Every finding on record at Cfhc No12 Inc

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, supplements, herbal remedies, 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 and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 1: The patient elected that hospice benefit on 12/03/2024. During the home visit observation on 10/21/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the patient’s home medications to the hospice medication profile printed on 10/21/2025. The hospice medication profile included Atorvastatin Calcium Oral Tablet 10 mg, one tablet by mouth daily, started on 12/03/2024, Levothyroxine Sodium Oral Tablet 50 MCG, one tablet by mouth every day before breakfast, started 12/03/2024 and Restoril Oral Capsule 15 MG, one capsule by mouth every night before bedtime, started 12/03/2024. The patient’s current home medications did not include Atorvastatin, Levothyroxine, and Restoril. The paid caregiver, who manages the patient's medications, reported that Atorvastatin and Levothyroxine were discontinued approximately 10 months ago, and Restoril was discontinued about 4 or 5 months ago. The paid caregiver stated that the patient would refuse to take medications. The RN verified that the medications were on the printed medication profile dated 10/21/2025. The hospice medication profile also included orders for Cyanocobalamin (Vitamin B12) Injection Solution 1000 MCG/ ML, inject 1 ML every month on the 29th, started 06/05/2025, Vitamin B-12 Sublingual Tablet Sublingual Tablet 2500 MCG, one tablet by mouth daily, started 06/05/2025, Furosemide Oral Tablet 20 MG, one by mouth daily, started 06/05/2025, and Furosemide Oral Tablet 20 MG, take one tablet by mouth once a day for edema, started 09/16/2025. The family reported that when the "Vitamin B-12 shots started, (the patient) stopped taking the ones by mouth." There was no documented evidence that the patient's medications were reviewed for duplicate drug therapy at the time of the comprehensive assessment and drug profile updated. The last comprehensive assessment was dated 10/14/2025. During a joint record review and interview on 10/22/2025, the Director of Nursing/Alternate Administrator/Bereavement Coordinator confirmed that there was no documented evidence the patient's medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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. THIS IS A PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The hospice election of benefit was dated 11/02/2022. At the time off the review on 09/25/2023, there was no evidence of completion of an initial bereavement assessment. Clinical Record 2: The hospice election of benefits was dated 11/21/2022. At the time off the review on 09/25/2023 there was no evidence of completion of an initial bereavement assessment. During interview 09/25/2023, Administrator reviewed the associated record and stated that the initial bereavement risk assessments were not completed.

