Every finding on record at American Hospice Inc

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that elected hospice aide services that required the aide to report changes in the patient medical needs to the registered nurse (RN) revealed the agency did not ensure the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. CLINICAL RECORD 6: The aide care plan dated 10/16/2025 ordered the task "Shower" every visit. The aide was ordered to complete two (2) visits per week. On the aide visit note dated 11/04/2025, the aide documented the patient refused the ordered task "Shower". The record lacked supportive documentation as to the reason the task "Shower" was refused. Furthermore, the record lacked evidence that the aide notified the RN of the above changes in the patient's medical needs as related to the ordered task "Shower". The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record review on 12/10/2025 that they both agreed that the aide did not report that the patient refused the bathing task ordered: "Shower" to the RN.

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 clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients that either, revoked the hospice benefit or were discharged from the hospice because no longer terminally ill, revealed the agency did not ensure a copy of the hospice discharge summary were forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient's family revoked the hospice benefit on 11/17/2025 and scheduled an appointment with the patient's attending physician to pursue aggressive treatment. The record lacked evidence that the agency forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient was discharged from hospice on 05/18/2025 because the interdisciplinary group (IDG) determined the patient was no longer terminally ill. The record lacked evidence that the agency forwarded the discharge summary to the patient's attending physician. The Administrator and the Director of Patient Care Services stated in an interview while performing joint clinical record reviews on 12/10/2025 that they both agreed the clinical records did not have evidence that the discharge summaries were forwarded to the patient's attending physician for the patient/family that revoked the hospice benefit and the patient that was discharged for being no longer terminally ill.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not inform the patient/family/private caregiver verbally nor in writing on the admission consent of the non covered items, services, and drugs. For example, in RRHV #1, RRHV #2, and RRHV #3 and RRNHV #1 to 7, RRDC #1 and 2, and RRBR #1 and #2 although, the consent form had the patient's signature at the bottom, there are two boxes on the consent that specify whether the patient wanted a copy or declined a copy. Both boxes were left blank. This was reviewed and validated with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization prepopulated the Medical Director's name on the admission consent section where the patient chooses an attending Physician. For example, in RRHV #1, RRHV #2, and RRHV #3 and RRNHV #1 to 7, RRDC #1 and 2 and RRBR #1 and #2 the first line has the Hospice's Medical Director's name and the second line was left blank. There was no choice indicated other than the prepopulated Hospice Medical Director's name on the consent. This was reviewed and validated with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization documented conflicting documentation in the clinical record. For example, in RRHV #1 on the plan of care, the frequency of visit indicated SC: declined. During review of the Spiritual Care (SC) or Chaplain's initial assessment documentation indicated frequencies on recertification and PRN and also noted in the documentation were two questions, spiritual care declined by pt/fx answer: no and will care be provided by hospice Spiritual counselor answer: yes. The Surveyor also spoke with the Chaplain in the field who indicated a PRN visit was made to the patient the week prior to the Surveyor's visit which confirmed ongoing spiritual care was needed. In RRHV #2, the Skilled Nurse documented on the visit note, when asked, is the patient alert, oriented, and able to verbalize pain-yes and then in the narrative part of the note documented the patient is non verbal. Upon the Surveyor's visit to the patient, the patient was witnessed to be non verbal and unable to answer any questions and or follow commands. This was validated and reviewed with the Administrator and the Director of Patient Care Services Designee.