Every finding on record at Crescent Hospice, LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #IC.15 "Hand Hygiene" (last reviewed 09/01/2024) stated in part, "Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with the recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet...Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: prior to initial entry into the supply bag;... before moving from a contaminated body site to a clean body site during patient care;... after removing gloves." In 1 of 3 (33%) home visits observed, the organization did not ensure that hand hygiene was performed when indicated per the agency's policy. HOME VISIT 1: During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 08/13/2025, the HA washed their hands with soap and water, dried them with a hand towel hanging on the towel bar, and then used the hand towel to turn off the water faucet. The HA did not use a clean paper towel to dry their hands or turn off the faucet per the agency's policy. The HA returned to the patient's room, donned gloves, and began removing the bedding for the bath. Due to the patient being uncooperative, the HA bathed the left side of the patient's body, and then the patient's perineum and buttocks. The HA began to change the bed and the patient's brief. The HA did not doff their gloves and sanitize their hands after cleaning the patient's perineum and buttocks before moving to changing the bed. During an interview on 08/14/2025, the Area Vice President of Operations/Interim Executive Director/Registered Nurse agreed that the staff did not follow the hand hygiene policy.

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 and interview. 1 of 13 (8%) clinical records reviewed revealed that the initial comprehensive assessment was not completed within five calendar days. Clinical Record 10: The patient elected the hospice benefit on 3/24/2021 with a primary hospice diagnosis of Senile Degeneration of the Brain. The Social Worker documented on 3/27/2022 that the family requested the visit occur on 3/31/2022. There was no additional documentation from the Social Worker. The initial social worker assessment was not completed until 5/31/2022. The Patient Care Manager was interviewed on 10/26/2022 and agreed that the assessment was late and she was not able to find any additional documentation to explain why the visit was late.

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. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy. 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 a review of clinical records, interviews, and observations. 1 of 13 (8%) clinical records reviewed identified that the drug profile was not updated with each comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 8/19/2021 with a primary diagnosis of Chronic Diastolic Heart Failure. During a home visit on 10/26/2022, the medications were reviewed with the RNCM. The drug profile indicated that the patient was prescribed Potassium Chloride ER 10meq tablet; one tablet daily. There was no potassium in the home and the caregiver reported that she had not refilled this medication for "a while". The patient was also prescribed Tramadol 50mg tablet, one tablet three times a day. The medication in the home was Tramadol 50mg, one tablet twice daily, and was last filled on 10/14/2022. The caregiver reported that the patient was taking the medication twice a day. The drug profile and medication bottles were reviewed with the RNCM during the visit. The Patient Care Manager was interviewed on 10/26/2022 and acknowledged the discrepancy with the drug profile.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition and related diagnosis(es) if any. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) clinical records reviewed identified that the written certification did not include the required elements. Clinical Record 5: The patient elected the hospice benefit on 12/9/2021 with a primary hospice diagnosis of Chronic Systolic Heart Failure. In reviewing the Certifications of Terminal Illness (CTI's), the initial CTI narrative completed on 12/16/2021 stated in part "93 y old female hospice dx senile degeneration of the brain..." The CTI Narrative completed on 9/22/2022 stated, in part, "91-year-old Hispanic male living at home, hospice diagnosis Non-ischemic Cardiomyopathy..." There were no physician orders to change the hospice diagnosis. The Executive Director and Patient Care Manager were both interviewed on 10/27/2022 and acknowledged that there was incorrect information in the CTI's.