Every finding on record at Community Hospices of America, 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 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; [and 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, observation and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient's comprehensive assessment included a drug profile that included the patient's current medications. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The Registered Nurse’s (RN) admission visit dated 06/21/2025 documented that the patient’s respiratory rate was 26 breaths per minute and that the patient had recently been hospitalized for 14 days for a COPD exacerbation, requiring BiPAP support during the first week of hospitalization. On 01/28/2026, the RN documented that the patient was receiving 4 liters per minute (LPM) of continuous oxygen via nasal cannula (N/C), with an oxygen saturation of 89%...." During a Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026, the patient was documented as alert and oriented ×4 but tachypneic and dyspneic at rest, with an oxygen saturation of 85% on 4 LPM of continuous oxygen..." The NP Face-to-Face visit dated 04/10/2026, documented the patient’s oxygen saturation as 84% on 4 LPM via nasal cannula...” The patient’s medication profile did not document oxygen administration. CLINICAL RECORD 19: The RN admission visit note dated 08/15/2025 documented that the patient was alert and oriented ×3, short of breath, with a dyspnea score of 2/10, and that oxygen therapy was initiated. On 09/05/2025, the skilled nurse (SN) visit note documented a respiratory rate of 32 breaths per minute, crackles auscultated in the lung fields, and intermittent oxygen requirement. On 10/06/2025, the RN documented that the patient continued to have diminished lung sounds throughout all lung fields and now required 2 liters per minute of continuous oxygen via nasal cannula. The patient’s medication profile did not document oxygen administration. During a joint clinical record review and interviews on 04/23/2026, the Area Executive of Clinical Operations confirmed that patient medication profiles include the oxygen or medications the patients were receiving.

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 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected patient/family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected hospice care on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN admission visit note dated 06/21/2025 documented the patient's respiratory rate as 26 breaths per minute and a recent 14-day hospitalization for a COPD exacerbation, which required BiPAP support for the first week. On 01/28/2026, the skilled nurse (SN) visit note documented that the patient’s oxygen saturation was 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula, with visible cyanosis and reports of orthopnea when lying down. A Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026 documented that the patient was alert and oriented ×4 but tachypneic and dyspneic at rest. The NP Face-to-Face visit on 04/10/2026 documented the patient’s oxygen saturation was documented at 84% on 4 LPM via nasal cannula. The Interdisciplinary Group (IDG) documentation dated 03/04/2026, 03/19/2026, 04/01/2026, and 04/16/2026 documented oxygen needs, ranging from 4–8 LPM. The patient’s plans of care for the benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 identified planned interventions for the patient's respiratory-related problems shortness of breath (SOB) using an appropriate SOB scale, however no patient/family reflected goal for shortness of breath was documented. CLINICAL RECORD 6: The patient elected hospice care on 01/02/2026 with a terminal diagnosis of metastatic pancreatic cancer. On 02/27/2026, the SN visit note documented that the patient reported severe pain rated at 10/10, accompanied by abdominal cramping and nausea, and that the patient was fluctuating between diarrhea and hard stools. New physician orders were obtained for an adjusted pain regimen and ondansetron (Zofran) to address nausea. The IDG meeting dated 03/04/2026 documented a generalized comfort goal of maintaining pain below the patient’s stated goal of 3/10, with reference to an “effective bowel regimen.” Medication changes were noted, including a new order for dicyclomine (Bentyl) for cramping. The same information was repeated during the IDG meeting on 03/18/2026. The SN visit note dated 04/10/2026 documented that the patient reported mild abdominal pain and persistent nausea, stating that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting dated 04/10/2026 documented the new order for simethicone and ondansetron. During a nursing assessment on 04/10/2026, the patient reported mild abdominal pain and persistent nausea, stating that that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting on the same date documented medication changes, including the prior addition of Bentyl on 03/04/2026 and a new order for simethicone. The plans of care for the benefit periods dated 01/02/2026 to 04/01/2026 and 04/02/2026 to 06/30/2026 documented no planned interventions, nor patient/family reflected goals for the patient's identified problem with nausea. CLINICAL RECORD 8: The patient elected hospice care on 01/20/2026 with a terminal diagnosis of Parkinsonism. On 02/24/2026, the RN documented that the patient was continuing antibiotics for a urinary tract infection and aspiration pneumonia. On 02/27/2026, the SN visit note documented that the patient “continued to not feel very well,” slept most of the time, and had coarse lung sounds, prompting the physician's approval of another round of antibiotics. The IDG meeting on 03/04/2026 documented intermittent oxygen use for shortness of breath or low oxygen saturation, treatment with Cefdinir for aspiration pneumonia, and Macrobid for urinary tract infection (UTI), with no measurable respiratory, infection-related, or neurological goals identified. The documentation regarding oxygen use was repeated during the IDG meeting on 04/16/2026, with no evidence of updated goals despite continued decline. On 04/17/2026, the RN documented the patient’s staying awake all night after previously sleeping 14–16 hours/day, increased agitation, and worsening neck pain. The hospice physician ordered morphine sulfate extended release, 15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. On 04/21/2026, the SN visit note documented a recurrence of aspiration pneumonia symptoms, with crackles throughout the right lung to the bases, productive cough with yellow-green sputum, confusion, and hallucinations. Cefdinir was restarted. The plans of care for the benefit periods dated 01/20/2026 to 04/19/2026 and 04/20/2026 to 06/18/2026 did not include documentation of patient/family reflected goals for the patient’s recurrent problems with aspiration pneumonia, agitation, hallucinations, confusion, and respiratory symptoms. CLINICAL RECORD 18: The patient elected hospice care on 05/17/2022 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and a comorbid condition of malignant neoplasm of the larynx. During the Registered Nurse’s (RN) admission visit on 05/17/2022, the RN documented significant swallowing impairment, including dysphagia, inability to chew and swallow most foods, and coughing with sips of liquid. The RN further documented that the patient had a gastric tube (G-tube) in place and was administered Ensure feedings via G-tube approximately every 2–3 days. The SN visit note dated 11/13/2025 documented that staff assisted the patient with clearing a blockage in the feeding tube. The patient’s plans of care for the hospice benefit periods dated 08/29/2025 to 10/27/2025 and 10/28/2025 to 11/17/2025 did not include interventions or patient/family goals for the feeding tube and management, enteral nutrition, dysphagia, or aspiration risk. During an interview and review of the findings on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients' plans of care did not include interventions, or goals for the identified patients' problems.

