Every finding on record at Community Hospices of America, LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed the agency did not ensure that all hospice employees received initial emergency preparedness training and emergency preparedness training every two years. PERSONNEL RECORD 8: The Hospice Medical Director (contracted) employee's date of hire was 01/10/2024. The personnel record lacked documentation of emergency preparedness training. During a joint record review and interview on 01/14/2026, the Area Executive of Clinical Operations confirmed the above finding that Emergency Preparedness training was not documented in the personnel record.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that all planned interventions based on problems identified in the initial and updated comprehensive assessments were included in the patients' individualized written plans of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/16/2025. A physician's order dated 06/16/2025 read in part, "Eliquis 5mg tablet by mouth twice daily". The plans of care dated 06/16/2025 through 09/13/2025, 09/14/2025 through 12/12/2025, and 12/13/2025 through 02/10/2026 did not include interventions related to the patient being at risk for bleeding. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/21/2025. A physician's order dated 02/21/2025 read in part, "Eliquis 2.5mg tablet by mouth twice daily". The plans of care dated 02/21/2025 through 04/20/2025, 04/21/2025 through 06/19/2025, and 06/20/2025 through 08/13/2025 did not include interventions related to the patient being at risk for bleeding. During joint record reviews and interview on 01/12/2026 and 01/14/2026, the Area Executive of Clinical Operations confirmed the above findings, stating "There are no bleeding risk interventions on either of these patients' plans of care".

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. 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 that all medical supplies and appliances necessary to meet the needs of the patient were included in the patient's individualized written plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/23/2025. The plans of care dated 06/23/2025 through 09/20/2025, 09/21/2025 through 12/19/2025, and 12/20/2025 through 02/17/2026 included orders for "Oxygen 2 liters via nasal cannula continuously". The plans of care did not include the patient's oxygen supplies. During a joint record review and interview on 01/12/2026, the Area Executive of Clinical Operations confirmed the above finding, stating "There are no oxygen supplies listed on the plans of care".

It is required that Hospice Aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The Hospice Aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure that Hospice Aide (HA) supervisory visits were completed no less frequently than every 14 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/05/2024. The plans of care dated 03/05/2025 through 06/02/2025 and 06/03/2025 through 08/01/2025 ordered "HA 1 time per week". The first HA visit was dated 03/06/2025. HA supervisory visits were dated 03/11/2025, 03/21/2025, 04/01/2025, 04/11/2025, 04/22/2025, 05/06/2025, and 05/20/2025. The next HA supervisory visit was dated 06/06/2025, a total of 17 days later and 3 days outstanding. During a joint record review and interview on 01/13/2026, the Director of Clinical Services confirmed the above finding that Hospice Aide supervisory visits were completed less frequently than every 14 days.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review. 1 of 6 (17%) records reviewed of patients who accepted hospice aide services, revealed the hospice aide plan of care did not include information specific to the patient so that the aide could provide safe, quality care. Clinical Record 11: The patient elected hospice services on 8/10/22. It was documented in the initial assessment, 8/10/22, and on visits conducted 8/11/22 and 8/22/22 in the RN routine visit notes, that the patient was on oxygen 3 liters continuously. This was also documented on the patient's individualized plan of care and the medication list; however, this information was not documented on the aide plan of care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records. In 4 of 6 (67%) records reviewed with hospice aide services ordered, the agency did not ensure the hospice aides provided the services in ordered in the plans of care with respect to visit frequencies and/or assigned tasks. Clinical Record 2: Aide services were ordered on 4/4/22 at a visit frequency of 2 times a week. The aide missed visits on 4/22/22, 5/31/22, and 7/4/22. Clinical Record 6: There was a scheduled aide visit on 12/26/22 that was missed. Clinical Record 10: This patient's primary hospice diagnosis is Senile Degeneration. Aide services were ordered on 8/7/22 at a visit frequency of 1 time a week throughout the course of care. The aide plan of care assigned the aide, in addition to other tasks, to document the last date of the bowel movement (BM). On the aide visit dated 8/8/22 the aide documented, "No BM, the aide did not answer". (It is unclear if the aide asked another aide in the facility this question). On 10/3/22 the aide did not perform the assigned task of oral care and documented re. the last BM, "No BM, the patient did not answer". On the aide visit dated 10/31/22, there was no care performed, documenting, "no cares performed, the patient refused." Clinical Record 7: Aide services were ordered on 11/14/22 on the recertification plan of care at a visit frequency of 2 times weekly. The aide did not perform 3 of the assigned tasks, oral care, emptying the trash, and changing linens, documenting, "the tasks were already done" on the aide care plan in 14 out of 17 visits.

