Every finding on record at Community Home Care & Hospice

Upon patient record review, 2 of 27 (Patient #4,14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 4: During home visit medication reconciliation with the pt's caregiver, hospice medication profiles did not match what was being given in the home. The hospice profile contained orders for Mucinex 2 times daily, Spiriva 1 puff daily, Symbicort 2 puffs twice daily, and Zyrtec daily. The caregiver reported that the patient does not take those medications on a daily basis, they are being given PRN daily. Patient 14: RN documentation indicated that the patient uses oxygen at 2LNC as needed. No evidence that an order was received for oxygen at 2L via NC PRN. No evidence of a titration order with parameters for titration. The current oxygen order on the medication profile is for 4L via NC as needed.

Upon patient record review, 1 of 27 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 03/26/2026. The bereavement risk assessment was completed on 04/01/2026.

Upon patient record review, 3 of 27 (Patient #1, 12,17) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: The medical record indicated that the agency preformed a UA on the patient for suspected UTI on 04/07/2026. No evidence that the RN completed a follow up or that those results were uploaded to the chart at the time that the chart was surveyed. Patient 12: MSW documentation on 04/02/2026 indicated that the caregiver informed her that the patient was more agitated at night and has hit the caregiver twice. The caregiver inquired about a way to give medications when the patient is agitated. The MSW documented that she told the RNCM on 04/02/2026. There was no indication that a follow up was completed by the RN. Patient 17: MSW documentation on 03/30/2026 indicated that the patient had complaints of new onset dizziness and trouble reading. The MSW documented that she told the RNCM on 03/30/2026. There was no indication that a follow up was completed by the RN.

Upon patient record review, 2 of 27 (Patient 11,12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. of care. Patient 11: The medical record contained nursing documentation upon admission identifying patient as having altered mobility. There was no evidence of problems, goals, and interventions related to altered mobility included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient as having altered mobility. There was no evidence of problems, goals, and interventions related to altered mobility included in the plan of care.

Upon patient record review, 4 of 27(Patient #4,5,8,14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: During home visit medication reconciliation with the pt's caregiver, hospice medication profiles did not match what was being given in the home. The hospice profile contained orders for Mucinex 2 times daily, Spiriva 1 puff daily, Symbicort 2 puffs twice daily, and Zyrtec daily. The caregiver reported that the patient does not take those medications on a daily bases, they are being given PRN daily. No evidence that an order was received to change the frequency of those medications. Patient 5: RN documentation that the patient had an indwelling 16fr foley catheter. No evidence that an order was received for placement of the 16fr foley catheter. The current order is for 14fr foley catheter. Patient 8: RN documentation indicated that the patient has a suprapubic cath. No evidence that an order was received that included the catheter size, change frequency, or maintenance instructions. Patient 14: RN documentation indicated that the patient uses oxygen at 2LNC as needed. No evidence that an order was received for oxygen at 2L via NC. The current oxygen order is for 4L via NC as needed.

Upon patient record review, 1 of 27 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 7: The medical record indicated that both the RN and the MSW identified a need to assist with applying for assistance and SNF placement. No evidence that the plan of care was updated to include the problem, goals, and interventions related to applying for assistance or SNF placement.

Upon client record review, 3 of 27 (Patient #6,17,20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: Plan of care has SN visits ordered as 3 times weekly. No evidence that the patient received 3 visits for the week of 02/01/2026. No evidence that the visit was missed at the request of the patient or the caregiver. No evidence that a physician order was received to decrease the visit frequency for the week. Patient 17: Plan of care has SN visits ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 02/08/2026. No evidence that the visit was missed at the request of the patient or the caregiver. No evidence that a physician order was received to decrease the visit frequency for the week. Patient 20: Plan of care has SN visits ordered as 4 times for the week of 3/08/26. No evidence that the patient received 4 visits for the week of 03/08/2026. No evidence that the visit was missed at the request of the patient or the caregiver. No evidence that a physician order was received to decrease the visit frequency for the week.