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: 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected patient/family goals with measurable outcomes. CLINICAL RECORD 1: The patient elected hospice care on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. On 03/06/2026, the Registered Nurse (RN) documented slurred speech, mumbling, and slowed, effortful word finding, episodes of choking when drinking liquids, and observed to be visibly frustrated and distressed by their declining ability to communicate. On 04/08/2026, the Licensed Practical Nurse (LPN) documented bowel incontinence, lethargy, and orientation only to person and place. On 04/15/2026, the LPN documented both bowel and bladder incontinence, with the patient sleeping throughout the visit and not awakening. The patient’s mother reported administration of Ativan and pain medication, and that anti-nausea medication was required that morning. On 04/17/2026, the RN documented that the patient’s last bowel movement occurred on 04/14/2026, that the patient was sleeping 22–23 hours per day, taking only small sips of fluids with medications and a few bites of food daily, and that a priest had visited to administer the Sacrament of the Sick. The plans of care for the benefit periods dated 01/20/2026 to 03/20/2026 and 03/21/2026 to 05/19/2026, documented the patient’s comfort goal: maintain a pain score below SIT 3, with assessment for signs and symptoms of death and dying; and a sensory/neurological goal: changes will be identified promptly and interventions initiated to minimize discomfort, with success defined as patient/caregiver acceptance of comfort at each visit. These goals did not include documentation of measurable outcomes. CLINICAL RECORD 5: The patient elected hospice care on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN admission visit note dated 06/21/2025 documented the patient's respiratory rate as 26 breaths per minute and a recent 14-day hospitalization for a COPD exacerbation, which required BiPAP support for the first week. On 01/28/2026, the skilled nurse (SN) visit note documented that the patient’s oxygen saturation was 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula, with visible cyanosis and reports of orthopnea when lying down. A Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026 documented that the patient was alert and oriented ×4 but tachypneic and dyspneic at rest. The NP Face-to-Face visit on 04/10/2026 documented the patient’s oxygen saturation was documented at 84% on 4 LPM via nasal cannula. The Interdisciplinary Group (IDG) documentation dated 03/04/2026, 03/19/2026, 04/01/2026, and 04/16/2026 documented oxygen needs, ranging from 4–8 LPM. The patient’s plans of care for the benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 documented the patient’s goals: “comfort” the patient and caregiver will understand symptom scales, symptom management, and when to report changes to hospice. The plans of care did not include documentation of a comfort goal with measurable outcomes. CLINICAL RECORD 6: The patient elected hospice care on 01/02/2026 with a terminal diagnosis of metastatic pancreatic cancer. The RN admission visit note dated 01/02/2026 documented that the patient was alert and oriented to person, place, time, and situation, and reported moderate, generalized abdominal aching pain rated at 4/10. The patient complained of constipation. On 01/23/2026, the physician ordered Senna Plus 8.6 mg–50 mg, two (2) capsules twice daily, to address constipation. During the IDG meeting dated 02/04/2026, the patient’s pain level was documented as 3/10, with a stated goal of 3/10. The SN documented a two-week goal to maintain pain below the stated level and to achieve an effective bowel regimen. The same goals were documented during the IDG meeting dated 02/18/2026. On 02/27/2026, the SN visit note documented that the patient reported severe pain rated at 10/10, accompanied by abdominal cramping and nausea, and that the patient was fluctuating between diarrhea and hard stools. New physician orders were obtained for an adjusted pain regimen and ondansetron (Zofran) to address nausea. The IDG meeting dated 03/04/2026 documented a generalized comfort goal of maintaining pain below the patient’s stated goal of 3/10, with reference to an “effective bowel regimen.” Medication changes were noted, including a new order for dicyclomine (Bentyl) for cramping. The same information was repeated during the IDG meeting on 03/18/2026. On 03/30/2026, the SN visit note documented that the patient had no bowel movement on 03/29/2026, followed by three episodes of diarrhea on 03/30/2026. During the IDG meeting on 04/01/2026, the plan again reflected the goal of maintaining pain below the pain scale score through effective medication management and bowel regimen. The SN visit note dated 04/10/2026 documented that the patient reported mild abdominal pain and persistent nausea, stating that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting dated 04/10/2026 documented the new order for simethicone. The plans of care for the benefit periods dated 01/02/2026 to 04/01/2026 and 04/02/2026 to 06/30/2026 documented the comfort problem with the patient’s goal: caregiver to identify gastrointestinal changes within 3 days of symptom onset and to initiate interventions promptly to minimize discomfort. The plans of care did not include measurable outcomes for the patient's comfort goals related to the identified gastrointestinal problems. During an interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients' plans of care did not include goals with measurable outcomes.

