Every finding on record at Always Present Hospice

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. 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. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the drug profiles included the patients' current prescriptions. CLINICAL RECORD 8: The patient elected hospice on 12/09/2025 with a diagnosis of unspecified combined systolic (congestive) and diastolic (congestive) heart failure. The initial plan of care and physician orders dated 12/09/2025 documented the patient had oxygen 2 liters per nasal cannula as needed. The medication profile, reviewed on 01/13/2026, did not include oxygen. CLINICAL RECORD 13: The patient elected hospice on 12/11/2025 with a diagnosis of chronic obstructive pulmonary disease. The initial comprehensive nursing assessment, dated 12/11/2025, documented the patient was oxygen-dependent. The initial plan of care/physician order dated 12/11/2025 documented the patient had an oxygen concentrator. The medication profile, reviewed on 01/14/2025, did not include oxygen. CLINICAL RECORD 14: The patient elected hospice on 09/22/2025 with a diagnosis of chronic obstructive pulmonary disease. The initial comprehensive nursing assessment, dated 09/22/2025, documented the patient was using oxygen at 2 liters/minute and had become oxygen-dependent. The initial plan of care/physician order dated 12/11/2025 documented the patient had an oxygen concentrator. The medication profile, reviewed on 01/14/2025, did not include oxygen. During an interview on 01/14/2026, the Director of Nursing reviewed the records and verified the medication profiles did not include oxygen. She stated the "Nurses have been educated on how to enter the medications on the medication profiles when entering the physician's order. This must have been overlooked during documentation review."

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 the drugs and treatments necessary to meet the needs of the patient. 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 patient's individualized written plan of care included all services necessary for the palliation and management of the terminal illness including treatments necessary to meet the needs of the patient. CLINICAL RECORD 14: The patient elected hospice on 09/22/2025 with a diagnosis of chronic obstructive pulmonary disease. The registered nurse (RN) comprehensive assessment, dated 11/3/2025, stated the patient was using continuous positive air pressure (CPAP) at night. The initial plan of care, dated 10/6/2025, did not include respiratory goals and interventions related to the use of CPAP, frequency, and/or instruction to the patient/caregiver. During an interview on 01/14/2026, the Clinical Director reviewed the patient's plan of care and verified there were no interventions or goals for the use of CPAP. She stated she "reviews documentation regularly and has been working with the nurses to improve the documentation in the plan of care and this was an oversight."

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. 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 that the written plan of care (POC) durable medical equipment (DME)/supplies included oxygen equipment and supplies. CLINICAL RECORD 8: The patient elected hospice on 12/09/2025 with a diagnosis of unspecified combined systolic (congestive) and diastolic (congestive) heart failure. The initial nursing assessment and physician orders dated 12/09/2025, documented oxygen 2 liters/minute per nasal cannula. The initial POC, dated 12/09/2025, DME list did not include oxygen equipment/supplies. During an interview on 01/13/2026, the Director of Nursing and Administrator reviewed the clinical record and verified the POC did not include oxygen/supplies in the DME/Supply list. She stated, "This is usually added at the time the order is written and was inadvertently not added."

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. In 2 of 17 (12%) records reviewed of patients accepting hospice aide services, the agency did not ensure the hospice aide care plan included specific patient care instructions. CLINICAL RECORD 1: The patient elected hospice on 08/13/2025 with a diagnosis of multiple sclerosis. The registered nurse (RN) initial comprehensive assessment dated 08/13/2025, and subsequent RN comprehensive assessments dated 12/17/2025, 12/31/2025, 01/07/2026, documented a stage 4 pressure ulcer on the sacro-coccyx with a dressing. The hospice aide care plan dated 08/14/2025 did not include instructions for what to do with the dressing during bathing or if the dressing was dislodged. CLINICAL RECORD 9: The patient elected hospice on 10/07/2025 with a diagnosis of cerebral infarction. The initial RN comprehensive assessment documented a patient with dysphagia and at risk for aspiration secondary to stroke. The hospice aide care plan dated 01/12/2026 did not include aspiration precautions. During an interview on 01/13/2026 the Director of Nursing (DON) and Administrator reviewed the findings and confirmed that specific instructions were not included in the hospice aide care plans. The DON stated that she "reviews documentation when it is submitted but must have missed that the instructions were not entered" and that she has been "working with the nurses to improve documentation."

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, including physicians' orders. 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 a physician order was written for all past and current identified patient needs. CLINICAL RECORD 13: The patient elected hospice on 12/11/2025 with a diagnosis of chronic obstructive pulmonary disease. The initial comprehensive nursing assessment, dated 12/11/2025, documented the patient was oxygen-dependent. The initial plan of care/physician order dated 12/11/2025 documented the patient had an oxygen concentrator. The clinical record did not contain evidence of a physician order for oxygen use, liter flow, frequency, and method of delivery. During an interview on 01/14/2026, the Director of Nursing reviewed the clinical records and was not able to provide evidence that a physician's order was present in the record for oxygen. She stated, "The physician order is usually entered when the equipment is requested and must have been overlooked."