It is required that hospice aides must report changes in the patient’s medical, nursing, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by a review of clinical records and interview. 4 of 6 (67%) records reviewed where hospice aide services were provided, revealed that the agency did not ensure that the hospice aides reported changes, with respect to the assigned tasks on the care plans and/or visit frequencies, to the registered nurse (RN). Clinical Record 2: Aide services were ordered on 4/4/22 at a visit frequency of 2 times a week throughout the course of care. The aide missed visits on 4/22/22, 5/31/22, and 7/4/22 and did not notify the registered nurse that she was not able to make the visits. Clinical Record 6: There was a scheduled aide visit on 12/26/22 that was missed; the aide did not notify the RN that she wasn't seeing the patient. Clinical Record 7: Aide services were ordered on 11/14/22 patient recertification at a visit frequency of 2 times a week. The aide did not perform 3 of the assigned tasks, oral care, emptying the trash, and changing linens, documenting, "the tasks were already done" on the aide care plan in 14 out of 17 visits; there was no documented evidence that the aide notified the RN of the tasks not performed. Clinical Record 10: This patient's primary hospice diagnosis is Senile Degeneration. Aide services were ordered on 8/7/22 at a visit frequency of 1 time a week throughout the course of care. The aide plan of care assigned the aide, in addition to other tasks, to document the last date of the bowel movement (BM). On the aide visit dated 8/8/22 the aide documented, "No BM, the aide did not answer". (It is unclear if the aide asked another aide in the facility this question). On 10/3/22 the aide did not perform the assigned task of oral care and documented re. the last BM, "No BM, the patient did not answer". On the aide visit dated 10/31/22, there was no care performed, documenting, "no cares performed, the patient refused." There was no documented evidence that the aide notified the RN of the tasks not performed. The Area Executive of Clinical Operations was interviewed on 1/19/23 during joint clinical record review and she agreed that there was no documentation in the records that the aides notified the RNs that they did not complete the assigned tasks or when missed visits occurred.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records, document review, interviews and observation on home visits. The contract between the nursing facility and the hospice states in part, "The plan of care will identify the care and services that are needed and will specifically identify which provider is responsible for performing the respective functions that have been agreed upon. and they will be established and maintained in consultation with the Facility's representative, who will provide supplies, monitor wounds, manage medications or provide the equipment needed." In 3 of 3 (100%) records reviewed of patients residing in a Skilled Nursing Facility/Nursing Facility (SNF/NF) revealed that the agency did not ensure that the written plans of care with the SNF/NF specified which provider is responsible for performing the functions that are agreed upon and included in the plans of care. Clinical Record 7: The patient has been residing in the SNF/NF since her election to hospice services on 11/24/2020. There was no written plan of care with the facility identifying who is responsible for the care and services such as medication management, medication administration, and skin assessments, or who is providing what durable medical equipment (DME) and supplies that the patient needs, and which provider is responsible for performing the functions that are agreed upon. Clinical Record 10: The patient resides in a SNF/NF and since the patient elected hospice services on 8/5/22, there was no written plan of care with the facility identifying who is responsible for the care and services such as medication management, medication administration, and skin assessments, or who is providing what DME and supplies that the patient needs, and which provider is responsible for performing the functions that are agreed upon. Clinical Record 11: The patient resided in an SNF/NF and for the time the patient was on hospice services, between 8/10/22 and 8/22/22, there was no plan of care with the facility identifying who is responsible for the care and services the patient needed. There is documentation that the patient had oxygen continuously at 3 liters and on 8/20/22 a foley catheter was placed. There is no evidence in the chart or included in the plan of care as to who will manage his oxygen and foley catheter care. Home Visit 4: On 1/18/23 during an observed home visit, the hospice facility chart records and the facility care plan were reviewed. There was no evidence of a coordinated plan of care between the hospice and the facility specifying which provider is responsible for functions that are agreed upon and who is responsible for managing the patient's needed care. The Director of Clinical Services (DCS) was interviewed during the home visit in the SNF on 1/18/23 asking if she had an integrated plan of care with the facility in the patient's hospice facility chart. She verbalized she didn't know she needed to state who was responsible for the patient care and who manages the needs of the patient. The Area Executive of Clinical Operations (ACO) was interviewed on 1/18/23 and said there is a form they often use, the Coordinated Task Plan of Care (CTPOC) that is used when a patient resides in a facility. The ACO showed the site visitor and DCS the form they use.