Every finding on record at Cherish Hospice LLC

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, and other alternative treatments that could affect drug therapy. 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. 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, interview, and observation. In 4 of 19 (21%) clinical records reviewed and home visit observations, it was revealed that the agency did not ensure that the documented comprehensive assessment included a drug profile that contained the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and impact the medication review process. CLINICAL RECORD 1/Home Visit 1: A home visit was conducted on 01/15/2025 to observe the Registered Nurse (RN) (Personnel Record 1). The patient resided in a Nursing Facility and had a terminal diagnosis of Chronic and Acute Respiratory. A review of the facility orders revealed oxygen was ordered at 2 LPM as needed and may be titrated as needed. The current hospice drug profile included an order for continuous oxygen 2-4 LPM. CLINICAL RECORD 2/Home Visit 2: A home visit was conducted on 01/15/2025 to observe the Registered Nurse (RN) (Personnel Record 2). A review and comparison of the facility medication profile and the hospice medication profile revealed the following: facility medication profile included Diltiazem CD 180mg, while the hospice profile had 120mg (effective 11/02/2024); facility listed Bisacodyl 5mg daily as needed (effective 10/21/2024), hospice listed four times daily as needed; facility listed Omeprazole 40mg daily as needed (effective 01/07/2025), hospice listed 40 mg daily. The hospice list included the following medications: ascorbic acid 500mg two tabs daily, atorvastatin 80mg daily, omega-3 acid ethyl esters 1000mg two capsules daily, Vitamin D3 1000 units daily, and Vitamin B12 500 mg two tablets daily; these medications were not on the facility medication list thus the patient was not receiving them. The facility medication list included Losartan 25 mg tabs (take one half of a tablet, 12.5mg) twice daily (effective 09/26/2024) the hospice drug profile did not include this medication. CLINICAL RECORD 3/Home Visit 3: A home visit was conducted on 01/15/2025 to observe the Medical Social Worker (MSW) (Personnel Record 3). A review and comparison of the facility medication profile and the hospice drug profile for the certification period of 12/27/2024 to 02/24/2025 revealed the following: Bisacodyl 10 mg rectal suppository as needed, and Furosemide 20 mg daily were included on the hospice drug profile but were not active medications in the facility. The facility medication profile included Donepezil 10mg PO (oral) at bedtime (effective 05/20/2024) and Myrbetriq 25 mg po daily (effective 05/20/2024); these medications were not included on the hospice drug profile. CLINICAL RECORD 4/ Home Visit 4: A home visit was conducted on 01/16/2025 to observe the Chaplain (Personnel Record 4). A review of the home medications revealed that the patient takes Tums, one tablet daily as a calcium replacement and per the patient’s daughter he has been taking one Tum daily for more than a year. The patient also had a medication bottle for escitalopram 10mg, dated 10/11/2024; the drug profile included escitalopram 5 mg. In an interview with the patient's daughter, the daughter stated the medication had been increased from 5mg to 10mg before the patient was admitted to hospice on 10/31/2024. In an interview with the Administrator, Director of Clinical Services (DCS), and Alternate DCS on 01/15/2024, the DCS and Alternate DCS agreed the medications were not reconciled.