Upon observation 1 of 6 home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #6: During the home visit, the hospice aide placed her electronic tablet onto the counter in the patient's room without a barrier of any sort.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. Patient 12: Medical record indicated that the patient was diagnosed with a UTI in March 29th 2026. No evidence that a surveillance report was completed at the time of survey.

Upon patient record review, 1 of 27(Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: Aide plan of care task included both bed bath and a shower, both ordered to given at every visit.

Upon patient record review 4 of 27 (Patient #4,6,19,20) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4: The plan of care had aide frequency ordered as twice a week. No evidence that 2 visits were completed for the week of 04/12/26. Only one visit documented, that visit occurred on 04/16/26. Patient 6: The aide plan of care has weekly linen changes, nail care, and hair shampooing. The medical record indicated that the aide performed nail care at every visit. For the week of 3/29 and 4/13 linen changes/ hair shampoos were completed at every visit. Patient 19: The aide plan of care has weekly linen changes. The medical record indicated that aide completed linen changes at every visit starting at 04/01/2026. Patient 20: The plan of care had aide frequency ordered as once for the week of 03/06/2026 and twice for the week 03/08/2026. No evidence that a visit was completed for the week of 03/06/26, nor did 2 visits occur for the week of 3/08/3026. Only one visit documented for the week of 03/08/2026, that visit occurred on 03/09/26.

Upon patient client record review, 1 of 27 (Patient #15) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 15: Patient choice an attending at the time of admit, 3/17/2026. The admitting nurse obtained verbal certification at that time. No evidence that the attending physician signed the CTI at the time that the chart was surveyed. Gentiva policy is all orders must be signed and within the chart within 30 days

Upon client record review, 1 of 27 (Patient #22) did not have evidence that the discharge summary includes all required information. Patient 22: No evidence that a discharge summary was completed at the time that the patient was discharged.

Based on agency policy, clinical record review, and staff interviews the agency failed to include a Do Not Resuscitate order in the hospice plan of care for 1 of 1 patient with a change in code status. (patient #2) Findings included: --- A policy, The Plan of Care (revised 08/30/23) received on 09/03/24 at approximately 2:50 PM from the agency area director of clinical operations stated, ";The written plan of care will contain, but not limited to, the following: ... End-of-life preferences." Patient #2 was admitted for routine home care on 08/01/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow). Review of the clinical record revealed that on 08/13/24 patient #2 was transported to an emergency room and admitted for hospice general inpatient care. On 08/14/2024 hospice registered nurse #3 stated, ";New order, DNR [Do Not Resuscitate]..." There was no evidence in the hospice plan of care of a DNR order. An interview with the area director of clinical operations on 09/03/24 at approximately 2:30 PM revealed that the expectation is for the hospice plan of care to be updated with a change in code status.

