Every finding on record at Community Hospices of America, LLC

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the plan of care was revised based on the patient's updated comprehensive assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/20/2026 with a diagnosis of malignant neoplasm of the bronchus/lung. Review of the clinical record indicates the initial plan of care was established on 02/20/2026. Beginning on 02/26/2026, the patient developed bilateral upper extremity edema, initially documented as 2+ edema in the right hand and arm and 1+ edema in the left hand. At that time, furosemide (Lasix) 40 mg was ordered. On 03/10/2026, redness of the upper extremities was observed, and doxycycline 100 mg twice daily for seven days was prescribed. By 03/13/2026, the patient demonstrated increased swelling extending into the breast area with worsening redness; the fentanyl dosage was increased to 50 mcg, and a second antibiotic, Augmentin 875 mg twice daily for seven days, was initiated. Documentation on 04/14/2026 further noted tight skin extending from the hands to the upper arms, furosemide was increased to 40 mg twice daily, and the introduction of compression garments for the upper extremities. Despite the progression of symptoms and multiple corresponding treatment changes since the onset of edema on 02/26/2026, the plan of care has not been updated to reflect the patient’s current condition or interventions at the time of the survey. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/26/2026 with a diagnosis of moderate protein-calorie malnutrition. Upon admission, the patient had an indwelling Foley catheter in place. On 01/19/2026, an order was documented to remove the Foley catheter per patient request. Review of the recertification plan of care dated 03/12/2026 revealed that it continued to include references to the indwelling catheter, including associated supplies, and the goal stating: “patient/caregiver will verbalize adequate knowledge of required care to manage indwelling catheter.” The plan of care was not updated to reflect the discontinuation of the Foley catheter. Documentation further indicates that the comprehensive plan of care was subsequently updated on 03/12/2026, at which time the Foley catheter problem was discontinued. Following a joint record review and discussion with the Administrator (Personnel Record 1) on 05/21/2026, she confirmed that the patients’ plans of care had not been updated to reflect the changes noted in their comprehensive assessments.

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 1 of 13 (8%) clinical records reviewed who received hospice aide services, it was revealed that the agency did not ensure that the written patient care instructions for the hospice aide included information related to changes in the patient's condition and/or needs. CLINICAL RECORD 5: The patient elected hospice benefits on 02/20/2026 with a diagnosis of malignant neoplasm of the bronchus/lung and was ordered hospice aide services twice weekly. A hospice aide plan of care dated 02/21/2026 was active at the time of the survey. Over the past month, the patient developed significant bilateral upper extremity edema requiring pharmacologic intervention, including medications to manage edema and antibiotics for a suspected infection. Compression garments for the upper extremities were additionally ordered in March 2026. The hospice aide plan of care has not been revised to reflect these changes in the patient’s condition or the updated treatment interventions. Following a joint record review and discussion with the Administrator (Personnel Record 1) on 05/20/2026, she acknowledged that the hospice aide plan of care had not been updated to reflect recent changes identified in the patient’s comprehensive assessment.

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, including physician orders. This standard was not met, as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure that the patient's record contained physician orders. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/26/2026 with diagnoses including malignant neoplasm of the tongue, malignant neoplasm of the head, face, and neck, and secondary malignant neoplasm of the bone. The patient had a gastrostomy tube for nutritional support. On 05/04/2026, nursing documentation indicated that the patient was unable to administer tube feeding the prior evening due to a clogged tube. The patient reported attempting to flush the tube with Coca-Cola that morning; however, resistance remained. The nurse provided instructions to flush the tube with 30–60 cc of water before and after feedings. There were no corresponding physician orders on the initial plan of care dated 03/26/2026, nor at the time of the survey, authorizing the use of Coca-Cola for tube flushing or the administration of water flushes before and after feedings. Following a joint record review and discussion on 05/21/2026 with the Administrator (Personnel Record 1), she confirmed that physician orders should have been in place for both the use of Coca-Cola to flush the G-tube and for routine water flushes.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, [and] includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) records reviewed, the agency did not ensure that the plan of care identified all interventions required to meet the patient's needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 3/28/23. The initial comprehensive nursing assessment dated 3/28/23 documented that the patient was hard of hearing. During the home visit on 6/29/23, as the Medical Social Worker (MSW) started speaking, the patient stated, "You know I am deaf; you have to use this," and proceeded to hand the MSW a speaker/microphone device that was attached to headphones that the patient wore. The plan of care did not include documentation of problems, goals, or interventions related to the patient being hard of hearing or the use of the communication device. During an interview and a joint record review, the Area Executive of Clinical Operations/Administrator confirmed that the plan of care did not include the communication device required by the patient. The Director of Client Services (DCS) [Personnel Record 5] was the admission nurse and reported that this patient had utilized this device since admission and agreed it should have been added to the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, in which aide services were accepted, the agency did not ensure the aide notified the Registered Nurse (RN) of changes in the plan of care, including missed or refused visits. Clinical Record 13: The patient elected hospice on 2/25/23 with a terminal diagnosis of senile degeneration of the brain. The patient was not able to make decisions. The clinical record contained multiple entries documenting the patient's confusion, garbled speech, and "word salad" language. The aide care plan, effective from 5/26/23 to current, ordered the aide to make two visits per week. On 6/21/23, the hospice aide entered a missed visit with the reason, "patient refused." The record did not contain documentation that the RN was notified, and the visit was not rescheduled; thus, the patient only received one visit that week. During an interview and a joint clinical record review, the Area Executive of Clinical Operations/Administrator confirmed that the record did not contain evidence the RN was notified of the missed visit.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, in which volunteer visits were accepted, the agency did not ensure that the volunteer services were included in the plan of care (POC). Clinical Record 7: The patient elected the hospice benefit on 3/11/23. The volunteer assignment was initiated on 4/27/23 with a visit frequency of 2 times per month with the assigned task "caregiver relief visits." The clinical record contained paper forms with volunteer visits documented on 5/9/23, 5/10/23, and 6/2/23. The plan of care effective from 3/11/23 did not include problems, goals, or interventions related to volunteer services. During an interview, the volunteer coordinator stated that volunteer visits are added to the POC using the Medical Social Worker (MSW) notes during the Interdisciplinary Group meeting (IDT). A review of the MSW IDT notes dated 5/11/23 and 6/8/23 revealed the question, "Does this person need a volunteer?" which was answered, "No." The volunteer coordinator stated that perhaps they forgot to inform the MSW. The Area Executive of Clinical Operations/Administrator was present during the record review and the interview with the volunteer coordinator and agreed that this process needed to be changed to ensure the plan of care contained volunteer services.