Every finding on record at Compassionate Hospice Care LLC

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services was out of compliance. --- A total of 5 clinical records were reviewed for compliance with the condition and Standards for Interdisciplinary Group, Care Planning, and Coordination of Services. Record review revealed a pattern of failure in regard to care planning and coordination of services. This failure resulted in unqualified caregivers administering medications, including controlled substances, without hospice oversight or documentation.L547- Based on record review and interview, the hospice failed to develop an individualized plan of care (POC) which included a detailed statement of the scope and frequency of services necessary to meet patient needs. Specifically, the POC did not include information regarding the involvement of employees from an external agency or information regarding who would administer medications for 1 of 5 sample hospice patients (Patient #3).L554- Based on interview and record review, the hospice failed to maintain an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided. Specifically, this failure resulted in unqualified caregivers administering medications, including controlled substances, without hospice oversight or documentation, which prevented the IDG from fulfilling its regulatory duty to coordinate and supervise all care and services for 1 of 5 sample hospice patients (Patient #3).L558- Based on record review and interview, the hospice failed to provide for an ongoing sharing of information with an external agency. Specifically, the hospice did not communicate and supervise plan of care services, including determining who would administer medications, with non-hospice healthcare providers who performed services for 1 of 5 sample hospice patients (Patient #3).

Based on record review and interview, the hospice failed to develop an individualized plan of care (POC) which included a detailed statement of the scope and frequency of services necessary to meet patient needs. Specifically, the POC did not include information regarding the involvement of employees from an external agency or information regarding who would administer medications for 1 of 5 sample hospice patients (Patient #3). --- Findings include:The clinical record for Patient #3 was reviewed on 1/5/26. The patient was admitted to hospice care and services on 12/8/25, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period, dated 12/8/25 to 3/7/25, included orders for skilled nursing services twice per week for symptom management, medical social work services twice per month for psychosocial support, and hospice aide services once per week to assist with activities of daily living and personal hygiene.a) The agency failed to include information in the POC regarding the involvement of employees from an external agency.Review of the clinical record revealed a registered nurse (RN #1) documented non-hospice employees from an external agency were with Patient #3 seven days a week and 24 hours per day (24/7). Further review of the clinical record revealed the POC, dated 12/8/25, did not contain information regarding the roles and responsibilities of the non-hospice employees. During an interview with RN #1 on 1/5/26 at 3:14 p.m., RN #1 stated the non-hospice employed caregivers were employed by Patient #3 prior to Patient #3’s start of care with the hospice agency. RN #1 stated the non-hospice employed caregivers' roles were to assist with activities of daily living. RN #1 also stated the roles of the caregivers were not in the POC, but stated she talked frequently with the caregivers when making skilled nursing visits to Patient #3.b) The agency failed to include information in the POC regarding who would administer medications.Review of the clinical record for Patient #3 revealed the POC, dated 12/8/25, did not indicate whether medications were to be self-administered or who was to administer medications for the following physician ordered medications listed in the POC:Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/ML); Instructions: Take 3 mL (2.5 mg) by nebulization every 6 hours as needed for wheezingProventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT; Instructions: Inhale 2 puffs every 6 hours as needed for wheezingAtorvastatin Calcium Oral Tablet 40 MG; Instructions: Take 1 tablet (40 mg) by mouth daily for cholesterolThe clinical record revealed additional physician orders, dated 12/10/25, for the following medications:Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML; Instructions: Take 0.25 mL (5 mg) by mouth under the tongue very 3 hours as needed for pain/ shortness of breathLorazepam Intensol Oral Concentrate 2 MG/ML; Instructions: Take 0.25 mL (0.5 mg) by mouth under the tongue every 6 hours needed for anxiety/agitation.The updated POC for Patient #3, dated 12/23/25, did not contain information regarding whether the medications were to be self-administered or who was to administer medications.During an interview with the hospice director of nursing (DON) on 1/5/26 at 2:23 p.m., the DON stated she could not find documentation in the medical record or POC regarding who was to administer medications.During an interview with the hospice administrator on 1/7/26 at 9:45 a.m., the administrator stated the hospice did not document information regarding who would administer medications in the patient POC or medical record. She stated the hospice would update the medical record to include the information.