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, observation, and interview. In 1 of 4 (25%) home visits observed and clinical records reviewed, the agency did not ensure that the patient's plan of care included medical supplies needed to meet the patient's needs. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. The skilled nurse (SN) visit notes dated 04/08/2026 and 04/15/2026, documented the patient's bowel and bladder incontinence. During the home visit with the Hospice Aide (HA) on 04/22/2026, the HA utilized wipes, chux, and a brief due to the patient’s incontinence. The plans of care for the benefit period dated 03/21/2026 to 05/19/2026 did not include documentation of incontinence supplies (briefs, wipes, chux pads). The finding was confirmed following a joint clinical record review and interview on 04/23/2026 with the Area Executive of Clinical Operations.

It is required that the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the IDG reviewed, revised, and documented the patient's plan of care no less frequently than every 15 calendar days CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. The Registered Nurse (RN) visit note dated 03/06/2026, documented that the patient was experiencing significant neurological changes, including slurred speech, mumbling, and difficulty finding and articulating words, and was having episodes of choking when drinking liquids. Additionally, the RN documented that the patient was visibly frustrated and distressed by their decline in the ability to communicate, and the patient reported constipation, having gone up to five days without a bowel movement. On 04/08/2026, the Licensed Practical Nurse (LPN) visit note documented bowel incontinence, lethargy, and orientation only to person and place. On 04/15/2026, the LPN visit note documented bowel and bladder incontinence, with the patient sleeping through most of the visit and not awakening. The patient’s mother reported administering Ativan and pain medication, and that nausea medication was required that morning. On 04/17/2026, the Skilled Nursing (SN) visit note documented that the patient’s last bowel movement had occurred on 04/14/2026, that the patient was sleeping 22–23 hours per day, taking only small sips of fluids with medications and a few bites of food daily, and that a priest had visited and administered the Sacrament of the Sick. A review of the patient’s plans of care revealed that the problems, interventions, and goals (P/I/G) were not updated since 07/2025, except for a revised comfort goal specifying a measurable pain score of =3. The plans of care for the benefit periods dated 01/20/2026 to 03/20/2026 and 03/21/2026 to 05/19/2026 were not updated to were not updated to include the patient's identified problems with dysphagia and choking with liquids, nausea requiring medication, constipation, and subsequent bowel and bladder incontinence, patient frustration, anxiety, and emotional distress related to communication loss. CLINICAL RECORD 8: The patient elected hospice care on 01/20/2026 with a terminal diagnosis of Parkinsonism. On 02/24/2026, the RN documented that the patient was being treated with antibiotics for both a urinary tract infection (UTI) and aspiration pneumonia. On 02/27/2026, the SN visit note documented that the patient “continued to not feel very well,” slept most of the time, and had coarse lung sounds, prompting the physician's approval of another round of antibiotics. The IDG meeting on 03/04/2026 documented intermittent oxygen use for shortness of breath or low oxygen saturation, treatment with Cefdinir for aspiration pneumonia, and Macrobid for urinary tract infection (UTI), with no measurable respiratory, infection-related, or neurological goals identified. On 04/17/2026, the RN documented the patient’s staying awake all night after previously sleeping 14–16 hours/day, increased agitation, and worsening neck pain. The hospice physician ordered morphine sulfate extended release, 15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. The hospice physician ordered morphine sulfate extended release,15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. The IDG meeting dated 04/21/2026, documented that the patient exhibited signs and symptoms of aspiration pneumonia, was oriented to person and place, was confused, and was experiencing hallucinations. The patient’s plans of care for the benefit periods dated 01/20/2026 to 04/19/2026 and 04/20/2026 to 06/18/2026 were not updated to include the patient's identified problems with aspiration, aspiration pneumonia, agitation, confusion, or hallucinations. During a joint clinical record review and interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients’ plans of care were not revised to reflect changes in patient condition, acknowledging that newly identified problems, planned interventions, and patient-specific goals were neither added nor updated.