Based on agency policy, clinical record review, and staff interviews the agency failed to notify a patients family/power of attorney of a planned discharge for 1 of 3 patients with a planned discharge and a decline in mental status. (Patient #2) Finding included: --- A policy LIVE DISCHARGE AND DISCHARGE PLANNING PROCESS (revised 01/22/2024) was received on 06/03/2024 at approximately 12:00 P.M. from the agency director. The policy stated, ";As soon as the IGD [interdisciplinary group] determines the patient will be discharged because his/her condition has plateaued organization personnel will: ... Consult with the patient and family/caregiver regarding the need for discharge." Patient #2 was admitted on 01/25/2022 with a diagnosis of hypertensive chronic kidney disease (high blood pressure causing damage to the kidneys). The plan of care (POC) for 03/15/2024-05/13/2024 included orders for skilled nurse (SN) visits 2 times a week for 9 weeks and 4 PRN (as needed). The POC for 05/14/2024-07/12/2024 included orders for SN visits 2 times a week for 9 weeks, 3 PRN, and effective 05/07/2024 SN TO INITIATE DISCHARGE PLANNING. For the following SN visits the SNs stated: On 03/18/2024 the registered nurse case manager (RNCM) #3 stated, ";Periods of confusion... cognitive impairment." On 03/21/2024 the licensed practical nurse (LPN) #7 stated, ";Periods of confusion... has cognitive deficits." On 03/26/2024 RNCM #3 stated, ";forgetful...cognitive impairment." On 03/27/2024 LPN #7 stated, ";periods of confusion...forgetful...has cognitive impairment." On 04/01/2024 RNCM #3 stated, ";periods of confusion... cog [cognitive] impairment." On 04/03/2024 RNCM #3 stated, ";forgetful...cognitive impairment." On 04/16/2024 RNCM stated, ";disorganized thinking...cognitive impairment." On 04/23/2024 RNCM #3 stated, ";Abnormal new learning ability...inability to recall recent events... periods of confusion... cognitive impairment." On 04/25/2024 RNCM #3 stated, ";forgetful... periods of confusion... cognitive impairment." On 04/29/2024 RNCM #3 stated, ";disorganized thinking...forgetful... cognitive impairment." On 05/01/2024 RNCM #3 stated, ";Explained that he [patient #2] did not meet the criteria to stay on hospice...periods of confusion." On 05/06/2024 RNCM #3 stated, ";forgetful... cognitive impairment." On 05/09/2024 LPN #7 stated, ";has cognitive deficits... Patient aware of discharge from hospice next week." For the discharge visit of 05/25/2024 RNCM #3 stated, ";cognitive impairment." There was no evidence in the clinical record of patient #2s family/power of attorney being notified of the discharge. An interview was conducted on 05/30/2024 with patient #2s son/power of attorney. The patients son stated, ";He was informed of the discharge by the assisted living facility on the day of discharge." An interview was conducted on 06/03/20/24 at approximately 12:45 P.M. with RNCM #3. RNCM #3 stated, ";I did not [notify the patients son of the discharge], the facility said they did. If the patient is not alert and oriented, I would notify the family. Why would I call him [patients son] I never had any contact with him? I was never told that we had a power of attorney. Yes, I would tell the family of a pending discharge if they were cognitively impaired" An interview with the agency director on 06/03/2024 at approximately 12:50 P.M. revealed that the nurses have access to the power of attorney documents and the family should be included in the plan of care.

Based on policy review, clinical record review, and staff interviews the agency failed to perform a catheter change as ordered and failed to include orders for flushes in the plan of care (POC) for 1 of 1 patient with a suprapubic catheter (flexible tube inserted through the abdominal wall in the bladder to drain urine) (#3) Findings included: --- A policy, The Plan of Care (revised 08/30/23) was received on 09/05/23 from the agency director at approximately 2:45 P.M. The policy stated, ";The care provided must be in accordance with the plan of care... The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatments..." Patient #3 was admitted on 06/29/12 with diagnoses of paralytic syndrome (acceding weakness) following a cerebral infarction (stroke) and flaccid neuropathic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem.) The POC for 06/29/23-09/26/23 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 6 PRN (as needed) visits and SN to change suprapubic catheter 18 French; with 30 mL balloon Q month (1 time a month) and PRN. There was no evidence in the clinical record of the catheter being changed. For the RN visit of 07/22/23 RN #4 stated, ";Foley catheter flushed..." There was no evidence on the plan of care of suprapubic catheter flushes. An interview was conducted with the regional director of clinical operation (RDCO) on 09/05/23 at approximately 3:00 P.M. The RDCO stated, ";The catheter should have been changed on or around 07/28/23 and an order for flushes should be included in the plan of care."