Based on interview and record review, the hospice failed to maintain an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided. Specifically, this failure resulted in unqualified caregivers administering medications, including controlled substances without hospice oversight or documentation, and prevented the IDG from fulfilling its regulatory duty to coordinate and supervise all care and services for 1 of 5 sample hospice patients (Patient #3). --- Findings include:The clinical record for Patient #3 was reviewed on 1/5/26. The patient was admitted to hospice care and services on 12/8/25, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care, for the certification period dated 12/8/25 to 3/7/25, included orders for skilled nursing services twice per week for symptom management, medical social work services twice per month for psychosocial support, and hospice aide services once per week to assist with activities of daily living and personal hygiene.a) The hospice agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for the supervision of the care and services provided which resulted in unqualified caregivers administering medications, including controlled substances, to Patient #3.Review of Patient #3’s record revealed medication orders, dated 12/10/25, for 0.25 mL of morphine (5 milligram) was to be administered sublingually (by mouth under the tongue) every three hours as needed and for 0.25 milliliter (mL) of lorazepam (0.5 milligram) to be administered sublingually every six hours.On 1/5/26, record review revealed an initial hospice agency comprehensive assessment, completed by a registered nurse (RN #1) on 12/8/25. Patient #3 was shown to reside at home alone. In the comments section of the initial assessment, RN #1 noted non-hospice employees from an external agency were with Patient #3 seven days a week and 24 hours per day (24/7). The section for medication management was blank and contained no notes regarding whether or not Patient #3 was assessed for the ability to self-administer medications or who would administer medications. Record review did not reveal interdisciplinary meeting notes regarding coordination of services, or other documentation regarding coordination of services, with the external agency where the non-hospice caregivers were employed. Record review revealed a narrative note, documented by RN #1 on 12/12/25, which stated “Dosing reviewed and caregivers are instructed to write down what time Morphine is given as she can not have it any more often than every 3 hours.”During an interview on 1/5/26 at 3:14 p.m., RN #1 confirmed the caregivers from the external agency had administered morphine and lorazepam as needed to Patient #3 between 12/10/25 and 12/30/25. RN #1 stated the non-hospice caregivers had not been trained to administer medications. RN #1 stated the orders for liquid morphine and lorazepam had been changed to orders for the tablet forms of the medications because Patient #3 could self-administer tablets.During an interview on 1/7/26 at 9:45 a.m., the director of nursing (DON) stated Patient #3 had complex needs and communication regarding patient needs was ongoing. The DON further stated not all communication between IDG members had made it into the medical record. During an interview on 1/7/26 at 10:00 a.m., the hospice administrator acknowledged communication regarding patient needs, including who performs medication administration, should be discussed with the hospice IDG and placed in the patient’s plan of care.

Based on record review and interview, the hospice failed to provide for an ongoing sharing of information with an external agency. Specifically, the hospice did not communicate and supervise plan of care services, including determining who would administer medications, with non-hospice healthcare providers who performed services for 1 of 5 sample hospice patients (Patient #3). --- Findings include:The clinical record for Patient #3 was reviewed on 1/5/26. The patient was admitted to hospice care and services on 12/8/25, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care, for the certification period dated 12/8/25 to 3/7/25, included orders for skilled nursing services twice per week for symptom management, medical social work services twice per month for psychosocial support, and hospice aide services once per week to assist with activities of daily living and personal hygiene.a) The hospice agency failed to coordinate care and communicate with an external home care agency employing non-hospice healthcare providers who performed services for Patient #3.Review of the clinical record revealed a registered nurse (RN #1) documented non-hospice employees from an external agency were with Patient #3 seven days a week and 24 hours per day (24/7). Further review of the clinical record revealed the POC, dated 12/8/25, did not contain information regarding the roles and responsibilities of the non-hospice employees or how coordination between the hospice and the external agency would be coordinated. During an interview on 1/5/26 at 3:14 p.m., RN #1 confirmed the medical record did not have documentation regarding the communication that took place between the external agency, the caregivers employed by the external agency, and hospice staff.During an interview on 1/7/26 at 9:45 a.m., the director of nursing (DON) stated Patient #3 had complex needs and communication regarding patient needs was ongoing. The DON further stated not all communication between IDG members made it into the medical record. During an interview on 1/7/26 at 10:00 a.m., the hospice administrator acknowledged communication regarding patient needs, including the roles and responsibilities of caregivers from the external agency, should be discussed with the hospice IDG and placed in the patient’s plan of care.

