Every finding on record at At Home Healthcare and Hospice, LLC

Based on records review, facility documents, and family and staff interviews, it was determined the hospice facility failed to ensure that a continuity of care was initiated after improper discharge. --- Findings included: Review of P1 record revealed P1 was admitted to hospice on 10/4/2021 with diagnoses of chronic obstructive pulmonary disease (COPD-progressive lung conditions that restrict airflow and make it difficult to breathe) Congestive heart failure (CHF-condition where the heart muscle becomes too weak to pump blood efficiently,) and cerebrovascular accident (CVA-commonly known as stroke). On  April 14, 2026, during interdisciplinary group (IDG) meeting, the doctor gave an order to discharge P1, stating that she was not eligible for hospice recertification. The hospice agency notified P1’s family of the order received from the doctor. P1 family disagreed with the doctor’s order to discharge the patient and contacted the government agency responsible for hospice oversight to file an appeal. On April 17, 2026, the appeal was granted, and P1 was determined to be eligible to continue in the hospice program. P1’s family discussed the appeal decision with the hospice agency. Review of RN AA nurse’s notes dated 04/17/2026 revealed that “patient observed bedbound and continues to demonstrate advanced decline in overall condition.” Review of appeal document dated 04/17/2026 reveals that according to the physician review of the medical record, ending services is not appropriate. Review of verbal physician order dated 04/28/2026 revealed order description: “DISCHARGE FROM HOSPICE CARE AS OF 4/28/2026 DUE TO NO LONGER MEETING HOSPICE ELIGIBILITY FOR TERMINAL ILLNESS.” The hospice agency proceeded with discharging P1 and failed to forward P1’s information to another hospice agency for continuity of care. The agency failed to notify the State Agency about P1’s discharge. A phone interview was conducted on 06/01/2026 at 2:01 PM with P1’s family who stated that the hospice agency discharged P1 without continuity of care despite the fact that the appeal was granted. P1’s family also expressed their disappointment with the hospice agency, as P1 had been admitted to and remained with this hospice agency for five years. P1’s family stated that the durable medical equipment (DME) company associated with the hospice agency had been calling them and threatening to remove the hospital bed and oxygen equipment. P1 was on 4l iters of continuous oxygen around the clock. P1’s family stated that they refused to allow the DME company to remove the equipment, and the DME company informed them that they would be charged daily for the equipment which added to their stress. A phone interview was conducted on 06/01/2026 at 2:34 PM with Registered Nurse (RN AA) who stated that based on her assessment P1’s condition was declined. An interview was conducted with the Executive Director (ED) in her office. The ED stated that P1 was admitted to hospice on 10/4/2021 and that P1 had been receiving hospice services for almost five years and that during the IDG meeting on 04/17/2026, the physician gave an order not to recertify P1 and to discharge P1 from the hospice program. The ED said that on 04/28/2026 the hospice agency discharged P1. On 4/29/2026, the ED said that she spoke with P1’s family who inform her that despite the appeal being granted, the agency proceeded with discharging P1. ED confirmed that the hospice agency failed to assist P1’s family with continuity of care and also failed to notify State Agency of the improper discharge.

Upon patient record review 1 of 19 (Patient #14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 14: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 1 of 19 (Patient #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 2: The medication profile contained instructions for metoprolol succinate ER tablets and simvastatin tablet to indicate alternate route of administration under the tongue. The listed medications are not able to be dissolved sublingually. Corrected on site.

Upon patient record review, 2 of 19 (Patients #13,#14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 13: The medical record contained an initial bereavement assessment dated 3/11/24 with start of care 3/5/24. Patient 14: The medical record contained an initial bereavement assessment dated 4/9/24 with start of care 3/9/24.

Upon patient record review, 4 of 19 (Patients #1,#3,#6,#12) 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: The medical record contained nursing documentation 3/5/24 identifying patient use of a CPAP. There was no evidence of problems, goals, and interventions related to the need for CPAP. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient issues with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient inability to swallow foods requiring a pureed diet. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 12: The care plan contained problems, goals, and interventions related to spiritual needs to be completed by a chaplain. The medical record contained documentation upon admission identifying the patient declined to receive chaplain visits. Corrected on site.

Upon patient record review, 2 of 19 (Patients #2,#5) 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 2: The medical record contained orders for metoprolol succinate ER tablets and simvastatin tablets to instruct an alternate route of administration under the tongue. The listed medications are not able to be dissolved sublingually. Corrected on site. Patient 5: The medical record contained nursing documentation 5/29/24 identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. The record also contained documentation upon admission identifying patient has a suprapubic catheter. There was no evidence of an order for catheter maintenance. Corrected on site.

Upon patient record review, 6 of 19 (Patients #1,#5,#6,#8,#13,#14) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation 3/5/24 identifying patient use of a CPAP. There was no evidence of an order for the CPAP included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 3/15/24 identifying patient use of a Hoyer lift. There was no evidence of an order for the Hoyer lift included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and bedside table. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon recertification 4/9/24 identifying patient use of a hospital bed. There was no evidence of an orders for the bed included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon recertification 4/18/24 identifying patient use of a cane, walker, and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon recertification 5/22/24 identifying patient use of a hospital bed and bedrails. There was no evidence of an order for the bed with rails included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 7: The medical record contained an order 5/21/24 for a mechanical soft diet due to aspiration. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site.

Upon patient record review, 3 of 19 (Patients #2,#7,#9) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient's needs. Patient 2: The aide care plan did not contain instructions for transfer assistance needed. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a Hoyer lift. The aide care plan did not contain instructions for transfer with a lift. Corrected on site. Patient 9: The aide care plan did not contain instructions for transfer assistance needed. Corrected on site.

Upon patient record review 2 of 19 (Patients #6,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 6: The aide care plan contained a task for the aide to shave the patient each visit with frequency of three times weekly. There was no evidence the aide completed the task at any visit since 5/20/24. Patient 14: The medical record contained an ordered aide frequency of once weekly. There was no evidence of a visit completed the week of 5/26/24. Corrected on site with late entry of missed visit documentation.

Upon patient client record review, 1 of 19 (Patient #7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 7: The medical record contained an election form identifying the patient representative chose to received the Notification of Hospice Non-Covered Items. There was no evidence the information requested was received. Clarification from signee, that the form was not requested and the choice to elect to receive was in error.

Upon patient client record review, 4 of 19 (Patients #3,#5,#8,#12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The medical record contained identical nursing visit narratives 5/14/24, 5/21/24, and 5/24/24. There was no evidence of appropriate authentication based on individual events of each visit. Patient 5: The medical record contained nursing documentation 5/29/24 identifying patient use of oxygen. After agency investigation of patient oxygen use, it was determined use of oxygen was documented in error. Corrected on site with clarification of data entry error. Patient 8: The medical record contained a CNA supervisory visit completed by the RN 4/4/24. There was no evidence the patient received any CNA visits. Patient 12: The medical record contained identical nursing visit narratives 5/9/24, 5/11/24, 5/16/24, 5/19/24, 5/23/24, 5/25/24, 5/30/24, 6/3/24. There was no evidence of appropriate authentication based on individual events of each visit.

Upon client record review, 1 of 19 (Patient #5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 9: The medical record contained an ordered social work visit frequency of once weekly effective 5/1/24. There was no evidence of a visit completed the week of 5/5/24. Corrected on site with explanation of missed visit documented with late entry.