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not establish measurable goal and timeframe for the pain goal on the plan of care. For example, in RRHV #1 the goal, pt will have increased comfort/satisfaction from pain discomfort as exhibited by verbal and non verbal communications with a target date until the end of the certification period. This is to long of a timeframe to manage the patient's pain and the goal is not measurable. in RRHV #2 in review of the plan of care it was noted that the timeframes/target dates on the plan of care had not been updated for 1 year on some of the goals and 2 years on the other goals with review of the plan of care in the clinical record. There were similar findings in RRHV #3, RRNHV 1 to 7, RRDC #1 and 2, and RRBR #1 and 2. This was validated and reviewed with the Administrator and the Director of Patient Care Services Designee. Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not establish individualized and measurable goals for the patient/pcg/family. For example, in RRHV #1, the plan of care goals stated, patient will maintain BP within individually acceptable range. There was no indication as to what the patient's individually acceptable range was. Patient will participate in activities to reduce BP/cardiac workload. There was no indication as to the specific activities to reduce BP/cardiac workload. This was validated and reviewed with the Administrator and the Director of Patient Care Services Designee.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not establish an appropriate length of time for the plan of care goals. For example, in RRHV #1 the goals stated, pt will have increased comfort/satisfaction from pain discomfort as exhibited by verbal and non verbal communications. All the goals on the plan of care were to be achieved by the target date which was indicated as the end of the certification period. The pain goal is to long of a timeframe to manage pain. This was validated and reviewed with the Administrator and the Director of Patient Care Services Designee.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not have a signed plan of care upon admission of the patient onto hospice services. For example, in RRHV #1 the plan of care orders were not signed until 56 days after the start of care. In RRHV #2, and RRHV # 3, RRNHV #1, 2, 3, 4, 5, 6, and 7, RRDC #1 and 2, RRBR #1 and 2 there is no documented evidence that the initial plan of cares were not signed by the Physician. This was validated and reviewed with the Administrator and the Director of Patient Care Services. Observed in Record Review. In 2 of 14 patient records reviewed, the organization did not establish completed frequencies for PRN visits. For example, in RRHV #1 the spiritual counselor (SC) frequencies on the plan of care indicated, every recertification and PRN for spiritual support to patient/family. There was no indication as to the number of PRN visits on the plan of care. The SC stated, during the Surveyor's visit a visit was made the week prior to the Surveyor's visit and a visit was also made with the Surveyor which indicated 2 PRN visits was needed within the past 2 weeks. In RRHV #2, the organization did not establish frequencies for the wound care to the sacrococcyx area. The wound orders were: sacro coccyx treatment: cleanse wound sacrococcyx with wound cleanser, pat dry then mix calmoseptine and vitamin A &D on the affected area then cover with mepilex. There was no frequency as to how often the wound care should be performed. This was validated and reviewed with the Administrator and the Director of Patient Care Services Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not discontinue medications on the medication list. For example, in RRHV #2 the plan of care in the clinical record noted medications such as Hydrocortisone 2.5 % 1 cream topical PRN, Albuterol Sulfate 0.083% 1 sol respiratory every 4 hrs PRN, Tylenol extra strength 500 mg 1 tab oral every 6 hours, mupirocin 2% 1 0.5 grams topical twice a day as needed, Narcan 4mg/0.1 ML nasal spray 4mg 1 spray nasal as needed, fleet bisacodyl enema 10 mg 1 enema rectal PRN, lotrisone topical cream 1% 1 application topical twice a day, Flexeril 5 mg tablet oral once a day, nystatin 100,000 units/g topical powder 1 apply topical once a day, Dulcolax 10 mg 1 supp rectal PRN, 7 select acetaminophen 650 mg 1 supp rectal every 4 hrs PRN for mild pain and fever, atropine 1% 2 drops sublingual every 2 hrs PRN, Compazine 25 mg 1 supp rectal every 12 hrs PRN, and Lorazepam 0.5 ml sublingual every 4 hrs PRN and Lorazepam 0.5mg 1 tab oral TID, to be taken 4 hours apart from Norco and or Temazepam. During the Licensed Vocational Nurse (LVN) medication reconciliation it was noted the patient was currently only taking Lorazepam 0.5 mg sublingual twice a day as needed, MiraLAX powder for solution 17 g oral once a day at bedtime, senna 8.6 mg tablet 2 tab oral once a day at bedtime, Norco 10/325mg by mouth every 4 hours, Temazapam 30 mg 1 cap oral once a day at bedtime, and morphine sulfate 10mg/5ml solution 0,25 ml oral give 0.25 ml every 2 hours as needed for breakthrough severe pain (8-10/10). With the Surveyor speaking with the patient's PCG the PCG indicated the Flexeril was discontinued a month prior to the Surveyor's visit and the Lorazepam was also changed from three times a day to twice a day as needed months ago. The PCG could not attest to the other