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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 15 (20%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided at home. On 01/28/2026, the Registered Nurse (RN) visit note documented that the patient had an oxygen saturation of 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula and was cyanotic. The plans of care (POC) for the hospice benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 ordered HA services twice weekly. The HA care plans dated 04/03/20260 and 09/16/2025 did not provide the HA with instructions regarding the patient's use of continuous oxygen during personal care. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/25/2026 with a terminal diagnosis of Huntington’s disease. The patient resided at home. During the Registered Nurse’s (RN) admission visit on 03/25/2026, the RN documented that the patient had a gastric tube (G-tube) in place for nutrition and medication administration. The plans of care (POC) for the hospice benefit periods dated 03/25/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 ordered HA services twice weekly. The HA care plan dated 03/25/2026 did not provide the HA with instructions related to the G-tube during personal care activities. CLINICAL RECORD 19: The patient elected the hospice benefit on 08/15/2025 with a terminal diagnosis of heart failure, unspecified. On 09/22/2025, the RN documented an unstageable coccyx wound measuring 1 cm x 2.2 cm x 1 cm. On the same date, the physician ordered wound care, including cleansing with wound cleanser, application of Medihoney gauze to the wound bed, and covering with a foam dressing on Monday, Wednesday, Friday, and as needed. The RN visit note dated 10/01/2025, documented that the patient required continuous oxygen at 2 liters per minute via nasal cannula (N/C) and had venous stasis ulcers on the bilateral lower extremities (BLE). The physician ordered wound care: "application of Silvadene cream from the knees to the ankles, cover with Telfa, wrap with Kerlix, and secure with tape." For the hospice benefit period dated 08/15/2025 to 10/17/2025, the physician ordered HA visits twice weekly. The HA care plan dated 08/29/2025 assigned the HA to provide a partial sponge bath, shower, and shampoo at every visit. The HA care plan dated 08/29/2025 did not document instructions for the HA regarding the wounds or dressings should they become wet, soiled, or dislodged during bathing and personal care activities. The care plan did not include instructions for the HA regarding the patient's use of continuous oxygen during personal care. During a joint clinical record review and interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the HA care plans did not include instructions to meet the patient's needs.

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. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of Volunteer Program documentation and interviews with the Volunteer Coordinator on 04/23/2026, revealed that the average percentage of total patient care hours for all paid hospice employees and contract staff attributable to volunteers was 3.45% for 01/01/2025 through 12/31/2025. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. During the review of Volunteer Program documentation and interviews with the Volunteer Coordinator (Personnel Record 7) on 04/23/2026, it was determined that the average percentage of total patient care hours for all paid hospice employees and contract staff attributable to volunteers was 3.45% in 2025 and 1.86% year-to-date in 2026. These rates remain significantly below the targeted 5% volunteer requirement. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. The Volunteer Coordinator began with the organization in September of 2025 and has monthly meetings with the Area Executive of Clinical Operations to monitor progress. Documented recruitment strategies include posting opportunities on the Volunteer Match and Idealist websites, utilizing social media platforms, distributing flyers, outreach to local colleges, and participation in career and health fairs. Documented retention efforts include individualized phone calls and text messages to volunteers, inclusion of volunteers in staff gatherings, provision of small appreciation gifts, and one-on-one meetings to promote engagement through face-to-face interaction.

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. CONTINUED REQUIRED ACTION This standard was not met, as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies necessary to meet the patient's needs. Clinical Record 1: The patient elected hospice care on 12/06/2023 with the diagnosis of Unspecified Protein-Calorie Malnutrition. The initial assessment completed by the Registered Nurse (RN) on 12/06/2023 documented that the patient was incontinent of bowel and bladder, refused to wear Depends, and was cleaned with wipes. The plan of care dated 12/06/2023 did not include the Depends and wipes. Clinical Record 4: The patient elected hospice on 12/01/2023 with the diagnosis of malignant neoplasm of the pancreas. The initial assessment completed by the RN on 12/01/2023 documented that the patient was incontinent of bowel and bladder and that the patient wears size 8 Depends. The plan of care dated 12/01/2023 did not include the Depends. The Director of Clinical Services was interviewed on 03/07/2024 and confirmed that the medical supplies necessary to meet the needs of the patient were not included in the plan of care. REOCCURING REQUIRED ACTION.