It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, it was revealed that the agency did not ensure that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 5: The patient was admitted on 08/08/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and oxygen-dependent at 3 lpm (liters per minute). The comprehensive assessment dated 08/08/2024 identified the patient as a moderate fall risk (8/10) and, dependent on a walker for ambulation. The patient had two falls on 09/20/2024 and 09/21/2024. The patient had Type Two Diabetes Mellitus and medications included Glycogen 1mg injection administered for blood sugars less than 50mg/dl and Glucose chews 4mg take one-half tablets for blood sugars below 70mg/dl. Pain was identified as an active problem for the patient on the comprehensive assessment (08/08/2024) and was being treated with Tramadol. The Plan of Care (POC) for the certification period 08/08/2024 to 11/05/2024 did not include measurable outcomes for the fall risk interventions, diabetic management, or pain. CLINICAL RECORD 6: The patient was admitted to hospice on 12/16/2024 with a diagnosis of breast cancer. The patient was an insulin-dependent diabetic and received Lantus insulin 100 units per ml, 31 units at bedtime, and Humalog Insulin 100 units per ml, 10 units before meals. The patient had a diagnosis of depression and was being treated with Sertraline 50mg PO daily. The Plan of Care for the certification period 12/16/2024 to 03/16/2025 did not include measurable outcomes for diabetic management or depression. CLINICAL RECORD 9: The comprehensive assessment dated 12/20/2024 identified that the patient is a high risk for falls with a risk assessment of 10/10+. The patient was incontinent of bowel and bladder, had limited mobility, and had a poor appetite with a diagnosis of Protein Calorie Malnutrition. The Plan of Care for the certification period of 12/20/2024 to 03/19/2025 did not include measurable outcomes for the fall interventions or skin breakdown precautions. CLINICAL RECORD 11: The comprehensive assessment dated 04/08/2024 identified the patient as a high fall risk with a score of 13 on a scale of 0 to 10+. The patient was also noted to be at risk for skin breakdown as evidenced by incontinence of bowel and bladder habits, poor appetite, and spent most of her time in bed except to get up to smoke via wheelchair and required assistance with all activities of daily living. The Plan of Care for the certification period 09/05/2024 to 11/03/2024 did not include measurable outcomes for the fall interventions or skin breakdown prevention interventions under the safety precautions. CLINICAL RECORD 13: The comprehensive assessment dated 08/16/2024 identified the patient as a Diabetic. The Plan of Care for the certification period 08/16/2024 to 11/13/2024 did not include measurable outcomes for diabetic management. CLINICAL RECORD 14: The patient was admitted on 12/02/2024 with a diagnosis of COPD, Aspiration Pneumonia, Schizophrenia, Depressive Disorder, and bipolar disorder. The Plan of Care (POC) for the certification period 12/02/2024 to 03/01/2025 did not include measurable outcomes for respiratory or mental status. In an interview on 01/15/2025 with the Director of Clinical Services (DCS) and the Administrator, the DCS stated that they had identified this and were working on the plans of care.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home observations, it was revealed that the agency did not ensure that each patient’s individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient. CLINICAL RECORD 2/ Home Visit 2: During the home visit on 01/15/2025, which was conducted with the Registered Nurse (RN) (Personnel Record 2), the patient was observed with a CPAP (continuous positive airway pressure) machine in their room. The comprehensive assessment dated 09/10/2024 included the CPAP. The Plans of Care (POC) effective from 09/10/2024 to current, did not include the CPAP machine. The patient had an order for ACE elastic bandages 4-inch Velcro to bilateral lower extremities, applied from toes to knees in the am and removed in the pm. The ACE elastic bandages were not included in the POC. CLINICAL RECORD 3/Home Visit 3: On 01/15/2025, a home visit was conducted to observe the Medical Social Worker (MSW) (Personnel Record 3). A pink walker was present in the room. The patient was observed getting up from a chair and used the walker to ambulate when placed in front of her. The patient and spouse shared an apartment in an Assisted Living Facility; however, the spouse did not utilize a walker. The walker was not included in the Plan of Care (POC) for the certification period 12/27/2024 to 02/24/2025. In an interview on 01/15/2025 with the Director of Clinical Services (DCS) and the Administrator, the DCS stated that they had identified this and were working on the plans of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 2 of 4 (50%) of home observations revealed that the agency did not ensure that the hospice followed accepted standards of practice to prevent the transmission of infections and communicable disease that included the use of standard precautions, such as hand hygiene and other requirements of applicable state and federal law and regulation. Agency policy #PC.I10, Infection Control- Hand Hygiene and Bag Technique (Reviewed 08/2023), stated in part, "When carrying bag into the home it is to be kept on the shoulder until a waterproof disposable barrier can be placed on a table or hard chair and placed on the clean side of the barrier. Employees must cleanse hands before entering/removing supplies from bag, before examination, and after patient care. If additional supplies are needed during the visit, hands are to be cleansed before re-entering the bag.” Home Visit 1: A home visit was conducted on 01/15/2025 to observe the Registered Nurse (RN) (Personnel Record 1). The patient resided in a Nursing Facility and had a terminal diagnosis of Chronic and Acute Respiratory Failure. The patient had orders for wound care to the right hip for a pressure ulcer. The cleanser used to clean the wound was taken from the facility treatment cart and did not include a patient name or other identifier. The wound cleanser was returned to the treatment cart following the wound care. After the RN cleaned the reusable equipment, hands were not cleansed/sanitized before returning the clean equipment to the bag. Home Visit 2: A home visit was conducted on 01/15/2025 to observe the Registered Nurse (RN) (Personnel Record 2). After the RN cleaned the reusable equipment, hands were not cleansed/sanitized before returning the clean equipment to the bag. In an interview on 01/15/2025 with the Director of Clinical Services (DCS) and the Assistant DCS, both agreed that the hands should have been sanitized prior to re-entering the nursing bag and that the wound cleanser for Home Visit 1 treatment should have included the patient's identifier to only be used for that individual patient.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. In review of the volunteer cost savings report, the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The volunteer cost savings report revealed that for the calendar year 2024 the annual volunteer cost savings was 0.96%. The Administrator tracked the volunteer hours and stated in an interview, on 01/16/2025, that he was aware that the agency was not meeting the required 5% and that they have plans in place to meet the requirement. The volunteer cost savings report revealed that for the year 2024 and the months of January to December (full 12 months) the annual volunteer cost savings was 0.96%.

t 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 clinical record review and interview. In 2 of 2 (100%) clinical record reviewed, with live discharges, it was revealed that the hospice did not ensure that the patient’s attending physician was provided a copy of the hospice discharge summary and the patient's record, if requested. Clinical Record 18: The patient was admitted to hospice services, under general inpatient care, on 04/12/2024 and revoked services on 04/17/2024. There was no documented evidence that the discharge summary was sent to the attending physician. Clinical Record 19: The patient was admitted to hospice services on 09/24/2024 and was discharged on 12/21/2024 for a lack of decline. There was no evidence that the discharge summary was sent to the attending physician. In an interview with the Director of Clinical Services (DCS) on 01/17/2025, the DCS stated that the discharge summaries had not been sent.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, the hospice election statement. This standard was not met as evidenced by clinical records and interview. 8 of 9 (90%) applicable records for patients electing Hospice services since 1/5/2022 reviewed revealed the hospice failed to ensure the election statement provided to the patient including the required content in accordance with 42 CFR 418.24, “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #83008: Start of Care (SOC) dated 2/15/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #83330: SOC dated 2/9/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #32361: SOC dated 1/18/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #20607: SOC dated 2/23/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #32750: SOC dated 2/1/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #86907: SOC dated 1/20/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #21598: SOC dated 2/25/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. Record #74685: SOC dated 2/22/2022 showed no evidence that the election statement included the requested “Patient Notification of Hospice Non-Coverage Items, Services, Drugs” Form. In discussion with the DCS, it was found that the agency does not have a process that includes follow-up documentation when the form is provided to the patient and family.