Based on record review and interview, the hospice interdisciplinary group (IDG) failed to determine the ability of the patient and/or family to safely self-administer drugs and biologicals for 5 of 5 sample hospice patients (Patient #1, #2, #3, #4, #5). --- Findings include:Five sample hospice patient clinical records were reviewed from 1/5/26 through 1/6/26. Complete medical records for the five patients, including initial, comprehensive, and updated assessments, plans of care (POC), clinician notes, communication notes, physician orders, admission paperwork, attachments to the medical records, and IDG meeting notes, were reviewed.a) The hospice hospice IDG failed to determine the ability of the patient and/or family to safely self-administer medications.Review of five sample clinical records did not reveal documentation of patients’ abilities or their families’ abilities to safely self-administer medications.During an interview on 1/5/26 at 3:14 p.m., RN #1 confirmed the hospice medical records did not contain documentation regarding the ability of the patient and/or family to safely self-administer medications. RN #1 stated the information was obtained through conversations, but was not documented.During an interview with the hospice director of nursing (DON) on 1/5/26 at 2:23 p.m., the DON stated she could not find documentation in the medical records or POCs regarding who was to administer medications.During an interview on 1/7/26 at 10:00 a.m., the hospice administrator acknowledged, per policy and regulations, the ability to safely self-administer medications should be discussed with the hospice IDG and placed in each patient’s plan of care.

Based on record review and interview, the hospice failed to store controlled drugs appropriately. Additionally, the hospice failed to immediately investigate and report discrepancies in tracking medications for 1 of 5 sample hospice patients (Patient #3). --- Findings include:The clinical record for Patient #3 was reviewed on 1/5/26. The patient was admitted to hospice care and services on 12/8/25, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care, for the certification period dated 12/8/25 to 3/7/25, included orders for skilled nursing services twice per week for symptom management, medical social work services twice per month for psychosocial support, and hospice aide services once per week to assist with activities of daily living and personal hygiene.Review of the clinical record for Patient #3 revealed non-hospice employees from an external agency were with Patient #3 seven days a week and 24 hours per day (24/7). Further review of the clinical record revealed the POC, dated 12/8/25, did not contain information regarding the roles and responsibilities of the non-hospice employees.Review of the clinical record for Patient #3 revealed the POC, dated 12/8/25, revealed the following physician medication orders listed in the POC:Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/ML); Instructions: Take 3 mL (2.5 mg) by nebulization every 6 hours as needed for wheezingProventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT; Instructions: Inhale 2 puffs every 6 hours as needed for wheezingAtorvastatin Calcium Oral Tablet 40 MG; Instructions: Take 1 tablet (40 mg) by mouth daily for cholesterolThe clinical record revealed additional physician orders, dated 12/10/25, for the following medications:Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML; Instructions: Take 0.25 mL (5 mg) by mouth under the tongue very 3 hours as needed for pain/ shortness of breathLorazepam Intensol Oral Concentrate 2 MG/ML; Instructions: Take 0.25 mL (0.5 mg) by mouth under the tongue every 6 hours needed for anxiety/agitation.a) The agency failed to store controlled drugs appropriately.Review of the clinical record revealed a skilled nursing visit note by RN #1, dated 12/30/25, revealed a lock box was placed in Patient #3’s home on 12/30/25.Further review of the clinical record revealed RN #1 documented, on 12/30/25, placement of “a lock box in the home for comfort meds which will now only be administered by hospice nurses.”During an interview on 1/5/26 at 3:14 p.m., RN #1 confirmed the controlled drugs had been ordered on 12/10/25, but had not been stored in a lock box until 12/30/25.b) The agency failed to immediately investigate and report discrepancies in the counts of medications.Record review revealed a narrative note, from a Skilled Nursing Visit Addendum Page, documented by RN #1 on 12/23/25, which revealed medications were missing and RN #1 had spoken with the executive director of the external agency regarding the missing medications.The hospice director of nursing (DON) and administrator were interviewed at 9:45 a.m. on 1/7/26. The DON stated the plan of care for Patient #3 did not contain enough information to reflect the complex situation involved with multiple caregivers and medication administration for Patient #3. The administrator acknowledged the importance of oversight and stated the hospice had not documented information regarding who administered medications, or how medications would be stored. During an interview at 9:57 a.m. on 1/7/26, the administrator stated she had not been informed about the missing medications. She stated the issue should have been escalated to her, as the administrator, when the medications were determined to be missing on 12/23/25 so she could initiate an investigation.

