Every finding on record at Community Hospice Care LLC

Upon patient record review, 1 of 5 (Patient #1) 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 #1: Patient admitted 10/09/25. There is no evidence of a medication profile in the record.

Upon patient record review, 3 of 5 (Patients #1, 2, 4) 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 #1: There is no evidence in the record of an initial bereavement assessment being completed. Patient #2: There is no evidence in the record of an initial bereavement assessment being completed. Patient #4: There is no evidence in the record of an initial bereavement assessment being completed.

Upon patient record review, 1 of 5 (Patients #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #2: The Plan of care was not updated during the IDG on 09/30/25 as evidenced by the IDG note is blank. There are no updates or entries aside from signatures. The Plan of care update/IDG note from 10/14/25 is not completed by the nurse. The only portions completed are by the MSW and SC. The frequency orders are also incomplete.

Upon patient record review, 4 of 5 (Patients #2, 3, 4, 5) 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: The aide assignment does not include frequencies for Assist with dressing, check pressure areas, personal care, hair care, skin care, oral care, equipment care, universal precautions, and handwashing before and after tasks. Patient #3: The aide assignment does not include frequencies for tasks including mobility assist or check pressure areas. Patient #4: The aide assignment does not include frequencies for tasks including light housekeeping, wash clothes (put in laundry basket in hall), shower, personal care, assist with dressing, hair care, skin care, check pressure areas, shave, groom, deodorant, nail care, elimination, or oral care. Patient #5: The aide assignment does not include frequencies for mobility assist, nail care, oral care, shave/groom/deodorant, skin care, hair care, assist with dressing, personal care, or shower. Th frequency for elimination is listed as PRN. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 14 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24. Patient 5: The SOC comprehensive assessment completed on 8/19/25 is not signed or dated. The SN did complete pain, resp, skin and cardiovascular assessments but no evidence of GU, psych-social, meds, activities, equip, orders for disciplines and frequencies, goals/outcomes for neuro, mobility, ADLs, fall prevention completed at SOC. COS with completion of comprehensive assessment by RN.

Upon patient record review 1 of 14 (Patient # 10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 10: There is evidence of a MSW visit on 8/28/25, the SOC was 08/22/25 with no evidence the comprehensive assessment was completed within 5 days. No evidence of psychosocial assessment completed by RN.

Upon patient record review and home visits, 4 of 14 (Patient # 1,3,6 and 7) 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: Patient 1: The assisted living facility medication list contains orders for Antifungal powder, Calmoseptine ointment, and Imodium tabs that were not on agency medication list. COS with medication reconciliation and discontinuing facility medications. Patient 3: The assisted living facility medication list contains orders for Imodium, Artificial tears, Haldol, and Ammonium lactate lotion 12% not present on agency medication list. The agency medication list contains an order for Miralax without diluent instructions. COS with medication reconciliation and discontinuing facility medications. Patient 6: The medication list contains an order for Calmoseptine 15.7% topical ointment with no specifics directions on where to apply, how often and what dose. COS with updated medication orders. Patient 7: The medication list contains an order for transdermal Lidocaine patch with no directions for where to apply daily prn, COS with order being discontinued since patient is no longer to self report pain and verbalize where to apply patch and other analgesic interventions in place.

Upon patient record review, 3 of 14 (Patient #2,3,7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: RN visit frequency is scheduled on initial POC 6/13/25 once weekly with no indication of SN visits completed between 8/9/25 and 9/3/25. Patient 3: SN visit frequency is scheduled on initial POC 7/15/25 twice weekly with no evidence of SN visits after last documented SN visit on 7/29/25. Patient 7: RN visit frequency is scheduled on initial POC 6/12/25 once weekly with no SN visits documentation following the visit made on 7/29/25 with SN documenting “patient sustained witnessed fall from standing position in memory care unit."

Upon patient record review, 4 of 14 (Patient # 1, 3, 6 and 7) 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 1: The assisted living facility medication list contains orders for Antifungal powder, Calmoseptine ointment, and Imodium tabs that were not on agency updated Plan of Care 8/19/25. COS with medication reconciliation and discontinuing facility medications and POC updated. Patient 3: The assisted living facility medication list contains orders for Imodium, Artificial tears, Haldol, and Ammonium lactate lotion 12% and heel protectors not present on agency updated POC 8/19/25. The agency POC contains an order for Miralax without diluent instructions. COS with medication reconciliation and discontinuing facility medications and POC updated. Patient 6: The updated POC 8/19/25 contains an order for Calmoseptine 15.7% topical ointment with no specifics directions on where to apply, how often and what dose. COS with medication reconciliation and POC updated. Patient 7: The updated POC on 8/19/25 contains an order for transdermal Lidocaine patch with no directions for where to apply daily prn on 12 hours. COS with medication reconciliation and POC updated.

Upon patient record review, 4 of 14 (Patient # 2,3,5 and 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: RN visit frequency is scheduled on initial POC 6/13/25 once weekly with no indication of SN visits completed between 8/9/25 and 9/3/25. Patient 3: SN visit frequency is scheduled on initial POC 7/15/25 twice weekly with no evidence of SN visits after last documented SN visit on 7/29/25. Patient 5: RN visit on 8/27/25 remain blank with no indication of visit made. No evidence of SN visits completed after SOC on 8/22/25. Patient 7: RN visit frequency is scheduled on initial POC 6/12/25 once weekly with no SN visits documentation following the visit made on 7/29/25 with SN documenting “patient sustained witnessed fall from standing position in memory care unit."