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 medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and]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 and interview. In 3 of 4 (75%) home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Home Visit 2/Clinical Record 17: During the home visit with the hospice aide on 6/6/2023, a medication reconciliation was performed by comparing the patient's medication bottles and the agency's medication profile. The spouse stated the patient was not taking the first two medications on the medication profile: "Dronabinol 2.5mg by mouth at bedtime and Fluoxetine 40mg by mouth daily." Additionally, the medication profile documented "Morphine ER 15mg, two (2) tablets by mouth daily and Morphine ER 15mg, one (1) tablet by mouth at bedtime." The spouse stated the patient was taking one (1) tablet by mouth three times a day. The medication profile documented "Oxycodone 10mg by mouth every six (6) hours as needed for pain." The spouse stated the patient was taking one tablet by mouth four times daily, scheduled, and not "as needed for generalized arthritic pain." Additionally, the medication profile documented "Senna S 8.6mg-50mg, one (1) tablet by mouth twice a day;" The spouse stated the patient was taking one tablet by mouth every other day. The findings were reviewed with the Administrator and Director of Nursing on 6/7/2023, confirming the inaccurate medication profile. Home Visit 3/Clinical Record 18: During the home visit on 6/7/2023 with the Medical Social Worker, a medication reconciliation was performed comparing the patient's medication bottles and the agency's medication profile. The medication profile dated 6/7/2023 did not include documentation of: "Miralax powder 17gm by mouth daily; B12 2500mcg one tablet by mouth daily; and Vision Formula 50+ one tablet by mouth daily." The patient was taking "Vitamin D3 125mcg/5000 IU, one (1) tablet by mouth daily." The medication profile documented "Vitamin D3 (cholecalciferol) 25mcg (1,000 Units)," which was an incorrect dosage. The spouse stated the patient was not taking the following medications documented on the medication profile: Colace 100mg by mouth every other day, Donepezil 10mg by mouth at bedtime, Eliquis 5mg by mouth twice a day; and Omeprazole 20mg by mouth at bedtime since April 29, 2023. Additionally, the medication profile documented "Ferrous Sulfate 325mg by mouth daily in the morning," and not every other day per the medication profile. The findings were reviewed with the Administrator and Director of Nursing on 6/6/2023, and it was confirmed that the medication profile was inaccurate. Home Visit 4/Clinical Record 19: During the home visit on 6/8/2023 with the Registered Nurse, a medication reconciliation was performed comparing the patient's pharmacy-prepackaged bubble pack to the agency's medication profile. The bubble pack had seven (7) pills, and its contents were labeled on the back. Two bubble-packed medications were discontinued on the medication profile: Atorvastatin 40mg daily, discontinued on 11/21/2022; and enteric-coated aspirin 81mg daily, discontinued on 1/5/2023. The patient's daughter stated that she discarded the aspirin prior to giving the patient his pills to swallow, but the patient had been receiving the Atorvastatin. The findings were reviewed with the Administrator on 6/8/2023, and it was confirmed the medication profile was not accurate.

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, interview, and observation. In 7 of 19 (37%) clinical records reviewed, the hospice did not ensure that the written plans of care included documentation of the care and services necessary to meet the patient and family needs identified in the comprehensive assessments. Clinical Record 2: The patient elected hospice care on 2/21/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 2/21/2023 documented a Foley catheter in place due to urine retention. The plan of care did not include documentation of inventions or goals for maintenance or assessment of the Foley catheter until 6/6/2023, the first day of the site visit. Clinical Record 3: The patient elected hospice care on 11/12/2022. The initial comprehensive assessment completed by the RN on 11/12/2022 documented a "recent fall with bilateral wrist fractures... wheelchair bound when not in bed and slumps to the right in that chair." Fall precautions were not documented on the plan of care until 6/6/2023, the day of the site visit. Clinical Record 9: The patient elected hospice care on 1/18/2023. The RN visit note dated 1/23/2023 documented a wound to the right lateral ankle. On 1/23/2023, the physician ordered: "cleanse with wound cleanser, apply skin prep cover with silicone border foam QOD. Encourage to lie on left side, float feet if able and heel booties." In addition, on 2/6/2023, the physician ordered, "cleanse with wound cleanser, pat dry, apply silicone border foam," The location of the wound treatment was not documented in the orders or the plan of care. Clinical Record 10: The patient elected hospice care on 1/5/2023 with a primary diagnosis of cerebral infarction. The patient was receiving hospice services at a nursing facility. The initial comprehensive assessment completed by the RN on 1/5/2023 documented "admitted to hospice after being hospitalized for a thrombotic CVA resulting in right side hemiplegia, aphasia, and dysphagia requiring honey thick liquids." The plan of care nutritional requirements was documented as "diet as tolerated." Clinical Record 15: The patient elected hospice care on 7/1/2022. The wound record report documented two wound locations: a growth to the left forehead and a skin tear to the back of the left upper arm, with onset dates of 1/5/2023. The physician order dated 1/5/2023 documented, "cleanse with normal saline, cover with xeroform and form dressing with border daily and prn." The location of the wound treatment was not included in the order or the plan of care. Clinical Record 17/Home Visit 2: The patient elected hospice care on 2/16/2023 with a primary diagnosis of severe protein malnutrition. During the home visit with the hospice aide on 6/6/2023, the spouse stated the agency provided the supplemental drink Boost that the patient drinks three times a day. The plan of care dated 5/10/2023 for the benefit period 5/17/2023 through 8/14/2023 did not include documentation of the nutritional supplement drink Boost. Clinical Record 18/Home Visit 3: The patient elected hospice care on 5/23/2023. During the home visit on 6/7/2023 with the Medical Social Worker, a medication reconciliation was performed comparing the patient's medication bottles provided by the spouse and the agency's medication profile. The medication profile dated 6/7/2023 did not include documentation of: "Miralax powder 17gm by mouth daily; B12 2500mcg one tablet by mouth daily; and Vision Formula 50+ one tablet by mouth daily." The findings were reviewed with the Administrator and Director of Nursing on 6/6/2023, and it was confirmed that the medication profile was inaccurate.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. This standard was not met as evidenced by clinical record review and observation. 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the plan of care included the frequency of services necessary to meet the needs of the patient. Clinical Record 1/Home Visit 1: The patient elected hospice care on 8/16/2022 and resided in a nursing facility. The agency's wound care order dated 5/23/2023 documented "Wound order: left lateral lower leg, trauma. Cleanse wound with wound cleanser, apply calcium alginate, apply skin prep to peri-wound, cover with Optifoam." The patient had an abrasion to the left shin. During the home visit on 6/6/2023 with the RN, the RN stated during an interview that the patient received wound care twice a week, once by the RN and once by the facility nurse. The hospice agency's order did not include documentation of a frequency for the wound care.