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 6 of 13 (46%) clinical records reviewed revealed the hospice did not ensure that the patient's plan of care (POC) included goals and interventions based on problems identified in the initial and updated comprehensive assessments. The hospice policy #9-017, "The Plan of Care" (Dated 4/2021)," stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments. . . The plan will focus on identified problems, goals, and interventions." Clinical Record 1: The patient elected hospice care on 1/13/23. The initial nursing assessment dated 1/13/23 documented the patient's urinary incontinence. The interdisciplinary group (IDG) POC dated 1/13/23 did not include goals and interventions for urinary incontinence. Clinical Record 2: The patient elected hospice care on 12/31/22. The initial nursing assessment dated 12/31/22 documented the patient's urinary incontinence. The IDG POC dated 12/31/22 did not include goals and interventions for urinary incontinence. Clinical Record 3: The patient elected hospice care on 8/19/22. The initial nursing assessment dated 8/19/22 documented the patient's urinary incontinence. The IDG POC dated 12/31/22 did not include goals and interventions for urinary incontinence. Clinical Record 7: The patient elected hospice care on 12/16/22. The certificate of terminal illness dated 12/16/22 documented the patient was "COVID-19 positive." The IDG POC dated 12/16/22 did not include goals and interventions for COVID-19. Clinical Record 10: The patient elected hospice care on 11/7/22. The initial nursing assessment dated 11/7/22 documented the patient's urinary incontinence. The IDG POC dated 11/7/22 did not include goals and interventions for urinary incontinence. Clinical Record 11: The patient elected hospice care on 12/23/22. The initial nursing assessment dated 12/23/22 documented the patient's urinary incontinence. The IDG POC dated 12/23/22 did not include goals and interventions for urinary incontinence. During an interview on 2/16/23, the Administrator and the Director of Nursing reviewed and agreed with the above findings.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 7 of 7 (100%) clinical records reviewed revealed the hospice did not ensure that each patient’s record included signed copies of the notice of patient rights and the hospice election statement. The hospice policy #1-031, "Hospice Election Statement" (Revised 4/2021), stated in part, "The patient and family/caregiver, or his/her legal representative will be asked to sign hospice election statement which acknowledges the following... The right to receive an election statement addendum." Clinical Record 13: The patient elected the hospice benefit on 8/25/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. Clinical Record 9: The patient elected the hospice benefit on 8/11/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. Clinical Record 1: The patient elected the hospice benefit on 1/13/23. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. Clinical Record 2: The patient elected the hospice benefit on 12/31/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." The record lacked evidence that a completed Patient Notification of Hospice Non-Covered Items, Services, and Drugs was given to the patient/family as requested within the required 3 days. Clinical Record 3: The patient elected the hospice benefit on 8/19/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." The record lacked evidence that a completed Patient Notification of Hospice Non-Covered Items, Services, and Drugs was given to the patient/family as requested within the required 3 days. Clinical Record 7: The patient elected the hospice benefit on 12/16/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. Clinical Record 11: The patient elected the hospice benefit on 12/23/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. Clinical Record 5: The patient elected the hospice benefit on 10/7/22. The patient/family elected to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" by checking "Yes." There was no evidence that a completed "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" was given to the patient/family as requested within the required 3 days. During an interview on 2/17/23, the Administrator and the Director of Nursing (DON) reviewed and agreed with the above findings. The DON stated that a completed copy of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs was sent out to each of the patients/families listed above after 1/11/23, asking the patients/families to review, sign, and return.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 13 of 13 (100%) clinical records reviewed revealed the hospice did not ensure that the patient record was appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The agency policy #6-022, "Clinical/Service Data Collection" (Revised: 4/2021), stated in part, "Signature authorization of clinical/service documentation will include the staff member's name and credentials (as specified on professional licenses and/or certification documents)." Clinical Record 1: The patient elected hospice care on 1/13/23. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 2: The patient elected hospice care on 12/31/22. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 3: The patient elected hospice care on 8/19/22. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 4: The patient elected hospice care on 9/2/22. The Informed Consent & Election of Benefits form dated 9/2/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the certification of terminal illness (CTI) dated 9/2/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 5: The patient elected hospice care on 10/7/22. The Informed Consent & Election of Benefits form dated 10/7/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 10/7/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 6: The patient elected hospice care on 1/2/23. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 7: The patient elected hospice care on 12/16/22. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 8: The patient elected hospice care on 8/24/22. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 9: The patient elected hospice care on 2/12/22. The Informed Consent & Election of Benefits form dated 2/12/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 2/12/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 10: The patient elected hospice care on 11/7/22. The patient elected hospice care on 11/7/22. The Informed Consent & Election of Benefits form dated 11/7/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 11/7/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 11: The patient elected hospice care on 12/23/22. The patient elected hospice care on 12/23/22. The Informed Consent & Election of Benefits form dated 12/23/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 12/23/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 12: The patient elected hospice care on 5/1/22. The patient elected hospice care on 5/1/22. The Informed Consent & Election of Benefits form dated 5/1/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 5/1/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). Clinical Record 13: The patient elected hospice care on 8/25/22. The patient elected hospice care on 8/25/22. The Informed Consent & Election of Benefits form dated 8/25/22 stated the patient/family elected an Advanced Practice Nurse (APN)/Family Nurse Practitioner (FNP). The attending physician/provider listed on the CTI dated 8/25/22 was the FNP. The practitioner's name appeared without the appropriate credential, FNP. A review of the record revealed the CTI included the name of the Hospice Medical Director without the appropriate credential Doctor of Osteopathic Medicine (DO). During an interview on 2/17/23, the Administrator and the Director of Nursing reviewed and agreed with the above findings. The administrator stated the modification is in process with the electronic medical record (EMR) company. Also, the process to insure the correct credentials were listed was demonstrated directly in the EMR prior to the agency exit conference.

