Every finding on record at Aseracare Hospice-New Horizons, L.L.C.

Based on interview, record review, and review of agency policy, the Hospice agency failed to ensure discharge summaries were sent to the physician and/or organization the patients were transferred to for two of two patients (Patient (P) 10 and P12) reviewed for discharges out of a total sample of 14. This had the potential for continuity of care not being met. Findings include: --- 1. Review of P10's "Hospice Certification and Plan of Care," provided by the agency, revealed P10 had a start of care date of 12/27/25 with a primary diagnosis of Parkinsonism. P10 received skilled nursing services, social services, chaplain services, and volunteer services.  Review of P10's "Discharge-Transfer Summary Report," provided by the agency, revealed P10 was discharged to another hospice agency per the patient's family request on 01/13/26. There was no evidence in the patient's medical record that the "Discharge-Transfer Summary Report" was sent to the hospice agency who was taking over hospice services for the patient.  2. Review of P12's referral document (untitled) dated 07/09/25, provided by the agency, revealed the patient was referred to the hospice agency by a local hospital. Under the "Admission Information" in the referral document was listed an admitting physician, attending physician, and a referring physician.  Review of P12's "Hospice Certification and Plan of Care," provided by the agency, revealed a start of care date of 07/11/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). P12 received skilled nursing services, social services, aide services, and chaplain services.  Review of P12's "Discharge-Transfer Summary Report," provided by the agency, revealed P12 discharged from the agency on 11/16/25 due to being admitted to a non-contracted facility. There was no evidence in the patient's medical record that the "Discharge-Transfer Summary Report" was sent to the facility P12 was discharged to or to the patient's primary care physician (PCP).  During an interview on 06/24/26 at 8:45 AM, the Administrator confirmed there was no evidence that discharge summaries were sent to either the patient's PCP or to the facility the patient's transferred to. The Administrator revealed that they do send discharge summaries to PCPs or to organizations that the patients care was transferred to. The Administrator indicated it should be documented in the discharge coordination note and confirmed neither patient had evidence the discharge summaries were sent to P10's new hospice agency or to P12's PCP or the non-contracted facility the patient was transferred to.  Review of the agency's policy titled, "Discharge" last reviewed 06/06/26 revealed . . . Operational Guidelines: . . . 2. Criteria for patient-initiated discharge includes but is not limited to: a. The patient chooses to revoke their hospice benefit. b. The patient/family requests a transfer to another hospice program or home health agency . . . j. If a patient is discharged alive, the hospice will forward to the attending physician: i. A copy of the hospice discharge summary. ii. the patient's clinical record if requested . . . 7. When the patient is discharged to another organization, relevant medical information is provided to that agency and/or patient when requested . . . "

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and state, tribal, regional emergency management agencies. Corrected on site.

Upon patient record review, 2 of 14 (Patient #1,#2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Upon medication reconciliation during home visit in SNF and included on the Hospice medication profile, Haldol 5mg one PO PRN ordered 3/8/2024 and Buspirone 7.5mg one Q 12hrs PRN ordered 3/8/2024. There was no evidence in the SNF that these meds were on their medication profile and were not being given. Corrected on site. Patient #2: Medication profile dated 4/19/2024 included Furosemide 100mg one PO daily. Upon medication reconciliation during home visit found the medication had been dispensed as 20 mg tablets with the bottle stating take 5 tablets daily. Patient was taking one tablet for the days her weight was 114 lbs. or less, and two tablets if her weight was over 117 lbs. there was no evidence of a clear instructions for administration. Corrected on site.

Upon patient record review, 4 of 14 (Patient #1,#3,#5,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Per psychosocial assessment no funeral plans in place, no evidence on POC for problem/goals/interventions for funeral planning. Corrected on site. Patient #3: Per RN assessment "requires support for funeral planning", no evidence on POC for problem/goals/interventions for funeral planning. Corrected on site. Patient #5: Per RN assessment psychosocial assessment no funeral plans in place, no evidence on POC for problem/goals/interventions for funeral planning. Corrected on site. Patient #14: RN identified at SOC pt. using O2, has dysphagia, and is high risk for falls. No evidence on the POC of Problem/goals interventions for falls, O2 or aspiration precautions.

Upon patient record review, 2 of 14 (Patient #1,#2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Upon medication reconciliation during home visit in SNF and on hospice agency medication profile, Haldol5mg one PO PRN ordered 3/8/2024 and Buspirone 7.5mg one Q 12hrs PRN ordered 3/8/2024. There was no evidence of an order in the Hospice chart to discontinue these medications. Corrected on site. Patient #2: Order dated 4/19/2024 included Furosemide 100mg one PO daily. Upon medication reconciliation found the medication had been dispensed as 20 mg tablets with the bottle stating take 5 tablets daily. Patient was taking one tablet for the days her weight was 114 lbs. or less, and two tablets if her weight was over 117 lbs. there was no evidence of an order for this dosing. Corrected on site.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. No evidence of logging or surveillance of employee infections

Upon patient record review, 4 of 14 (Patient #3, #11,#13,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3: RN identified and placed aspiration precautions on the comprehensive POC. No evidence on aide assignment/POC of aspiration precautions. Corrected on site Patient #11:RN identified and placed aspiration precautions on the comprehensive POC. No evidence on aide assignment/POC of aspiration precautions. Patient #13:RN identified and placed fall risk, O2 use and anticoagulant use on the comprehensive POC. No evidence on aide assignment/POC of fall, O2 or bleeding precautions. Patient #14: RN identified at SOC pt. using O2, has dysphagia, and is high risk for falls. No evidence on aide assignment/POC of falls, O2 or aspiration precautions.

Upon patient record review 2 of 14 (Patient #1,#2) did not have evidence documentation in the patient record that a Registered Nurse made 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 to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: RN supervisory visit occurred on 5/25/2024 and 6/11/2024 (16 days). Patient #2: RN supervisory visit occurred on 6/14/2024 and 7/5/2024 (21 days).

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. End of year 2023 result 1.29%.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There is no evidence of a signed job description or orientation for this role.

Upon patient client record review, 3 of 14 (Patient #11,#12,#13) did not have evidence that each patient record contains Advance Directives. Patients #11,#12,#13: All identified as being DNR, no evidence of documentation to support this.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #12: there was no evidence the hospice forwarded a transfer summary to which the hospice pt. was transferred.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11: There was no evidence that a discharge summary was sent to the attending physician or hospital when patient entered hospital when they revocated.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: There was no evidence of a completed discharge summary.