Every finding on record at Caring Star Hospice LLC

The documented comprehensive assessment must include a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, Supplements, Herbal remedies, and Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 5/HOME VISIT 2: During the home visit observation on 07/22/2025 with the Registered Nurse (RN) (Personnel Record 1), a medication review was completed by comparing the hospice medication profile to the patient’s current home medications. During the medication review the patient’s granddaughter/caregiver stated that the patient was no longer taking Coreg 12.5mg daily. Coreg was listed as an active medication on the hospice medication profile. The medication profile had not been updated with the patient’s current medications. CLINICAL RECORD 6/HOME VISIT 3: During the home visit observation on 07/22/2025 with the Chaplain (Personnel Record 7), a medication review was completed by comparing the hospice medication profile to the patient’s current home medications. During the medication review with the patient’s power of attorney the following medications were found to be active for the patient and not included on the hospice medication profile: Docusate Sodium 250 mg 2x daily, MiraLAX 17 g daily, Vit D3 daily, MVI [multivitamin] daily, B complex with vitamin C daily, CQ10 100 mg daily, and a probiotic daily. During a joint review of the home visits and interview on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed the medication profiles were not up to date.

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the individualized written plan of care included planned interventions based on problems identified in the initial and updated assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/09/2025. The Registered Nurse (RN) documented on the initial comprehensive assessment dated 07/09/2025 that the patient had bilateral nephrostomy tubes (a tube inserted through the skin into the kidney to drain urine) and a colostomy (a surgical procedure that involves creating an opening in the large intestine through the abdominal wall). The plan of care did not include planned interventions related to the care and management of the nephrostomy tubes and colostomy. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/07/2025 with a diagnosis of Alzheimer's disease. The RN documented on the initial nursing assessment that the patient was extremely anxious, had a large skin tear on the right leg, and had two healed stage 2 pressure ulcers on the coccyx. The plan of care did not include planned interventions for the patient's extreme anxiety and the large skin tear identified during the comprehensive assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 03/11/2025. The RN documented on the initial comprehensive assessment that the patient was actively dying, had pain, shortness of breath, and had a Foley catheter. The plan of care did not include planned interventions to manager these identified problems. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/11/2025. The RN documented on the initial comprehensive assessment that the patient was having pain, shortness of breath, anxiety, and had a Foley catheter. The plan of care did not include planned interventions to manager these identified problems. During a joint review of records and interview on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed that the plans of care did not include interventions for problems identified in the comprehensive assessments.

It is required that consistent with current professional standards of, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This standard was not met as evidenced by document review, personnel record review, and interview. The agency did not ensure that professional standards were consistent with the standards for providing nursing services and social work services by direct staff only. During the review of contracts, it was revealed that the agency had a supplemental staffing contract for nursing services. Contract 5- Hospice Staffing Agreement included documentation that nursing staff would be provided under the contract with the hospice. During a review of contracts and interview on 07/21/2025, the Alternate Administrator (Personnel Record 5) stated that the after hours on-call staff were contracted staff. During an interview on 07/23/2025, the Director of Nursing (Personnel Record 1) explained that "The contracted staff take after-hours calls every day. They triage any calls, and they go visit patients if needed." On-call nursing services were provided by contract nurses and were not direct hire nurses as required by standard of practice for core services provided by the hospice. PERSONNEL RECORD 6: Medical Social Worker (MSW) date of hire 11/14/2024. Review of the personnel record revealed the MSW was a contracted employee and was not a direct hire as required by standard of practice for core services provided by the hospice. During a joint review of the personnel record, the Alternate Administrator (Personnel Record 5) called the Administrator and confirmed that the Social Worker was a 1099 employee (contract employee) and not a W2 employee (direct hire employee). The Administrator (Personnel Record 8) stated in the exit conference on 07/23/2025 that the Social Worker had been converted to a W-2 employee as of 07/23/2025.