medications but did indicate the patient is only prescribed 6 medications at this time. The Surveyor then spoke with the LVN who confirmed only 6 medications being prescribed at the time of the Surveyor's visit and reviewed all 6 medications to include the expiration dates of the morphine sulphate and the Lorazepam. The LVN did not update the plan of care to reflect the medications that had been discontinued before leaving the patient's home. This was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 10 of 14 patient records reviewed, the organization did not document the progress towards the goals. For example, in RRHV #2, RRNHV #1, 2, 3, 4, 6, and 7 and in RRDC #1 and 2, and RRBR #2 the patient's had several benefit periods and in review of the clinical record there is no documented evidence in the clinical record that the plan of care goals were achieved or not achieved but instead, each goal continued to be rolled over into the next benefit periods. This was validated and reviewed with the LVN Case Manager and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not follow Physician's orders for wound care treatment. For example, in RRHV #2 the patient had a right breast and a sacral wound. The orders on the plan of care given to the Surveyor and also was noted in the clinical record included, sacro coccyx treatment: cleanse wound sacrococcyx with wound cleanser, pat dry then mix calmoseptine and vitamin A &D on the affected area then cover with mepilex. Cleanse right breast wound with vashe wound cleanser, pat dry then leave open to air once a day. During the Surveyor's visit the Licensed Vocational Nurse (LVN) did not perform wound care as ordered but instead, lifted the top portion of the dressing from the sacral area and reapplied the same dressing to the area. The LVN also lifted an ABD pad cover with tape from the right breast of the patient and reapplied the same dressing to the area. This was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not maintain a clean environment with use of standard precautions. For example, in RRHV #2 the Licensed Vocational Nurse (LVN) set up two barriers before providing care to a patient with a stage 2 sacrum pressure ulcer and a left breast open wound. One barrier was used to sit the workbag atop and the second barrier was used for dirty equipment. The LVN did not have a clean barrier setup to place the cleaned equipment on after use and therefore, cleaned the equipment and then returned it to the dirty barrier for dry time. This was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Leadership Session. the Leaders of the organization did not review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services as evidenced by condition level deficiencies with provision of care. This was reviewed with the Administrator and the Director of Patient Care Services Designee.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not update the medication list. For example, in RRHV #2, the Private Caregiver (PCG) indicated the patient takes Norco 10/325 mg by mouth every 4 hours. The medication was not listed on the updated medication list provided to the Surveyor. Lorazepam 0.5 mg 1 tab oral TID to be taken 4 hours apart from Norco/and or Temazepam was decreased to 0.5 mg sublingual twice a day as needed according to the labeled box in the patient's refrigerator, the Licensed Vocational Nurse, and the patient's PCG. The Skilled Nurse did not update the medication list. In RRHV #3, the patient's daughter stated, according to the Skilled Nurse's instructions, the Hospice Medical Director advised, Morphine Sulfate 5 ml by mouth every 8 hours as needed 7 days prior to the Surveyor's visit and most recently the daughter reported the Skilled Nurse was made aware, 5ml seemed to make the patient more confused and lethargic and therefore, the Skilled Nurse advised the patient's daughter of the new order from the Hospice Medical Director, to administer Morphine Sulfate by mouth 3 ml every 8 hours as needed and alternate with Tylenol 500 mg by mouth every 8 hours as needed; do not exceed 6 tablets per day for pain. The daughter also reviewed the Morphine sulfate medication bottle with the Surveyor and it was noted, morphine sulfate 3 ml by mouth every 8 hours as needed and also, take 3ml (=6mg) every 2 hours as needed. The medication list in the clinical record stated, morphine sulfate solution 10mg/5ml strength, give 3ml oral every 2 hours as needed for severe pain 8-10/10, Tylenol Extra Strength 500mg tablet 1 tab oral every 6 hours as needed for joint pain, do not exceed 4 tablets in 24 hours, and 7 select acetaminophen 650 mg 1 supp rectal every 4 hrs PRN for mild pain and fever. The instructions given to the patient's daughter, the medication list in the home binder, and the medication list provided to the Surveyor were not updated to reflect the patient's current medication regimen. This was reviewed with the Administrator and the Director of Patient Care Services RN Designee.