It is required that If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary, and the patient's clinical record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 3 of 3 (100%) clinical records reviewed for transferred patients revealed the hospice did not ensure the receiving facility received a copy of the hospice transfer/discharge summary. The hospice policy #1-022, "Transfer Information" (dated 4/2021), stated in part, "Completed transfer/discharge summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer/discharge and file the original in the clinical record." Clinical Record 6: The patient elected hospice care on 1/2/23. The family had the patient transferred to the hospital, and revoked hospice services to pursue aggressive treatment on 1/19/23. The record did not include evidence that the hospice forwarded a copy of the transfer/discharge summary to the receiving facility (hospital). Clinical Record 7: The patient elected hospice care on 12/16/22. The family had the patient transferred to the hospital, and revoked hospice services to pursue aggressive treatment on 1/4/23. The record did not include evidence that the hospice forwarded a copy of the transfer/discharge summary to the receiving facility (hospital). Clinical Record 8: The patient elected hospice care on 8/24/22. The family had the patient transferred to another hospice on 10/19/22. The record did not include evidence that the hospice forwarded a copy of the transfer/discharge summary to the receiving hospice. During an interview on 2/16/23, the Administrator and the Director of Nursing reviewed and agreed with the above findings.

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 a review of clinical records, document reviews, and interviews. 4 of 4 (100%) clinical records reviewed for patients that revoked the election of hospice care or were discharged revealed the hospice did not forward the transfer/discharge summary to the patient's attending physician. The hospice policy #1-024 "Revocation of Hospice Benefit (Revised: April 2021)", stated in part, "The Case Manager will notify the attending physician … A discharge summary will be sent to the attending physician." The hospice policy #1-025 "Discharge from Hospice Program" (Revised: 4/2021)", stated in part, "A copy of the discharge summary will be sent to the attending physician." Clinical Record 6: The patient elected hospice care on 1/2/23. The family had the patient transferred to the hospital, and revoked hospice services to pursue aggressive treatment on 1/19/23. There was no evidence that the hospice forwarded a copy of the transfer/discharge summary to the attending physician. Clinical Record 7: The patient elected hospice care on 12/16/22. The family had the patient transferred to the hospital, and revoked hospice services to pursue aggressive treatment on 1/4/23. There was no evidence that the hospice forwarded a copy of the transfer/discharge summary to the attending physician. Clinical Record 8: The patient elected hospice care on 8/24/22. The family had the patient transferred to another hospice on 10/19/22. There was no evidence that the hospice forwarded a copy of the transfer/discharge summary to the attending physician. Clinical Record 9: The patient elected hospice care on 2/12/22. The patient was discharged due to an extended prognosis on 10/5/22. There was no evidence that the hospice forwarded a copy of the transfer/discharge summary to the attending physician. During an interview on 2/16/23, the Administrator and the Director of Nursing reviewed and agreed the summaries were not forwarded to the physicians.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by personnel record review, interview, and document review. 1 of 10 (10%) records reviewed revealed the hospice did not ensure staff were fully vaccinated or had an approved medical or spiritual exemption The hospice policy "COVID-19 ETS" (Revised 9/2022), stated in part, "Organization requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation." Staff 9: The licensed practical nurse (LPN) was hired on 1/14/21. A review of the personnel record and the hospice's "Vaccination Tracking Record" revealed no evidence of a COVID-19 vaccination or evidence of a pending or approved vaccination exemption. During an interview on 2/16/23, the Administrator and the Office Manager reviewed the COVID-19 tracking tool and agreed the employee did not have proof of the COVID-19 vaccine or an exemption.