It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of contracts, personnel record review, and interviews with the Alternate Administrator, Medical Director, and Director of Nursing, which revealed issues with Failure to ensure nursing services and medical social services were provided in a manner consistent with acceptable standards of practice [HCDT.2.I/L585] and Failure to ensure designation of a Medical Director who provided supervision to the other contracted physicians [HCDT.5.I/L590]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care from the agency.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. The hospice must designate a physician to serve as medical director. The medical director must be a Doctor of Medicine or osteopathy who is an employee or is under contract with the hospice. When the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. All physician employees, and those under contract, must function under the supervision of the hospice medical director. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) contracts reviewed for Medical Director, the agency did not ensure designation of a Medical Director who provided supervision to the other contracted physicians. A review of the agency’s hospice physician contracts, Contract 3-Hospice Medical Director Agreement dated 11/01/2023 and Contract 4- Hospice Medical Director Agreement dated 02/01/2024, revealed that the contracts were identical and did not designate one physician as the hospice medical director. During an interview on 07/22/2025, the Medical Director (Personnel Record 9/Contract 3) was asked how and if he provided oversight to the other contracted physician. He stated, "I don't provide oversight for him. We are equals, and I just see him as my partner." During the review of contracts on 07/21/2025, the Alternate Administrator (Personnel Record 5) stated they were both the Medical Director. After a discussion and review of contracts with the Administrator (Personnel Record 8) and Alternate Administrator, they identified one of the physicians to designate as the Medical Director.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse 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 1 of 10 (10%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided specific care instructions for the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/09/2025. The Registered Nurse (RN) documented on the initial assessment dated 07/09/2025 that the patient had a colostomy (a surgical procedure that involves creating an opening in the large intestine through the abdominal wall) and bilateral nephrostomy tubes (a tube inserted through the skin into the kidney to drain urine). The aide care plan dated 07/09/2025 did not include instructions to the aide related to the care of the patient's bilateral nephrostomy tubes and colostomy. During a joint review of the record and interview on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed that the aide care plan did not include instructions for care of the nephrostomy tubes or colostomy and should have.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse completed an aide supervisory visit no less frequently than every 14 days CLINICAL RECORD 11: The patient elected the hospice benefit on 03/07/2025 and had aide services ordered three times per week. Clinical record review revealed an aide supervisory visit was completed on 03/18/2025 and the next aide supervisory visit was completed on 04/04/2025, a total of 17 days and 3 days outstanding. During a joint review of the record and interview on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed that the aide supervisory visit was not completed every 14 days as required.