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, including all services necessary for the palliation and management of the terminal illness, including 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 11 of 19 (58%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies and durable medical equipment (DME) necessary to meet the needs of the patients. Clinical Record 1/Home Visit 1: The patient with an election of hospice benefits dated 8/16/2022 had a primary diagnosis of senile degeneration of the brain and received hospice services at a nursing facility. During the home visit with the RN on 6/6/2023, the DME utilized by the patient and provided by the agency included a high back wheelchair, hospital bed, scoop air mattress, over-bed table, heel protectors, pillow wedges, floor mat, and wound care supplies and incontinent supplies. The plan of care dated 8/16/2022 for the benefit period 8/16/2022 through 11/13/2022 and the plan of care dated 4/5/2023 for the benefit period 4/13/2023 through 6/11/2023 documented the DME and supplies as "none." The plans of care did not include documentation of the medical supplies and DME necessary to meet the needs of the patients. Clinical Record 2: The patient elected hospice care on 2/21/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 2/21/2023 documented a Foley catheter in place due to urine retention. The plan of care dated 2/21/2023 documented "none" for DME and Supplies; however, the patient had a Foley catheter. The POC did not include documentation of the medical supplies necessary to meet the needs of the patients. Clinical Record 3: The patient elected hospice care on 11/12/2022 with a primary diagnosis of senile degeneration of the brain. The initial comprehensive assessment completed by the Registered Nurse (RN) on 11/12/2022 documented a "recent fall with bilateral wrist fractures... wheelchair bound when not in bed and slumps to the right in that chair...incontinence of bowel and bladder." The plan of care dated 11/12/2022 for the benefit period from 11/12/2022 through 1/10/2023 documented "none" for DME and Supplies. The Director of Nursing stated on 6/7/2023 that the agency provided supplies of small briefs, wipes, underpads, and peri wash, and the patient owned a wheelchair. The POC did not include documentation of the medical supplies necessary to meet the needs of the patients. Clinical Record 4: The patient elected hospice care on 1/24/2023 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). The initial comprehensive assessment completed by the RN on 1/24/2023 documented the patient was incontinent of the bowel and bladder. The plan of care dated 1/24/2023 for the benefit period from 1/24/2023 through 4/23/2023 documented DME and Supplies as "none." The Director of Nurses stated the agency provided the following DME and supplies, which should have been included on the plan of care: bedside commode, nebulizer setup, oxygen concentrator setup with tanks, briefs, wipes, underpads, and peri-wash, shampoo, and lotion. The POC did not include documentation of the medical supplies and DME necessary to meet the needs of the patients. Clinical Record 7: The patient elected hospice care on 12/28/2022 with a primary diagnosis of Huntington's disease. The plan of care dated 12/28/2022 for the benefit period from 12/28/2022 through 3/27/2023 documented DME and supplies as "none." During the joint record review on 6/8/2923, the Director of Nurses stated that the agency provided the patient with a Broda chair, lateral arm support, a bolster cover for the mattress, a shower chair, briefs, and underpads. The POC did not include documentation of the medical supplies and DME necessary to meet the needs of the patients. Clinical Record 5: The patient elected hospice care on 11/4/2022 with a primary diagnosis of pulmonary fibrosis. The patient's functional limitations documented included bowel/bladder incontinence, fall precautions, and high risk for falls, and the activities permitted were up as tolerated, independent at home with a wheelchair and walker. The plan of care dated 11/4/2022 for the benefit period from 11/4/2022 through 2/1/2022 documented DME and Supplies as "none." The POC did not include documentation of the DME necessary to meet the needs of the patients. Clinical Record 10: The patient elected hospice care on 1/5/2023 with a primary diagnosis of cerebral infarction. The patient's functional limitations were documented as bowel and bladder incontinence, paralysis, endurance, and ambulation. The activities permitted were "up as tolerated, transfer bed/chair, wheelchair. with fall precautions." The plan of care dated 1/5/2023 for the benefit period from 1/5/2023 through 4/4/2023 documented DME and supplies as "none." During the joint record review on 6/8/2023, the Director of Nursing stated the agency provided the following DME: oxygen concentrator setup, fall pad, overbed table, ROHO cushion, Broda chair, and a hospital bed with the bed mattress. Clinical Record 12: The patient elected hospice care on 5/26/2022. The plan of care dated 5/26/2022 for the benefit period 5/26/2022 through 8/23/2022 documented DME and supplies as "none." During the joint record review on 6/8/2023, the Director of Nursing stated that the patient utilized and was provided wipes, gloves, small/medium briefs, and a wheeled walker. The POC did not include documentation of the medical supplies and DME necessary to meet the needs of the patients. Clinical Record 14: The patient elected hospice care on 11/18/2021. The patient's activities permitted a wheelchair. The agency provided a lightweight wheelchair, a hospital bed and mattress, an overbed table, a shower chair, and a bedside commode. The plan of care dated 11/18/2021 for the benefit period from 11/18/2021 through 2/15/2022 documented DME and supplies as "none." The POC did not include documentation of the DME necessary to meet the needs of the patients. Clinical Record 15: The patient elected hospice care on 7/1/2022. The initial comprehensive assessment completed by the RN documented the agency ordered and provided a walker, oxygen concentrator setup, bedside commode, toilet riser, and briefs. The plan of care dated 7/1/2022 for the benefit period 7/1/2022 through 9/28/2022 documented DME and Supplies as "none." The POC did not include documentation of the medical supplies and DME necessary to meet the needs of the patients. Clinical Record 17/Home Visit 2: The patient elected hospice care on 2/16/2023 with a primary diagnosis of severe protein malnutrition. The certification of illness narrative signed by the physician on 2/22/2023 documented that the patient was incontinent of bowel and bladder, had limited mobility, had recurrent falls, and suffered from an osteoporotic compression fracture. During the home visit with the hospice aide on 6/6/2023, the patient utilized: a walker, shower chair, wheelchair, and a hand brace. The plan of care dated 2/16/2023 documented DME and supplies as "none." The POC did not include documentation of the DME necessary to meet the needs of the patients.