Based on policy review, clinical record review, and staff interviews the agency failed to obtain wound measurements for 1 of 1 patient with a wound. (#1) Findings included: --- A policy, Wound Assessment, Documentation, and Clinical Oversight (revised 05/11/23) was received on 09/05/23 at approximately 4:00 P.M. from the agency director. The policy stated, ";The RN [registered nurse] will perform wound assessments as ordered by the physician but no less than once weekly." Patient #1 was admitted on 10/05/22 with diagnoses of chronic kidney disease, stage 4 and unspecified dementia. The plan of care for 08/01/23-09/29/23 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 PRN (as needed) and an order to clean stage 2 sacral wound. There was no evidence of wound measurements for the weeks of 08/13/23 or 08/20/23. An interview was conducted on 09/05/23 at approximately 3:30 P.M. with RN #5. RN #5 stated, ";I dont know why I didnt measure [the wound]." An interview was conducted with the regional director of clinical operations (RDCO) on 09/05/23 at approximately 3:40 P.M. The RDCO stated, ";Wounds should be measure weekly." An interview was conducted with the agency director on 09/04/23 at approximately 3:45 P.M. The agency director stated, ";If its [wound] not measured on Monday [the first visit of the week] it [measurements] should be done at the next visit."

Based on agency policy, clinical record review, and staff interviews the agency failed to perform hospice aide supervisory visits every 14 days for 1 of 3 patients with order for hospice aide services. (#2) Findings included: --- A policy, Responsibilities/Supervision of Clinical Services (revised 10/28/22) was received from the agency director on 09/05/23 at approximately 3:20 P.M. The policy stated, ";Hospice aide supervisory visits will be conducted on site at least every 14 days by a hospice registered nurse." Patient # 2 was admitted on 12/14/21 with a diagnosis of Alzheimers Disease. The plan of care for 06/08/23-08/06/23 included orders for skilled nurse visits 2 times a week for 9 weeks and 4 PRN (as needed) and hospice aide visits 5 times a week for 8 weeks, 4 times a week for 1 week. There was no evidence of hospice aide supervisory visits being conducted from 06/08/23 thru 07/19/23. An interview was conducted with the regional director of clinical operation (RDCO) on 09/05/23 at approximately 3:45 P.M. The RDCO stated that the nurse should conduct a hospice aide supervisory visit at least every 14 days.

Based on clinical record review and staff interviews the agency failed to include the correct size of a suprapubic catheter (flexible tube inserted through the abdominal wall in the bladder to drain urine) and failed to include the correct volume of balloon inflation in the clinical record for 1 of 1 patient with a suprapubic catheter. (#3) Findings included: --- Patient #3 was admitted on 06/29/12 with diagnoses of paralytic syndrome (acceding weakness) following a cerebral infarction (stroke) and flaccid neuropathic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem.) The POC for 06/29/23-09/26/23 included orders for skilled nurse (SN) visits 2 times a week for 13 weeks and 6 PRN (as needed) visits and SN to change suprapubic catheter 18 French; with 30 mL balloon Q month (1 time a month) and PRN. For the skilled nurse (SN) visit of 07/01/23 RN #4 stated, ";24 FR [French] with 30cc balloon. For the SN visit of 07/10/23 RN #4 stated, ";18 [French] with 5cc balloon. For the SN visit of 07/24/23 RN #4 stated, ";16 FR [French] with 30cc balloon. An interview was conducted with the regional director of clinical operation (RDCO) on 09/05/23 at approximately 3:45 P.M. The RDCO stated that the catheter size and volume of balloon inflation should be documented accurately or documented as not assessed.

Upon patient record review, 1 of 23 (Patient #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #8-On 03/25/23 the nurse documented the caregiver was administering prn medication for constipation. The medication profile does not include medication for constipation. On 04/10/23 the nurse documented the patient was on Oxygen. Oxygen is not listed on the medication profile (corrected on site).

Upon patient record review, 1 of 23 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component within 5 days which includes 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. Patient #4- The patient was admitted 03/06/23 and a bereavement risk assessment is not on record until 04/14/23.