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 clinical record review and interview. In 3 of 14 (21%) clinical records reviewed the agency did not ensure that the plans of care documented all interventions for the care of the patients. CLINICAL RECORD 9: The hospice benefit of the election was signed on 10/30/2023 with a primary diagnosis of protein deficiency malnutrition and a secondary diagnosis of Lung Cancer. IDG (interdisciplinary group meeting) updates and physician orders, dated 10/27/2023, documented an upper respiratory infection treated with antibiotics, increased secretions, and shortness of breath, with rare use of supplemental oxygen, as the patient feels it interrupts her sleep. IDG 06/25/2024 documented more use of the supplemental oxygen for a pulse ox of 80% but not wearing consistently per patient choice. IDG 8/2/2024 documented increasing SOB (shortness of breath) with activity and uses oxygen rarely. IDG 02/18/2025 documented that increasingly difficult-to-manage secretions and shortness of breath continue with some use of supplemental oxygen. The initial care plan documented 10/30/2023 and updated every 2 weeks each benefit period (10/30/2023 - 01/27/2024, 01/28/2024 - 04/26/2024, 04/27/2024 - 05/25/2024, 06/26/2024 - 08/24/2024, 08/25/2024 - 10/23/2024, 10/24/2024 - 12/23/2024, 12/23/2024 - 02/20/2025, and 02/21/2025 - 04/21/2025 did not document any interventions for shortness of breath or oxygen until the updated plan 03/25/2025. During an interview with the clinical manager, she stated they now have the interventions, but they had not been in the previous plans of care. The nursing assessments did document education and interventions.