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, interview, and observation. 2 of 17 (12%) clinical records reviewed where hospice aide services were accepted, the hospice did not ensure that the hospice aide received specific written instruction for the aide assignment. Clinical Record 17/Home Visit 2: The patient elected hospice care on 2/16/2023. The patient was receiving hospice aide services twice weekly. The Aide Care Plan dated 6/6/2023 assigned the tasks to be completed every visit: stand-by assistance with ambulation, shower bath, skincare, and dressing. During the home visit with the hospice aide on 6/6/2023, the spouse stated the patient suffered a fall with injury approximately a month ago, resulting in an emergency room visit and stitches to the forehead. The Aide Care Plan did not contain fall precautions. The findings were reviewed with the Director of Nursing and Administrator on 6/7/2023, and the Aide Care Plan was updated with the specific instructions for the aide. Clinical Record 7: The patient elected hospice care on 12/28/2022 and received hospice aide services at a nursing facility. The patient had a documented history of falls with injury. The Aide Care Plan dated 12/29/2022 documented the following assigned tasks to be completed every visit: shower bath, shampoo, and oral care. The patient was wheelchair-bound and fall precautions were not included in the Aide Care Plan. The Administrator confirmed the assigned tasks were not specific for the patient's safety during the joint record review on 6/8/2023, and the care plan was later updated.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, interview, and observation. 1 of 17 (6%) records reviewed of patients that accepted hospice aides, the hospice did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group and included in the care plan. Clinical Record 1/Home Visit 1: The patient elected hospice care on 8/16/2022 with a primary diagnosis of senile degeneration of the brain. The patient resided in a nursing facility and received hospice aide service two times a week. During the home visit on 6/6/2023 with the Registered Nurse (RN), the patient was observed in a high-back wheelchair due to poor trunk and neck control. The Hospice Aide Care Plans dated 8/17/2022 and updated 6/6/2023 documented the following assigned tasks to be completed at every visit: bed bath, denture care, dressing, hair care, nail care, oral care, shampoo, skincare, turn and position in bed. The hospice aide visit note dated 6/6/2023 documented bed bath "Y" completed. In addition, the hospice aide documented in the coordination notes dated 6/6/2023 that a "shower give, I usually give shower instead as patient prefers it as its fast and easier, and doesn't get as cold so anytime she can tolerate it, we shower instead...talked to RNCM and LPN about making patient's care plan reflect what we actually do for her..." The findings were reviewed with the Director of Nursing and Administrator on 6/8/2023, who confirmed that the hospice aide was performing shower baths for several months instead of the assigned bed baths and practicing outside of the aide's scope of practice. The Director of Nursing addressed the findings with the hospice aide and RN prior to the exit conference.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: nursing services; medical social services; physician services; hospice aide, volunteer, and homemaker services; physical therapy, occupational therapy, and speech-language pathology services; short-term inpatient care; counseling services, including spiritual counseling, bereavement counseling, and dietary counseling. Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure to provide medical supplies. Clinical Record 3: The patient elected hospice care on 11/12/2022 and received hospice services at an assisted living facility. The plan of care dated 11/12/2022 for the benefit period from 11/12/2022 through 1/10/2023 documented "none" for (Durable Medical Equipment) DME and Supplies. The certification of terminal illness narrative signed by the physician on 11/23/2022 and the initial comprehensive assessment completed by the Registered Nurse (RN) on 11/12/2022 documented the patient's bowel and bladder incontinence. During an interview and a joint review of the clinical record on 6/8/2023, the Administrator and Director of Nursing confirmed that the patient utilized incontinence supplies; however, the facility refused the hospice to provide the supplies. Prior to the conclusion of the site visit, the Director of Nursing contacted the facility, and they agreed to allow the hospice agency to supply the incontinence supplies, including small briefs, wipes, underpads, and peri-wash.