Upon patient record review, 1 of 23 (Patient #9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #9- On 04/11/23 the record documents the patient sustained a fall requiring ER observation/evaluation. The record does not contain goals/interventions for fall prevention/safety following the incidence. (corrected on site)

Upon patient record review, 4 of 23 (Patient #3, #5, #8, #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3- On 03/26/23 the nurse documents receiving an order for a urinalysis. The plan of care was not updated with orders for the urinalysis. (corrected on site). Patient #5- The 03/28/23 Plan of care includes orders that the nurse will assess the patients catheter for signs and symptoms of infection and patency. The plan of care does not address the catheter type/size and management. (corrected on site) Patient #8-On 03/25/23 the nurse documented the caregiver was administering a prn medication for constipation. The plan of care was not updated to include a prn medication for constipation. On 04/10/23 the nurse documented the patient was on Oxygen. Oxygen is not listed on the plan of care. (corrected on site) Patient #10-The record contains an order to update the plan of care on 04/06/23 which reads Cath Change. The order is not specific for the type/size/frequency of changes for the catheter. (corrected on site)

Upon patient record review, 2 of 23 (Patient #1, #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-On 3/10/23 orders were for the Social Worker to visit the patient once monthly for 1 month(1m1). The Social Worker visited the patient for routine visits 3/14/23 and 3/28/23 (twice monthly). Effective 03/10/23 orders were for the Chaplain to visit once monthly for 1 month(1m1). The Chaplain made visits on 03/13/23 and 03/31/23(twice monthly). (orders corrected on site) Patient #6- On 02/28/23 the Social Worker was ordered to visit 1q2m2 (once monthly every 2 months for 2 months). The patient was visited for routine visits 02/27/23, 03/14/23 and 04/11/23 (monthly). (orders corrected on site)

Upon patient record review, 2 of 23 (Patient #19 and 20) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #19-The Bereavement Plan of Care documents the bereaved were to receive a 3 month letter around 02/12/23. There is no documentation on record that the mailings were sent. (late entry correction on site) Patient #20- The Bereavement Plan of Care documents the patient was to receive a 3 month letter around 02/13/23. On 03/21/23 the record documents "Voided" and does not evidence the mailing was sent according to the plan of care.

Upon patient record review, 4 of 23 (Patient #2, #5, #10, #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of the hospice aide as specified under paragraph (h) of 418.76 Patient #2-The Aide care plan does not include bleeding precautions. The patient takes Aspirin daily. The patient is identified as a fall risk and fall precautions are not listed on the Aide care plan. The patient also has an ostomy which is not addressed on the Aide care plan. (corrected on site) Patient #5- The Aide care plan does not include bleeding precautions. This is pertinent as the patient is on Eliquis. (corrected on site) Patient #10- The Aide Care plan does not include bleeding precautions which is applicable as the patient is on Aspirin. (corrected on site) Patient #11- The Aide care plan does not include Oxygen precautions, fall precautions and skin breakdown precautions which are identified safety needs. (corrected on site)

Upon patient record review 2 of 23 (Patient #14, #17) did not have evidence documentation in the patient record that a hospice aide provides services that in accordance with the plan of care. Patient #14- The Aide was ordered to visit the patient five times weekly. The week of 04/14/23-04/22/23 the Aide visited four times. There is no documentation on record for the missed visit. (late entry correction on site) Patient #17- Effective 03/19/23 the Aide was ordered to visit the patient three times weekly. The week of 03/19/23-03/24/23 two visits were made. There is no documentation on record regarding the missed visit. (late entry correction on site)

Upon client record review, 1 of 23 (Patient #23) did not have evidence that the discharge summary includes all required information. Patient #23- The patient revoked the Hospice election 01/17/23. The Discharge summary only documents the patient revoked the election to receive more aggressive treatment. The Discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management