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 a review of clinical records, interviews and observations. In 1 of 3 (33%) home visits revealed the agency did not ensure the medication profile contained the patient's current prescription medications.. Home Visit 2: During the home visit ( Clinical Record 2) conducted with the registered nurse (RN) on 12/07/2022, the patient stated she was using eye drops and the dosage of Januvia was decreased. The patient stated she was using Systane gel and Systane ultra-eye drops for approximately 6 months and the decreased dosage of Januvia, with the dispensed date documented on the bottle as 09/30/2022 for "50 milligrams daily". The agency medication profile read, "Januvia 100 milligrams daily" and did not include eye drops as of 12/09/2022. During an interview on 12/08/2022, the Administrator confirmed that the medication profile was not current or completed and has since been corrected to reflect current medications.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 5 (40%) records reviewed revealed, the agency did not ensure that an initial bereavement assessment was completed. The agency's policy PC.26 "Bereavement", read in part, "On admission, a bereavement assessment will be completed by the hospice Spiritual Caregiver, Social Worker or the Registered Nurse". . Clinical Record 1: The patient elected hospice care on 11/02/2022. There was no evidence of a completed bereavement assessment as of 12/09/2022. The bereavement assessment was scheduled to be completed on 12/09/2022 by the chaplain. There were communication notes entered by the chaplain regarding attempts to complete the bereavement assessment from 11/02/2022 through 12/07/2022. There was no evidence of completion of the bereavement assessment by the chaplain, the nurse, who made weekly visits from 11/02/2022 through 12/06/202,2 or the social worker, who visited the patient on 11/01/2022. During an interview on 12/08/2022, the Administrator stated the bereavement assessment was not completed per agency policy. Clinical Record 2: The patient elected hospice care on 11/21/2022. There was no evidence of a completed bereavement assessment as of 12/09/2022. There were communication notes entered by the chaplain regarding attempts to complete the bereavement assessment from 11/21/2022 through 12/01/2022. There was no evidence of completion of the bereavement assessment by the chaplain, or the registered nurse who made weekly visits from 11/21/2022 through 12/07/2022. During an interview on 12/08/2022, the Administrator stated the bereavement assessment was not completed per agency policy.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 5 of 5 (100%) records reviewed, the agency did not ensure that all entries in the patient record contained credentials with the clinician's associated signature and date. The agency's policy #IM.7, read in part, "Each medical record entry will be dated and signed with the complete name and title/credentials of the person making the entry". Clinical Record 1: There were no associated credentials for entries made by the chaplain dated 11/02/2022 through 12/09/2022. The plan of care orders and the physician orders dated 11/02/2022 through 12/03/2022 did not contain credentials with the associated physician's signature and date. Clinical Record 2: There were no associated credentials for entries made by the chaplain dated 11/21/2022 through 12/09/2022. The plan of care orders and the physician orders dated 11/21/2022 through 12/09/2022 did not contain credentials with the associated physician's signature and date. Clinical Record 3: There were no associated credentials for entries made by the chaplain dated 11/02/2022 through 12/09/2022. The plan of care orders and the physician orders dated 11/02/2022 through 12/09/2022 did not contain credentials with the associated physician's signature and date. Clinical Record 4: There were no associated credentials for entries made by the chaplain dated 11/21/2022 through 11/30/2022. The plan of care orders and the physician orders dated 11/21/2022 through 11/28/2022 did not contain credentials with the associated physician's signature and date. Clinical Record 5: There were no associated credentials for entries made by the chaplain dated 11/02/2022 through 11/21/2022. The plan of care orders and the physician orders dated 11/02/2022 through 11/21/2022 did not contain credentials with the physician's signature and date. During interview 12/08/2022, the Administrator stated the clinician's signatures did not contain credentials and had since been corrected in the associated electronic medical record's clinician profiles.

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 a review of clinical records, document reviews and interviews. In 1 of 2 (50%) applicable live discharge records reviewed, the agency did not ensure that a discharge summary was completed and sent to the attending physician. The agency's policy, PE.7, "Patient Revocation", read in part, "The Hospice will forward copies of the following information to the patient's attending physician; the hospice discharge summary that includes but is not limited to a summary of the patient's care, the patient's current plan of care, the latest physician's orders; and any other documentation requested".. Clinical Record 4: was reviewed and identified the patient elected hospice care on 11/21/2022. The patient revoked hospice care on 11/28/2022 and the nursing 11/28/2022 discharge assessment read, "Discharge summary not indicated in this situation". During interview 12/08/2022, the Director of Nursing stated the discharge summary was not completed per agency policy.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes at least the following the patient’s current plan of care and the patient’s latest physician orders. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 2 (50%) applicable live discharge records reviewed, the agency did not ensure the discharge summary contained all the required components. The agency's policy, PE.7 "Patient Revocation", read in part, "The Hospice will forward copies of the following information to the patient's attending physician; the hospice discharge summary that includes but is not limited to a summary of the patient's care, the patient's current plan of care, the latest physician's orders; and any other documentation requested".. Clinical Record 5: was reviewed and identified the patient elected hospice care on 11/02/2022. The discharge summary completed on 11/21/2022 did not include the current plan of care or the most recent physician's orders. During interview 12/08/2022, the Director of Nursing stated the discharge summary was not completed per agency policy.