Every finding on record at Amenity Healthcare, LLC

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 treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, the organization did not ensure that each patient's individualized written plan of care (POC) included all drug and treatment instructions necessary to meet the needs of the patient. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/15/2025 with primary and pertinent secondary diagnoses that included end-stage heart failure, diastolic (congestive) heart failure, chronic respiratory failure with hypercapnia, COPD (chronic obstructive pulmonary disease), epilepsy, left BKA (below the knee amputation), chronic pain, a suprapubic catheter, and continuous oxygen. The patient resided in a Skilled Nursing Facility (SNF) and revoked services on 04/21/2025. The POC, effective 04/15/2025, did not include complete instructions for suprapubic catheter maintenance. The POC did not include the French/bulb size of the catheter, how often it should be changed, or by whom (facility staff, hospice staff, or physician), and did not include insertion site care or covering instructions. During a concurrent clinical record review and interview with the Administrator/Area Executive of Clinical Operations (ACO) on 12/12/2025, the Administrator/ACO confirmed the finding. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/05/2025, effective through 02/26/2026, with primary and pertinent secondary diagnoses that included Acute myeloblastic anemia, protein-calorie malnutrition, chronic AFIB (atrial fibrillation), and continuous oxygen. The patient resided in a private residence. The POC, effective 11/05/2025, included the medication MiraLAX 17gm oral packet daily without including reconstitution instructions. During a concurrent clinical record review and interview with the Administrator/ACO on 12/12/2025, the Administrator/ACO confirmed the finding. CLINICAL RECORD 15: The patient elected the hospice benefit on 10/11/2024, with benefit period 6, effective 10/06/2025 through 12/04/2025. The patient resided in an SNF and had primary and pertinent secondary diagnoses that included Alzheimer’s Disease, Bladder cancer, COPD, emphysema, protein-calorie malnutrition, and oxygen. The POC, effective 10/06/2025, included the medications Psyllium oral powder and Questran oral powder, both ordered once daily "for diarrhea, per instructions. The "instructions" for reconstitution/administration of both of the oral powders were not included as a part of the medication treatment on the POC. During a concurrent clinical record review and interview with the Administrator/ACO on 12/12/2025, the Administrator/ACO confirmed the finding.

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) 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 3 of 19 (16%) clinical records reviewed that included Hospice Aide (HA) services, the organization did not ensure that the HA received all written patient care instructions and precautions to meet patients' needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/26/2025 with a primary terminal diagnosis of chronic hepatic failure and was discharged after being determined to be no longer terminally ill on 04/25/2025. The patient resided in a private residence. The plan of care (POC), effective 01/26/2025 through discharge, included an order to apply a barrier cream to a rash under the patient’s breast after skin care was performed and orders for wound care and dressings to be applied for frequent skin tears and abrasions. The HA plan of care initiated 01/29/2025 and updated 02/04, 03/06, and 04/17/2025 did not include specific instructions for the HA to apply the barrier cream or on how to manage the patient’s wound dressings to protect them during bathing. During a concurrent clinical record review and interview with the Administrator/Area Executive of Clinical Operations (ACO) on 12/12/2025, the Administrator/ACO confirmed the finding. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/29/2025 and died in a Group Home on 09/26/2025. The patient’s primary terminal diagnosis was intractable epilepsy with metabolic encephalopathy. The POC, effective 08/29/2025 through the patient’s death, included seizure precautions. The HA plan of care initiated 08/29/2025 and last updated 09/22/2025 did not include seizure precautions. During a concurrent clinical record review and interview with the Administrator/ACO on 12/12/2025, the Administrator/ACO confirmed the finding. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/31/2025 effective through 01/28/2026, with primary and pertinent secondary diagnoses that included protein-calorie malnutrition, cerebral infarction due to occlusion or stenosis of a small artery, and a casted tibia/fibula fracture (from 10/12/2025) of the right lower extremity. The patient resided in a Skilled Nursing Facility. The HA plan of care initiated 10/31/2025 included instructions for the patient to be showered, but did not include instructions for covering or protecting the patient’s casted right lower extremity from getting wet during the shower. During a concurrent clinical record review and interview with the Administrator/ACO on 12/12/2025, the Administrator/ACO confirmed the finding.

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 need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed that included Hospice Aide (HA) services, the organization did not ensure that the HA was supervised by a registered nurse (RN) who made an on-site visit to the patient's home at least every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/26/2025 with a primary terminal diagnosis of chronic hepatic failure and was discharged after determined to be no longer terminally ill on 04/25/2025. The HA visit frequency was twice weekly. HA supervision was documented on 02/14/2025, and then next on 03/05/2025, 19 days later. During a concurrent clinical record review and interview with the Administrator/Area Executive of Clinical Operations (ACO) on 12/12/2025, the Administrator/ACO confirmed the finding. CLINICAL RECORD 21: The patient elected the hospice benefit on 11/06/2025, in Benefit Period 5, effective through 01/04/2026 with a primary terminal diagnosis of Alzheimer’s with dementia. The HA visit frequency was twice weekly. HA supervision was documented on 11/20/2025 and then next on 12/05/2025, 15 days later. During a concurrent clinical record review and interview with the Administrator/ACO on 12/12/2025, the Administrator/ACO confirmed the finding.

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 a review of clinical records, documents, and interviews. In 1 of 16 (6%) clinical records reviewed revealed that the agency did not complete a comprehensive spiritual assessment within the first five calendar days of the election of the hospice benefit. Agency policy states, in part, "a thorough evaluation of the patient's ongoing physical, emotional, psychological, and spiritual care and support needs as well as ongoing family/caregiver needs and willingness to maintain care for the patient. This assessment is completed by the interdisciplinary team in consultation with the patient's attending, if there is one, no later than five calendar days after the election of hospice services." Clinical Record 6: The patient was admitted to hospice services on 6/29/2022. The initial plan of care specified an initial Chaplain visit to assess any spiritual concerns of the patient or family. The Chaplain did not visit this patient until 7/5/2022. There was no documentation found in the clinical record that any contact had been made with the family by the Chaplain before this date. In an interview and joint review of the clinical record with the Director of Clinical Services and Area Director of Clinical Operations it was confirmed that the Chaplain did not visit until day six after the initial election of benefits. Agency policy states in part, "a thorough evaluation of the patient's ongoing physical, emotional, psychological, and spiritual care and support needs as well as ongoing family/caregiver needs and willingness to maintain care for the patient. This assessment is completed by the interdisciplinary team in consultation with the patient's attending if there is one, no later than 5 calendar days after the election of hospice services." In an interview and joint review of clinical record with director of clinical services and area director of clinical operations it was confirmed that there was no visit made by the chaplain until day 6 after the initial election of benefits.