Observed in HR File Review. The organization staff providing care, treatment, and services did not practice within the scope of their license. During the survey, the Licensed Vocational Nurse (LVN) serving as a case manager stated that she created plans of care. Review of the signed job description for the position of “Case Manager” indicated that an active RN license was required. The LVN did not possess an RN license, resulting in staff performing duties outside their licensed scope of practice.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization had the patient sign the revocation form hospice service upon admission to the organization. For example, in RRHV 1 and 2 and RRNHV #1 the revocation form was signed by the patient/family/private caregiver on admission. In RRHV #3 the revocation form was signed and also dated with the date of the start of care. The revocation form should not be signed in advance. This was reviewed and validated with the Administrator and the Director of Patient Care Services.

Observed in HR File Review. In 1 of 11 HR files reviewed, all staff were not trained on their emergency management roles, as volunteers were not included. In HR#7 and HR#8 personnel files review, the surveyor noted that the volunteer had not been trained on emergency management. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to assess the patient according to defined time frames. In HV#1/RR#1, the surveyor observed that the Social Worker failed to completed their initial assessment within five days. Patient is still pending a Social Worker visit. This was confirmed by the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to provide the patient with care, treatment, or services according to the patient's individualized plan of care. In HV#1/RR#1, the surveyor observed the RN performing wound care to patient's right forearm by applying a Duoderm patch, instead of using a non adhesive dressing as per the physician's order. In HV#2/RR#2, the surveyor noted upon record review that a SN visit was missed in Week 3. In HV#3/RR#3, the surveyor noted upon record review that 6 HHA visits were missed during benefit period #3 and the visit frequency changed from 2 x week to 1 x week during benefit period #4; however, patient continued to received 2 visits per week. This was confirmed by the Administrator.

Observed in Tracer Activities. Organization had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. Upon review of QAPI Program, the Administrator identified high discharge rate as a priority issues, but the surveyor noted that a performance improvement plan was not initiated. This was confirmed by Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization did not plan the bereavement care and support for the bereaved. In RR#8 and RR#9, the bereavement mailings were not sent out at the specific intervals. As evidenced by, RR#8 mailings for months 3, 6, and 9 were never sent and in RR# mailing for month 3 was not sent. This was confirmed by the Administrator.

Observed in Tracer Activities. The hospice had not documented the cost savings achieved through the use of volunteers. There was no documentation of volunteer hours/work time/cost savings available to review. This was confirmed by Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, staff competency not assessed as part of orientation. In HR#8 personnel file review, the surveyor noted that the volunteer did not have initial competencies on file. This was confirmed by the Administrator.

Observed in Record Review. The initial Certificates of Terminal Illness were not signed by the attending physician as required by regulation. In RR#7, the initial Certificate of Terminal Illness and Re-Certification Statements were not signed by the Medical Director. This was confirmed by the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, medication orders are not clear and accurate. In HV#1/RR#1, the surveyor noted that the patient was prescribed Bactroban 2% topical ointment, but the patient is using Bactroban 1% topical ointment. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, organization failed to maintain the integrity of health information. In RR#5, the surveyor noted that the consent form date was altered after the form was acknowledged by the patient. This was confirmed by the Administrator.