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 clinical record review and interview. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure the initial psychosocial assessments were completed within 5 calendar days after the election of hospice care. Record #75130 was reviewed and identified the patient was admitted to hospice on 12/23/2021 and declined social work. The clinical record did not contain documentation of an initial psychosocial assessment. Record #44302 was reviewed and identified the patient was admitted to hospice on 8/12/2021 and declined social work. The clinical record did not contain documentation of an initial psychosocial assessment. Record #68009 was reviewed and identified the patient admitted to hospice on 5/5/2022 and declined social work. The clinical record did not contain documentation of an initial psychosocial assessment. Record #26679 was reviewed and identified the patient admitted to hospice on 4/26/2022 and declined social work. The clinical record did not contain documentation of an initial psychosocial assessment. Record #78642 was reviewed and identified the patient admitted to hospice on 4/27/2022 and declined social work. The clinical record did not contain documentation of an initial psychosocial assessment. The Clinical Director was interviewed on 6/20/2022 and stated, "We missed these". She confirmed there were no initial psychosocial assessments completed in the records identified.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and interview. 4 of 11 (36%) clinical records reviewed revealed the hospice did not ensure the plans of care included orders for all interventions and services to meet specific patient needs that were identified in the comprehensive assessments. Record #75130: Start of Care (SOC) 12/23/2021, Diagnosis Alzheimer’s Disease. The nursing assessment completed on 12/23/2021 included documentation stating: “skin tear to right wrist with bleeding when nurse removed original dressing. Wound cleansed and Allevyn dressing applied". There was no documented evidence of an order for the wound care provided. Also, the comprehensive assessment dated 4/12/2022 was reviewed and revealed “pt ambulates without use of assistive device; she is a high fall risk." Plan of Care (POC) dated 4/19/2022 did not include evidence identifying the fall risk as a problem or interventions to address it. The Clinical Director was interviewed on 6/22/2022 and confirmed the finding. Record #85864: SOC 12/30/2021, Diagnosis Chronic Systolic Congestive Heart Failure. Comprehensive assessment on 12/30/2021 reviewed and revealed the patient had pain score of 5/10 with 2/10 target pain goal. On 1/17/2022 a physician’s order for Tramadol 25mg BID was scheduled. The POC dated 1/25/2022 did not include evidence identifying pain as a problem or interventions to address the pain. The Clinical Director was interviewed on 6/22/2022 and stated, “We missed putting pain on the plan of care.” Record #48432: SOC 1/12/2022, Diagnosis Chronic Obstructive Pulmonary Disease. Comprehensive assessment on 1/12/2022 reviewed and revealed “pressure wound to buttock 2cm x 2cm with excoriated skin surrounding wound. Foam dressing placed on buttock wound for healing and protection.” POC dated 1/12/2022-1/23/2022 did not contain evidence identifying the wound as a problem or interventions to address the wound. The Clinical Director was interviewed on 6/22/2022 and stated, the wound was not identified on the POC. Record #78642: SOC 4/27/2022, Diagnosis Malignant Pleural Effusion. Chaplain assessment on 4/28/2022 reviewed and revealed the patient was to receive Chaplain visits 3-4x month for companionship, prayer, and connection to faith tradition. POC dated 5/3/2022 did not include evidence of a spiritual plan of care. The Clinical Director was interviewed on 6/22/2022 and stated, there was no spiritual plan of care.

t is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. This standard was not met as evidenced by clinical record review, interview and document review. 1 of 2 (50%) clinical records reviewed with a bereavement plan of care revealed the hospice did not ensure bereavement services were provided up to one year following the death of the patient. Agency policy, “Bereavement Services” “Policy No. 9-023,” stated in part: “Ongoing bereavement contact will be concluded at the end of up to one (1) year, if the bereaved is no longer in need of hospice bereavement services. A letter will be sent indicating completion of bereavement services.” Record #48432 was reviewed and revealed the patient died on 1/23/2022. The daughter was discharged from bereavement services on 5/23/2022 due to, “no return call within 2 wks so discharged from bereavement program.” The Bereavement Coordinator was interviewed on 6/22/2022 and stated, a decision was made to make calls around three months and leave a message with the bereaved to see if they wanted to continue bereavement and if no return call, they were discharged with no further contact. She confirmed “no letters were mailed.” The Administrator was interviewed on 6/22/2022 and stated, “It was a miscommunication around the change in EMR, our policy hasn’t changed.” She confirmed the staff did not follow the bereavement policy.

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. This standard was not met as evidenced by clinical record review and interview. 3 of 3 (100%) applicable records of patients discharged from hospice revealed the hospice did not ensure a discharge summary was completed and provided to the attending physician. Record #75130 was reviewed and revealed the patient was discharged on 4/6/2022. There was no evidence a discharge summary was completed and sent to the attending physician. Record #85864 was reviewed and revealed the patient was discharged on 3/28/2022. There was no evidence a discharge summary was completed or sent to the attending physician. Record #62672 was reviewed and revealed the patient was discharged on 2/25/2022. There was no evidence a discharge summary was completed or sent to the attending physician. The Clinical Director was interviewed on 6/22/2022 and stated, “We missed these, we need to update our process.” The Administrator was interviewed on 6/22/2022 and confirmed the findings.