Every finding on record at Blessed Hope Hospice LLC

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed revealed that the agency did not ensure that the medication profile identified related or non-related medications related to the palliation and management of the terminal illness and related conditions as identified in the care plan. Clinical Record 6: The patient’s election of the hospice benefit was 05/03/2024 with Primary Dx: Chronic diastolic (congestive) heart failure, Secondary DX: coronary artery disease, myocardial infarction, bradycardia, pacemaker, Alzheimer's dementia, and shortness of breath. The Medication Profile dated 05/23/2024 lacked the identification of related or non-related medications to the palliation and management of the terminal illness and related conditions as identified in the care plan. During a joint clinical record review and interview on 11/26/2024, the Administrator/Director of Nursing/Registered Nurse/Volunteer Coordinator confirmed that the medication profile did not indicate the related and non-related medications. There was no evidence of where the agency paid for any medications for the patient.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 2 of 10 (20%) personnel records reviewed revealed that the agency did not ensure that the criminal background checks were obtained within three months of the date of employment. Personnel Record 7: The Chaplain's date of hire was 03/17/2024. The criminal background check was dated 08/27/2024. The record lacked a criminal background check within three months of the date of employment. Personnel Record 10: The Volunteer's date of hire was 03/23/2024. The criminal background check was dated 11/12/2024. The record lacked a criminal background check within three months of the date of employment. During a joint personnel record review and interview on 11/26/2024, the Administrator/Director of Nursing/Registered Nurse/Volunteer Coordinator confirmed that the record lacked a criminal background check within three (3) months of the date of employment.