Every finding on record at Community Hospice, Inc.

Observed in Record Review. In 10 of 14 active patient records reviewed, it was noted the organization failed to ensure that the written plan of care was based on measurable patient-centered goals with defined time frames. For example in review of record of RRHV#1, RRHV#2, RRHV#4, RRNHV#3, RRNHV#4, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10, the POC (SN) goal documented as pain will be controlled within 2 weeks lacked measurable parameters. It did not define how pain control would be measured or evaluated. This finding was discussed with the Chief Compliance and Quality Officer during record review.

Observed in Record Review. In 5 of 14 active patient records reviewed, it was noted the organization had failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including treatment necessary to meet the patient’s needs. For example, in record of RRNHV#2, a physician's order directed the hospice nurse to insert or change a Foley catheter, size 18 Fr with a 10 ml balloon, on or around 08/05/2025 or as needed (PRN). An additional order was written for wound care to multiple areas, including the coccyx, right lower extremity (RLW), and right buttock. Upon review, both orders were found to be incomplete. The PRN catheter order lacked a clearly defined clinical indication, and the wound care order did not specify the frequency of treatment. In record of RRHV#2, the ordered skilled nursing (SN) visit frequency of 1wk10 + 3 PRNs did not include a specified reason or clinical indication for the PRN visits. Another example, in RRNHV#3, two (2) PRN pain medications, Acetaminophen 500 mg, 2 tablets orally every 6 hours as needed for mild pain and Oxycodone 5 mg 1 tablet orally every 4 hours as needed for pain but it did not clearly defined parameters such as pain severity levels for the second one. In record of RRNHV#5, the hospice nurse was ordered to change the Foley catheter 18 Fr with 10 ml sterile water every 30 days and as needed. However, the order did not specify the clinical conditions or circumstances under which the PRN catheter change should be performed. Lastly, in RRNHV#7, an order written as to fill Foley catheter 16 Fr 10 ml sterile water. FC change monthly and as needed, did not clearly defined clinical indication or specified reason for the PRN visit. This finding was discussed and validated by the Chief Compliance and Quality Officer during record review.

Observed in Record Review. In 1 of 14 active patient records reviewed, it was noted the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example, in RRNHV#5, the hospice nurse performed a Foley catheter change and inserted a 16 Fr catheter with a 10 ml balloon of sterile water instead of the ordered 18 Fr catheter as specified in the plan of care. This finding was discussed with and validated by the Chief Compliance and Quality Officer during record review.

Observed in Record Review. In 5 of 14 active patient records reviewed, it was noted the organization failed to ensure that all disciplines that provide care, treatment or services to the patient collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. For example in RRHV#2, during the week of 07/14/2025, the hospice aide made only three visits despite the plan of care specifying four visits for that week. There was no documentation of a missed visit report to explain the reason for the missed visit. In record of RRNHV#4, a review of clinical documentation revealed that a missed visit by the hospice aide on 07/09/2025 was not accompanied by evidence that the case manager or supervising clinician was notified. In RRNHV#5, based on upon record review, on 07/28/2025, the patient's daughter called the office to report that the Foley catheter seems not working and there was no urine output noted. The hospice nurse went out and assessed the patient and found out that there was no urine output. However, there was no evidence documented that the physician was notified. Lastly for RRNHV#6, and RRNHV#9, Hospice Aide had a visit missed, reason for visit missed documented, however, there were no evidence documented if clinical nurse supervisor were contacted. This finding was discussed and validated by the Chief Compliance and Quality Officer.

Observed in Record Review. In 4 of 11 active patient records with personal care services, it was noted the organization failed to ensure that the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision prepares written patient care instructions for the hospice aide. For example in RRHV#3 and RRNHV#7, based upon review of clinical record, the patient is receiving oxygen at 2 LPM via NC continuously, as specified in the hospice plan of care. Although the Hospice Aide Care Plan includes instruction stating that oxygen may be removed during personal care as needed, however, it did not specify the duration for which oxygen may be discontinued. In record of RRNHV#3, and RRNHV#4, both Hospice Aide Care Plan includes written instructions to observe bleeding precautions. However, upon review of the clinical record, patient was not taking any medications or receiving any treatments that would warrant such precautions. This finding was discussed and validated by the Chief Compliance and Quality Officer during record review.

Observed in Record Review. In 10 of 13 patient records reviewed, The HCO did not ensure patient care plan goals were individualized, measurable, and reassessed at appropriate time frames. Examples include the following: Pt and family wish to remain at the facility for comfort and EOL care through death, Client/Family will express/exhibit improved coping abilities by 09/13/22, Client/family will express feelings of increasing peace, Patient/family spiritual needs will be met, Patient's oxygenation of tissue will be adequate to meeting needs within 2 weeks, Pt will receive tx for nausea/vomiting w/in one day of presenting condition within 4 wks, Medication compliant within 4 wks, Pt will have regular elimination pattern, Joyce will have desired amount of spiritual support. These stated goals do not contain specific information, including time frames, that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the organization’s CEO, Chief Quality and Compliance Officer, Team Leader and Infection Control Program Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to use standard infection prevention and control precautions at times required by the organization's policies. For example, with HV #3/RR #3, the surveyors observed the registered nurse, with gloved hands, handle the patient’s medication bottles, pour the tablets into her hand, count them one by one, return them to the bottles, and then use the same hand to enter data into the tablet, without changing gloves and completing hand hygiene in between. The organization’s policy requires standard precautions to be used, including changing gloves and washing hands when going from handling clean items, and contacting possibly contaminated surfaces. These findings were discussed and confirmed with the Team Leader and the Chief Quality and Compliance Officer.

Observed in Record Review. In 4 of 8 patient records reviewed, The HCO did not ensure the hospice aide care plan provide specific directions for ADL/personal patient care. For example, the surveyor observed in HV #2/RR #2 the care plan stated incontinence care prn, RR #4 only stated oxygen precautions, RR #9 stated report shortness of breath, and #12 stated fingernail care. Standards requires the register nurse to provide written patient care instructions that specify the duties of the hospice aide. These findings were reviewed, discussed, and validated with the Chief Quality and Compliance Officer.