Every finding on record at Compassionate Care Hospice of Central Florida, Inc.

Upon patient record review, 3 of 23 (Patient #2,7,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: Upon observation during the home visit, the patient was taking Carvedilol 12.5 mg and the medication record indicated Carvedilol 6.25 mg. Patient #7: There is evidence on the medication record for Cipro 500 mg Q12hrs. There is not a stop date for the antibiotic. A nurses' note on 11/13/25 indicates the Cipro to be taken for 10 days. Patient #8: There is evidence on the medication record for Prednisone dose pack. There is not a stop date for the dose pack. Additionally, there are no instructions for use, only "per instructions".

Upon patient record review, 1 of 23 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: The record indicated the patient had a coccyx wound with dressing. There is no evidence the nurse did a weekly wound assessment between 10/29/25 to 11/29/25.

Upon patient record review, 3 of 23 (Patient #2,7,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: Upon observation during the home visit, the patient was taking Carvedilol 12.5 mg and the plan of care indicated Carvedilol 6.25 mg. Patient #7: There is evidence on the plan of care for Cipro 500 mg Q12hrs. There is not a stop date for the antibiotic. A nurses' note on 11/13/25 indicates the Cipro to be taken for 10 days. Patient #8: There is evidence on the plan of care for Prednisone dose pack. There is not a stop date for the dose pack. Additionally, there are no instructions for use, only "per instructions"

Upon patient record review 1 of 23 (Patient #7) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #7: On the aide note 12/5/25, the aide noted for assist with shower, completed "N". "Patient declined not feeling well." There is no evidence the aide reported this information to the Nurse Case Manager.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer cost savings for 2024 was 0.2%.

Upon client record review, 2 of 23 (Patient #3,13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #3: There is evidence in the medical record for volunteer visit frequency of 2M1 for October 2025. There was a visit missing in October without a missed visit note. Patient #13: There is evidence in the medical record for volunteer visit frequency of 2M1 for October 2025. There were no visits in October without a missed visit note.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records. In 2 of 16 (12%) clinical records reviewed, the initial comprehensive assessment was completed after five calendar days. Clinical Record 9: The patient elected the hospice benefit on 9/22/2022. The spiritual assessment was completed on 10/18/2022. There was no documentation explaining why the assessment was delayed. Clinical Record 10: The patient elected the hospice benefit on 6/30/2022. The spiritual assessment was completed on 7/6/2022. There was no documentation explaining why the assessment was delayed.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 6 of 16 (38%) clinical records reviewed, the agency did not include planned interventions based on problems identified in the initial and updated comprehensive assessments on the individualized plan of care. Clinical Record 1: The patient elected the hospice benefit on 9/20/2022. The initial admission assessment identified that the patient was a high fall risk. There was no problem on the care plan to address the patient's safety related to falls. Clinical Record 5: The patient elected the hospice benefit on 10/11/2022. The initial admission assessment identified that the patient was a high fall risk. There was no problem with the care plan to address the patient's safety related to falls. Clinical Record 6: The patient elected the hospice benefit on 8/26/2022. The initial admission assessment identified that the patient was a high fall risk. There was no problem on the care plan to address the patient's safety related to falls. Clinical Record 8: The patient elected the hospice benefit on 1/3/2023. The initial admission assessment identified that the patient was a high fall risk. There was no problem on the care plan to address the patient's safety related to falls. Clinical Record 10: The patient elected the hospice benefit on 6/30/2022. The initial admission assessment identified that the patient was a high fall risk. There was no problem on the care plan to address the patient's safety related to falls. Clinical Record 11: The patient elected the hospice benefit on 10/11/2022. The initial admission assessment identified that the patient was a high fall risk. There was no problem on the care plan to address the patient's safety related to falls. The Administrator was interviewed on 1/18/2022 and agreed that the plan of care did not include the required information.

It is required that each patient’s individualized written plan of care which 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, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 16 (6%) clinical records reviewed, the plan of care did not include planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 6: The patient elected the hospice benefit on 8/26/2022. The Social Worker completed the initial assessment on 8/30/2022 and determined a visit frequency of one time every month. There were no problems, goals, or interventions in the plan of care for the Social Worker. The Chaplain completed the initial assessment on 8/31/2022 and determined a visit frequency of one time every month. There were no problems, goals, or interventions on the plan of care for the Chaplain. The Administrator was interviewed on 1/18/2022 and agreed that the plan of care did not include the required information.

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 a review of clinical records and interviews. In 1 of 1 (100%) applicable clinical record review of patient discharged from hospice services, the discharge summary was not forwarded to the attending physician. Clinical Record 14: The patient elected the hospice benefit on 8/6/2022. The hospice discharged the patient on 12/8/2022 for no longer meeting eligibility requirements. The discharge summary was completed on 12/8/2022, but there is no documentation that it was forwarded to the attending physician. The Administrator was interviewed on 1/18/2022 and agreed that the record did not include the required information.