: The patient elected the hospice benefit on 4/9/2022, with a terminal diagnosis of malignant neoplasm of the lung. The patient resided in a Nursing Facility (NF). During the home visit observation, a review of the patient’s hospice medication profile revealed the patient was ordered Roxanol 10mg/ml give 10mg every four hours in between four-hour tablets and Zofran 4mg injection as needed every four hours. The NF medication administration record did not contain the medications Roxanol and Zofran. The hospice medication profile and the NF medication administration record were not up to date per agency policy. A joint record review and interview with the Director of Clinical Services on 8/15/2023 confirmed the hospice agency medication profile did not match the medication profile in the Nursing Facility. The Director of Clinical Services reported the hospice does not order injectable medications for hospice patients and felt the medication "Zofran four (4) milligrams (mg) as needed injection every four (4) hours" was an error on the hospice agency's medication profile.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by, the hospice IDG [Interdisciplinary Group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure hospice care and services were provided according to the plan of care. Agency policy PC.P50 Plan of care (no revision date) stated in part, "Care provided to an individual patient is in accordance with the plan of care." Clinical Record 6: The patient elected the hospice benefit on 5/19/2023, with a terminal diagnosis of hypertensive heart disease with failure. The patient’s individualized plan of care included an order for spiritual services [Chaplain visit] once a month. The clinical record included documentation of Chaplain visits dated 5/23/2023, 6/13/2023 and 8/9/2023. There was no documented evidence in the clinical record that a Chaplain visit was provided in July and no documentation of a missed visits by the Chaplain for the month of July. During joint record review and interview dated 8/15/2023, the Director of Clinical Services confirmed Chaplain visits were ordered once a month for the patient and the patient did not receive a Chaplain visit in the month of July 2023. The Director of Clinical Services confirmed the record did not contain any evidence of the RN or the Interdisciplinary Group (IDG) being notified of a missed Chaplain visit.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services per the plan of care and under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, and family support systems to facilitate coping with end-of-life issues. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the psychosocial needs of the family and patient were assessed. Clinical Record 5: The patient elected the hospice benefit on 1/16/2023, with a terminal diagnosis of chronic kidney disease, stage 5. Clinical record review revealed the Registered Nurse completed the initial comprehensive assessment on 1/16/2023 and the Chaplain completed the initial spiritual assessment on 1/17/2023. The clinical record contained no documented evidence that a psychosocial assessment was completed at the start of care. During joint record review and interview with the Director of Clinical Services (DCS) on 8/14/2023, the DCS confirmed the initial psychosocial assessment was never completed for a patient with a hospice benefit election date of 1/16/2023. The DCS confirmed the RN addressed some of the psychosocial components during the initial RN assessment on 1/16/2023. However, the record did not contain evidence of the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, family dynamics and communication patterns, financial resources, and any constraints that were ever assessed.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 15 (20%) clinical records reviewed where hospice aide services were accepted, the agency did not ensure the hospice aide reported changes in patient needs to the Registered Nurse (RN). Agency policy PC.C90 Coordination of Services (revised 2020) stated in part, "The hospice will maintain a system of communication and integration in accordance with the policies and procedure to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under contract." Agency policy PC.C90 Coordination of Services (revised 2020) stated in part, "All members of the IDG [Interdisciplinary Group]/Hospice team have access to the patient's plan of care and are expected to provide care in accordance with it." Clinical Record 5: The patient elected the hospice benefit on 1/16/2023, with a terminal diagnosis of chronic kidney disease. Review of the hospice aide care plan assignment dated 1/16/2023 through 3/15/2023 revealed the aide was assigned to provide shower and shampoo with visits scheduled once a week. The hospice aide visit notes dated 3/1/2023, 3/8/2023, and 3/15/2023 documented the patient refused the shower. Hospice aide visit notes dated 3/1/2023 and 3/8/2023 documented the patient refused shampoo. The clinical record contained no documented evidence that the hospice aide notified the RN or the IDG of the hospice aide interventions not completed. Clinical Record 8: The patient elected the hospice benefit on 5/25/2023. Review of the hospice aide care plan assignment dated 5/25/2023 through 7/7/2023 revealed the aide was assigned to provide a complete bed bath at each visit. The hospice aide visit note dated 6/27/2023 documented the facility staff had completed the bed bath prior to the hospice aide’s arrival. The clinical record contained no documented evidence that the hospice aide notified the RN or the IDG of the hospice aide intervention not completed. Clinical Record 13: The patient elected the hospice benefit on 6/8/2023, with a terminal diagnosis of Parkinson’s Disease. Review of the hospice aide services care plan assignment dated 6/8/2023 through 9/5/2023 revealed the aide was assigned to assist with ambulation using wheelchair as needed. The hospice aide documented the patient refused assistance with ambulation using wheelchair as needed on 7/21/2023 and 7/24/2023. The clinical record contained no documented evidence that the hospice aide notified the RN or the IDG of the hospice aide interventions not completed. During joint record reviews with the Director of Clinical Services (DCS) dated 8/15/2023 and 8/16/2023, the DCS confirmed the records did not contain evidence the RN or the interdisciplinary group was notified of the interventions not completed by the hospice aide.

The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 9 (11%) clinical records reviewed where hospice care is provided in a facility, the agency did not ensure the written plan of care specified the services provided by the hospice versus those provided by the facility. Agency policy PC.C90 Coordination of Services (revised 2020) stated in part, "The hospice will maintain a system of communication to (b) ensure care and services are provided in accordance with the plan of care, (c) ensure that the care and services provided are based on all assessments of the patient's needs, (d) provide for and ensure the ongoing sharing of information between all disciplines providing care, whether directly or under arrangement." Agency policy PC.P50 Plan of Care (no revision date) stated in part, "The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG [Interdisciplinary Group] and is developed with measurable goals and outcomes. The plan must include all services necessary for the palliation and management of the terminal illness. The hospice written plan of care is developed and individualized for each patient and family and includes all services necessary for palliation and management of the terminal illness, including the following: (h) treatments, drugs and interventions to manage pain and symptoms of the terminal illness." Clinical Record 5: The patient elected the hospice benefit on 1/16/2023, with a terminal diagnosis of chronic kidney disease (CKD), stage 5. The patient resided in a Skilled Nursing Facility. The Registered Nurse documented in the initial comprehensive assessment dated 1/16/2023 that the patient had bilateral nephrostomy tubes. The certificate of terminal illness signed by the physician on 1/23/2023 stated in part, 66-year-old with stage 5 CKD, recent bladder tumor, and nephrostomy tubes placed. The hospice plan of care did not contain any evidence or reference to the patient’s nephrostomy tubes. The hospice plan of care did not identify the care and services that would be needed to care for the nephrostomy sites or who would be responsible for providing the care. During joint record review and interview dated 8/15/2023, the Director of Clinical Services confirmed the patient’s plan of care did not reference the patient’s nephrostomy tubes. The Director of Clinical Services also confirmed the plan of care did not include which provider would be responsible to care for the nephrostomy tubes. The Director of Clinical Services stated, "The facility should have taken care of the nephrostomy sites and tubes. That's not something we would typically do."