Every finding on record at Casa Mia Hospice Care, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/16/2025. The initial nursing assessment dated 04/16/2025 included the following documentation: "Spiritual support: Needs spiritual support? Yes, Psychosocial support: Needs psychosocial support? Yes." However, there was no documented evidence in the clinical record that the initial spiritual assessment and the initial psychosocial assessment were completed. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/08/2025. Clinical record review revealed the initial nursing assessment was dated 10/08/2025 and the initial spiritual assessment was dated 10/10/2025. However, the initial psychosocial assessment was dated 11/10/2025, a total 35 days after the election of benefit and 30 days outstanding. During an interview on 03/05/2026, the Director of Clinical Services (Personnel Record 6) stated she did not know how those initial assessments were missed, but that they would provide additional education to clinical staff.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 10 (30%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals providing care were assessed as required by agency policy. Agency policy HR.10 Administrative Policy Manual: Staff Competency, last reviewed: 111524, required in part, "The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff's basic skill levels for all staff providing care, including volunteers, contracted staff, paraprofessionals, and professionals." PERSONNEL RECORD 4: Spiritual Counselor date of hire 12/15/2022. Personnel record review revealed an initial spiritual competency dated 03/23/2023. However, there was no documented evidence of annual competency assessments for 2024 and 2025. PERSONNEL RECORD 8: Nurse Practitioner date of hire 06/05/2025. Personnel record review revealed no documented evidence of an initial competency assessment. The personnel record included a hand hygiene competency dated 06/04/2025, but there was no other documentation of skill and competency assessment upon hire. PERSONNEL RECORD 10: Volunteer date of hire 01/10/2023. Personnel record review revealed an initial volunteer competency dated 01/20/2023. However, there was no documented evidence of annual competency assessments for 2024 and 2025. During an interview on 03/05/2026, the Director of Clinical Services (Personnel Record 6) stated they would provide additional education and ensure competencies were completed at hire and annually.

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 document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed with patient live discharge, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. Agency policy PE.20 Administrative Policy Manual: Patient Discharge, last reviewed: 100125, required in part, "The Hospice will forward copies of the following to the patient’s attending physician upon revocation and discharge from Hospice’s services: The Hospice discharge summary which included but is not limited to: a summary of the patient’s care, the patient’s current POC (plan of care), including medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient’s post-discharge continuity of care." CLINICAL RECORD 14: The patient elected the hospice benefit on 11/24/2025 and choose to revoke hospice services on 11/26/2025. Clinical record review revealed no documented evidence that a copy of the hospice discharge summary was forwarded to the patient's attending physician. During an interview on 03/05/2026, the Director of Clinical Services (Personnel Record 6) stated she was not aware that she needed to send a discharge summary to the attending physician, but she did send it to the Hospice Medical Director but not the attending physician.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) records reviewed it was revealed that the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription drugs. Clinical Record 2: The patient was utilizing oxygen 2-4 liters via nasal cannula as needed for shortness of breath as ordered by the physician on 05/02/2023 in the plan of care and documented in the comprehensive assessment by the registered nurse dated 5/2/2023. Oxygen was not listed on the drug profile dated 5/2/2023. Clinical Record 3: The comprehensive assessment dated 04/14/2023 documented that the patient was utilizing oxygen 2-4 liters via nasal cannula as needed for shortness of breath. The plan of care dated 04/14/2023 included an order for oxygen 2-4 LPM as needed for shortness of breath. Oxygen was not listed on the drug profile at the time of the record review. Clinical Record 8: The comprehensive assessment dated 04/19/2023 documented that the patient was utilizing oxygen 2-4 liters via nasal cannula as needed for shortness of breath. The plan of care dated 04/19/2023 included an order for oxygen 2-4 LPM as needed for shortness of breath. Oxygen was not listed on the drug profile at the time of the record review. Clinical Record 11: The comprehensive assessment dated 09/16/2023 documented that the patient was utilizing oxygen 2-4 liters via nasal cannula as needed for shortness of breath. The plan of care dated 09/16/2023 included an order for oxygen 2-4 LPM as needed for shortness of breath. Oxygen was not listed on the drug profile at the time of the record review. During Interview on 05/11/2023, with the Director of Patient Services and review of the associated records, it was stated that oxygen had been inadvertently omitted from the drug profiles.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) records reviewed it was revealed that the agency did not ensure that the written plan of care included the treatment necessary to meet the needs of the patient. Clinical Record 2: The comprehensive assessment completed by the registered nurse on 05/02/2023 documented the patient had a feeding tube (PEG). There were no orders for care of the PEG Tube included on the plan of care dated 5/2/2023. Clinical Record 3: The comprehensive assessment completed by the registered nurse on 04/14/2023 documented the patient had a coccyx stage 2 pressure ulcer and the caregiver was applying Calazine protective paste daily. There were no orders for the protective paste included on the plan of care dated 4/14/2023. Clinical Record 6: The comprehensive assessment completed by the registered nurse on 12/14/2022 documented the patient had an 18 French 30cc indwelling catheter. The physician order on the plan of care dated 12/14/2022 instructed the nurse to change the catheter monthly and as needed. There were no qualifiers for catheter changes as needed. Clinical Record 9: The comprehensive assessment completed by the registered nurse on 12/28/2022 documented the patient had a 16 French 30cc indwelling catheter. The physician order on the plan of care dated 12/28/2022 ordered catheter changes monthly and as needed with no qualifiers for catheter changes as needed. During Interview on 05/11/2023, with the Director of Patient Services who reviewed the associated records, it was stated the treatments were incomplete or inadvertently omitted from the plans of care.