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (6%) clinical records reviewed, the hospice did not ensure the patient's record included complete physician orders. Clinical Record 15: The physician order dated 1/5/2023 documented, "cleanse with normal saline, cover with xeroform and form dressing with border daily and prn." The wound record report documented two wound locations: a growth to the left forehead and a skin tear to the back of the left upper arm, with onset dates of 1/5/2023. The location of the wound treatment was not included in the order.

It is required that if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward to the receiving facility, a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 1 (100%) clinical record review of a patient transferred to a Medicare/Medicaid certified facility, the hospice did not ensure to forward a copy of the hospice discharge summary to the receiving facility. The hospice policy #C04 "Discharge/Transfer/Revocation" (revised 2/6/2023) stated in part, "[the agency name] will provide a discharge summary to the …. receiving facility containing...Treatments, symptoms and pain management information...Current plan of care...Latest physician's order...Other documentation facilitating continuity of care and/or requesting by the attending physician or receiving facility." Clinical Record 12: The patient elected hospice care on 5/26/2022 and was discharged from hospice care on 7/28/2022 due to transferring to a non-contracted hospital. The Discharge Summary dated 7/28/2022 documented the reason for discharge. There was no documentation or evidence that the discharge summary was forwarded to the receiving facility, the local hospital. During the joint record review and an interview on 6/9/2023, the Administrator and the Director of Nursing confirmed that the discharge summary was not sent to the local hospital.

It 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, document review, and interview. In 1 of 2 (50%) clinical records reviewed of live discharges, the hospice did not ensure that the patient's discharge summary was forwarded to the attending physician. The agency policy #C04, "Discharge/Transfer/Revocation" (revised 2/6/2023), stated in part, "will provide a discharge summary to the attending physician and/or receiving facility containing...Treatments, symptoms and pain management information...Current plan of care...Latest physician's order... Other documentation facilitating continuity of care and/or requesting by the attending physician or receiving facility." Clinical Record 12: The patient elected hospice care on 5/26/2022. The patient was discharged effective 7/28/2022 from the agency due to transferring to a non-contracted hospital. The Discharge Summary dated 7/28/2022 documented the reason for discharge, but there was no documented evidence that the discharge summary was sent to the attending physician. During the joint record review on 6/9/2023, the Administrator and the Director of Nursing confirmed that the discharge summary was not sent to the attending physician.

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 or ICF/IDF 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 clinical record review, document review, and interview. Agency policy #C26, "Care in the Nursing Facility" (revised 5/17/2018), stated in part, "[Name of Agency] collaborates with the facility to establish a coordinated plan of care, and the plan of care is maintained by both the facility and the hospice. Care is provided according to the plan of care...The hospice plan of care identifies the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care..." In 2 of 3 (67%) clinical records reviewed of patients currently receiving hospice services at a nursing facility, the hospice did not ensure that the hospice plan of care specified which provider was responsible for performing the functions that are agreed upon and included in the plan of care. Clinical Record 1/Home Visit 1: The patient elected hospice care on 8/16/2022 and resided in a nursing facility. A clinical record review revealed the hospice wound care order dated 5/23/2023, which documented "Wound order: left lateral lower leg, trauma. Cleanse wound with wound cleanser, apply calcium alginate, apply skin prep to peri-wound, cover with Optifoam." The order did not include the wound care frequency. During the home visit on 6/6/2023 with the Registered Nurse (RN) [Personnel Record 9], the RN stated the patient received wound care twice a week, once by the RN and once by the facility nurse. A review of the facility's patient record revealed a facility wound care order dated 5/5/2023, which documented a frequency of three times a week: Monday, Wednesday, and Friday. The "Hospice and Facility Coordinated Plan of Care" dated 6/1/2023 did not specify which provider was responsible for providing the wound care. Clinical Record 10: The patient elected hospice care on 1/5/2023 and received hospice services in a nursing facility. The patient had a documented wound to the right ankle. The agency form titled "Hospice and Facility Coordinated Plan of Care," dated 1/5/2023, did not specify which provider was responsible for providing the wound care. During an interview and the joint record reviews on 6/8/2023, the Administrator stated that it had been identified that the Hospice and Facility Coordinated Plan of Care form was not being completed accurately, and a performance improvement plan was initiated on 5/26/2023.

It is required that the hospice must provide the SNF/NF or ICF/MR with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by clinical record review, document review, interview, and observation. The agency policy #C26, "Care in the Nursing Facility" (revised 5/17/2018), stated in part, " The hospice agency provides the SNF/NF or ICF/IID with the following information...Hospice election form and any advance directives specific to the patient..." 1 of 1 (100%) home visit observation, where the patient received hospice services at a nursing facility, the hospice did not ensure to provide the SNF (Skilled Nursing Facility) with a copy of the patient's hospice election form and advance directives. Home Visit 1/Clinical Record 1: The patient that elected hospice care on 8/16/2022 received hospice services at a nursing facility. During the home visit on 6/6/2023 with the Registered Nurse (RN) [Personnel Record 9], a review of the nursing facility's "Hospice Facility Binder" revealed no documented evidence of the patient's hospice election form and advance directives. The RN present at the visit confirmed the documents were missing from the binder.