Upon patient record review and home visit 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #2: The patient verbalizes frustration in not being kept informed of "when SN and Aide visits will occur" and expresses dissatisfaction with the timeliness of obtaining a specialty wheelchair from hospice and her ability to participate in the process of selecting a different wheelchair.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: Patient 14: There is not evidence of bereavement plan of care or evidence of follow-up phone calls, notes or support offered to bereaved family member following patient's death and the following 13 months.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel 6: The aide does not have evidence of skills competency assessment completion by RN. The aide competency observation checklist is dated and signed off in the top task box only on page 1, the tasks on page 1 such as bathing, shower, and shampoo are left blank. On page 2 it is signed and dated with a line drawn through all tasks by RN. Corrected on site with RN signing and dating each task during Day 3 of survey following personnel review and surveyor education of requirement of RN to observe each aide task.

Upon observation, there was no evidence the Home Health Aide competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate. Upon observation and verbal discussion with DCPS, it is observed that aide is being trained on position tasks by another aide.

Upon personnel record review, 1 of 13 (Personnel # 3) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel 3: Upon personnel record review, DCPS does not have evidence of prior hospice and home care experience. DCPS states "I have been a director of facilities but have never worked in home care prior to this position.

Upon patient record review, 8 of 14 (Patient #1,3,5,6,7,8,9 and 10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The Aide POC 8/25/25 contains task options for bathing including both tub and shower with no specific instructions for aide. COS with updated Aide POC Patient 3: The Aide POC 7/15/25 contains tasks for options for bathing including either tub or shower with no directions for how often or what type of bathing. COS with updated Aide POC. Patient 5: The Aide POC 8/19/25 contains tasks for options of bathing including either tub or shower with no specific instructions for aide for bathing type or how often. COS with updated Aide POC. Patient 6: The Aide POC for cert period 6/21/25-8/19/25 contains tasks as needed for nail hygiene, elimination assistance and inspect dressing to right foot. Reinforce as needed. Turn/reposition every 2 hours and as needed as tolerated. Beginning 8/19/25 there is no updated Aide POC for new cert period. Patient does not have mental capacity to decide prn tasks. Inspection and reinforcing dressing is unclear if within the scope of the Aide to be able to perform. Patient 7: The Aide POC 06/12/25 contains tasks as needed for elimination assistance PRN, ambulation assist with wheelchair, walker, cane PRN wash clothes prn, light housekeeping tasks PRN. Patient does not have mental capacity to decide prn tasks. Patient 8: The Aide POC 7/31/25 contains tasks for options of bathing including tub or shower with no specific instructions for aide. COS with updates to aide POC. Patient 9: The Aide POC 7/29/25 contains tasks for options of bathing including tub or shower and prn elimination assist task. COS with updates to aide POC. Patient 10: The Aide POC 8/22/25 contains tasks for options of bathing including tub or shower with no specific instructions for aide for bathing type or frequency. COS with updates to aide POC.

Upon patient record review 6 of 14 (Patient # 2, 3, 4, 5, 6 and 8) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The Aide POC contains orders to shower weekly indicated on POC. Nurse aide documents on 6/20/25 a bath completed with no indication of the type of bathing completed. 6/20/25 an additional note indicates bed bath given. Patient 3: Aide visits scheduled on 8/22, 8/27, 8/29 and 9/2/25 with no aide visit documentation completed. Agency reports "She is a newly hired aide still learning the documentation." Patient 4: Aide visits scheduled on 8/22, 8/25, 8/28/25 with no aide documentation completed. Patient 5: Aide visits scheduled on 8/22, 8/25, and 8/28/25 with no aide documentation completed. Patient 6: Aide visits scheduled on 7/25, 7/31, and 8/15/25 with no aide documentation completed. On Aide visit note 8/29/25, the aide documents last BM 7/3/25, no indication if RN was to be notified. Patient 8: Aide visit scheduled on 8/25 with no aide documentation completed.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The hospice agency demonstrates non-compliance with regulatory requirements related to administrative oversight, staffing, and documentation. There is no evidence of W-2 forms verifying that the Administrator or Alternate Administrator are employed by the hospice. The administrator verbally stated that they took over operations of the hospice after convincing their brother not to sell it when he returned to their home country. The Alternate Administrator is no longer involved, and the last Governing Body meeting occurred in December 2024, indicating a lack of active governance and oversight. Staffing transitions have occurred without ensuring qualifications: a new Director of Patient Care Services (DCPS) and Alternate DCPS were hired in May and August 2025 without hospice or home care experience, not meeting requirements for qualified and experienced nursing leadership. Additionally, a hospice aide was hired without a completed application or fully completed competency assessment. The organizational chart was only updated during the survey, showing a lack of ongoing administrative maintenance. There is further evidence of operational deficiencies, including nursing and aide visit notes not being completed timely, with some patient care documentation delayed by over a month. These findings collectively reflect inadequate oversight by the Governing Body, noncompliance with staff qualifications and documentation standards.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient 12: No evidence of discharge summary including details of all the items sent and report to facility and who report was given to.