It is required that a written agreement with another organization or individual to furnish hospice care or services includes: the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice, care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice, and care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by document review and interview. The agency did not ensure the contract for inpatient respite care included how IDG management oversight and coordination would be provided. Review of the hospice respite contract dated March 20, 2025, revealed no documented evidence that the agreement included how Interdisciplinary Group (IDG) management oversight and coordination would be provided, how communication with the IDG and hospice administration occurs, that care is provided only upon authorization of the hospice, care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice, and care delivered in accordance with patient’s plan of care. During a review of the contract and interview with the Alternate Administrator (Personnel Record 5) on 07/23/2025, the Alternate Administrator confirmed the respite contract did not include the required elements.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review, interview, and observation. The agency did not ensure the alternate delivery site was approved by Medicare. The site visitor arrived at the agency’s listed address on 07/21/2025 to begin the survey. The building was locked and appeared to be unoccupied. The site visitor called the phone number posted on the door to notify the agency of the survey. The person who answered the phone stated that they (agency staff) were in the office and the site visitor must be in the wrong location. The person provided the address and description of the building where the agency was located and during the conversation it was determined that the office where the hospice was conducting business was approximately a four-and-a-half-hour drive from the address listed as the current location of the agency. The site visitor was asked to hold on and another person came on the phone and stated that the Alternate Administrator was running late and would be at the location where the site visitor was within 20 minutes. The Alternate Administrator arrived at 9:45 AM unlocked the office. The Alternate Administrator (Personnel Record 5) explained that there were no patients and no employees at this location because all the patients lived by the other office that was 4 ½ hours away. The Alternate Administrator stated that the Administrator and the Director of Nursing work from the other location and there is no Alternate Director of Nursing. The Alternate Administrator stated that there was no printer in the office to print a patient list, but she would go get one. The Alternate Administrator stated that there have not been any patients at this location since they purchased the agency but were told they could not change the address, or they could lose their state license. The Alternate Administrator was asked what would happen if they received a call for a referral, and she stated they would decline the referral. Review of the hospice agency's patient handbook revealed the documented address for the agency was the office address for the community where the current patients are located and not the address on file with Medicare and CHAP. A three-fold marketing flyer for the hospice agency also included the address where the patients and staff are located and not the address on file with Medicare and CHAP. The site visitor arrived at the second location on 07/22/2025, which was the address listed on the patient handbook and marketing materials. Upon entering the office, the site visitor observed 3 home health licenses posted on the wall. The Administrator (Personnel Record 8) greeted the site visitor and thanked them for coming 4.5 hours. The Administrator stated that she was the Administrator for all three home health agencies and the hospice agency. She explained that she must be at this location because she is so busy with the home health agencies as well. The Administrator confirmed that the hospice staff work from this office. The agency was providing hospice care to patients at a location that was not approved by Medicare. Observations and interviews revealed that the agency did not ensure that each location was approved by Medicare.

It is required that each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the clinical record included complete physician orders. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/07/2025. The skilled nurse documented on the nursing visit note dated 03/10/2025 that the patient had a closed pressure wound to the sacrum and a large skin tear on the right leg. The physician ordered wound care on 03/10/2025 that read "Medihoney external gel, apply thin layer topically to wound daily and PRN (as needed)." The wound care order was incomplete when it did not include the location of the wound. During an interview and review of the record on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed the wound care order was incomplete.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with live discharge, the agency did not ensure the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/23/2025 with a diagnosis of Parkinson’s disease. The clinical record included a note that the patient and family requested a revocation from hospice services on 04/08/2025 to receive home health services. There was no documented evidence in the clinical record that a discharge summary was sent to the patient’s attending physician or home health agency. During a joint review of records and interview on 07/23/2025, the Director of Nursing (Personnel Record 4) confirmed the clinical record did not include a discharge summary.

It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: the hospice provides a copy of the patient’s plan of care to the inpatient provider and specifies the inpatient services to be provided. This standard was not met as evidenced by document review and interview. The agency did not ensure the contract for general inpatient care included that the hospice provides a copy of the patient’s plan of care to the inpatient provider and specifies the inpatient services to be provided. Review of the general inpatient services agreement/general inpatient contract dated February 6, 2024, revealed no documented evidence that the agreement included the requirement that the hospice would provide a copy of the patient’s plan of care to the inpatient provider and specify the inpatient services to be provided. During a review of the contract and interview with the Alternate Administrator (Personnel Record 5) and the Director of Nursing (Personnel Record 4) on 07/23/2025, the Director of Nursing stated, "Ok, we didn't know that was required."

It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: the hospice retains responsibility for ensuring that training has been provided to personnel who will be providing the patient’s care. A description of the training and names of personnel trained are documented. The methods used by the hospice to ensure the preceding requirements are met. This standard was not met as evidenced by document review and interview. The agency did not ensure the contract for general inpatient care included that the hospice retained responsibility for training personnel who will be providing care to the hospice patient. Review of the general inpatient services agreement/general inpatient contract dated February 6, 2024, revealed no documented evidence that the agreement included the requirement that the hospice would retain the responsibility for training personnel who will be providing the hospice patient’s care. During a review of the contract and interview with the Alternate Administrator (Personnel Record 5) and the Director of Nursing (Personnel Record 4) on 07/23/2025, the Director of Nursing stated, "Ok, we didn't know that was required."