Every finding on record at Crossroads Hospice of Tennessee, LLC

Based on document review and interview, the hospice agency failed to conduct exercises to test the emergency plan on an annual basis.  The findings included: Review of the hospice agency's Emergency Preparedness plan revealed there was no documentation of exercises to test the emergency plan for 2025. In an interview on 12/17/2025 at 11:11 AM, the hospice agency's Clinical Director verified there was no documentation of emergency plan exercises for 2025.

Based on policy review, medical record review, observation and interview, the agency failed to ensure all medications in the home were documented accurately for 2 of 6 (Patient #1 and #3) sampled patients with home visits. --- The findings included:1.Review of the agency policy "Medication Reconciliation, Facility Orders..." last revised on 8/30/2023, revealed, "Policy Statement: This agency will ensure that all mediations are reviewed upon admission to the hospice program, with each medication addition/change/deletion to ensure that there are no contraindications, drug interactions...In addition, the medications reconciliation will occur upon admission, with each medication change, and will be discussed at each IDG [interdisciplinary group meeting] ...Procedure: To ensure patient safety and effective medical treatment, medication safety is a high priority of this Agency. Therefore, all medications will be carefully reviewed upon admission and with each medication change...Medication Review Each Visit-Home and Facility At each visit, the RN [Registered Nurse] or LPN [Licensed Practical Nurse] will be required to review with the patient/family during home visits and the facility chart (for facility patients) for new/changed telephone orders and or MAR [Medication Administration Record..."2. Medical record review for Patient #1 revealed an admission date of 7/16/2025 with a primary diagnosis of Senile Degeneration. The patient lived in the assObservations in the assisted care living facility on 12/16/2025 at 9:30 AM revealed the following medications were listed on the hospice medication profile, but were not found in the facility for Patient #1: Flonase allergy spray 2 sprays per nostril as needed (PRN), Hydrocodone/Apap (a pain medication) tablet 5-325  milligrams (mg) one tablet every 6 hours PRN, Oxybutynin (medication for overactive bladder) tablet 5 mg one tablet daily for anxiety, Vitamin D (vitamin supplement) 2,000 units one capsule daily and Saccharomyces Boulardii (a probiotic) 250 mg capsule.During an interview on 12/16/2025 at 9:35 AM, the agency nurse verified Patient #1 was no longer taking the above listed medications.3. Medical record review for Patient #3 revealed an admission date of 9/17/2025.  Patient #3 had a primary diagnosis of Cerebrovascular disease.Observations in the home on 12/16/2025 at revealed the following medication was listed on the hospice medication profile but was not found in the home:  Loratadine Solution (an allergy medication) 5mg/5 milliliters (ML).During an interview on 12/16/2025 at 1:50 PM, Patient #3’s granddaughter stated the patient only took that medication during allergy season, and there was no Loratadine in the home.4. During an interview on 12/16/2025 at 2:30 PM, the Clinical Director verified the nursing staff should review the medications at each visit and make any changes to the medication profile in the medical record.

Based on policy review, medical record review and interview the facility failed to ensure the Plan of Care (POC) was followed by the interdisciplinary team recommendations and according to physician orders, by providing skilled Nursing visits, Hospice Aide visits and Chaplain visits without physician orders and by failing to provide aide frequencies in accordance with the POC for 13 of 18 ( Patient #1, 2, 3, 5, 8, 11, 12, 13, 14, 15, 16, 17 and 18) sampled active patients. --- The findings included:1. Review of the facility’s “MISSED VISITS-RESCHEDULED VISITS-REFUSED VISITS” policy (6/1/2024) revealed, “…Staff must follow the frequencies established on the plan of care. In the event that a visit is missed, the following procedures must be followed…If a visit has been missed and has not been rescheduled or performed within the said work week/timeframe, this will be considered a “missed visit” and will be reported to supervisor and will be recorded on Change of Acuity Status form, the appropriate missed visit report log…” Review of the facility’s “IDG HOSPICE PLAN OF CARE-TEAM MEETINGS, CONTENT, PLAN, GOALS, INTERVENTIONS AND OUTCOMES” policy (1/11/2024) revealed, “…The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions…A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…” 2. Medical record review for Patient #1 revealed elderly female with admission date of 7/16/2025. The clinical staff failed to follow the POC for Aide services. 3. Medical record review for Patient #2 revealed elderly female with admission date of 10/1/2025.  The clinical staff failed to follow the POC for SN and Aide services.  4. Medical record review for Patient #3 revealed elderly female with admission date of 9/17/2025 with diagnosis of Cerebrovascular disease. The clinical staff failed to follow the POC for SN and Aide services.  5. Medical record review for Patient #5 revealed elderly female with admission date of 8/24/2024. The clinical staff failed to follow the POC for SN and Aide services. 6. Medical record review for Patient #8 revealed elderly female with admission date of 10/17/2025. The clinical staff failed to follow the POC for SN, and Aide services. 7. Medical record review for Patient #11 revealed elderly female with admission date of 11/5/2024. The clinical staff failed to follow the POC for SN, Aide and Chaplain services. 8. Medical record review for Patient #12 revealed elderly male with admission date of 7/16/2025. The clinical staff failed to follow the POC for Aide and Chaplain services. 9. Medical record review for Patient #13 revealed elderly female with admission date of 5/29/2025. The clinical staff failed to follow the POC for SN and Aide services. 10. Medical record review for Patient #14 revealed elderly female with admission date of 5/3/2025. The clinical staff failed to follow the POC for SN and Aide services. 11. Medical record review for Patient #15 revealed elderly female with admission date of 11/19/2025. The clinical staff failed to follow the POC for SN services. 12.Medical record review for Patient #16 revealed elderly male with admission date of 9/23/2025. The clinical staff failed to follow the POC for SN and Aide services. 13. Medical record review for Patient #17 revealed elderly female with admission date of 12/19/2023. The clinical staff failed to follow the POC for Aide services. 14. Medical record review for Patient #18 revealed male with admission date of 12/09/2025. The clinical staff failed to follow the POC for Aide services.

Based on policy review, medical record review and interview, the facility failed to ensure the plan of care (POC) was followed for 13 of 18 (Patient #1,2,3,5,8,11,12,13,14,15,16,17 and 18) active patients reviewed. The findings included: 1. Review of the facility’s “MISSED VISITS-RESCHEDULED VISITS-REFUSED VISITS” policy (6/1/2024) revealed, “…Staff must follow the frequencies established on the plan of care. In the event that a visit is missed, the following procedures must be followed…If a visit has been missed and has not been rescheduled or performed within the said work week/timeframe, this will be considered a “missed visit” and will be reported to supervisor and will be recorded on Change of Acuity Status form, the appropriate missed visit report log…” Review of the facility’s “IDG HOSPICE PLAN OF CARE-TEAM MEETINGS, CONTENT, PLAN, GOALS, INTERVENTIONS AND OUTCOMES” policy (1/11/2024) revealed, “…The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions…A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…” 2. Medical record review for Patient #1 revealed elderly female with admission date of 7/16/2025 with a diagnosis of Senile Degeneration. Review of a physician order dated 10/21/2025 revealed Hospice aide visits 2 times per week for 14 weeks. Review of Aide visits for Patient #1 revealed no visit was documented for 11/27/2025. In an interview on 12/15/2025 at 2:20 PM, the facility’s Team Leader Nurse verified there was no documentation in the medical record to explain the missed aide visit and failure to follow the Plan of Care (POC).  3. Medical record review for Patient #2 revealed elderly female with admission date of 10/1/2025 with diagnosis of Unspecified protein calorie malnutrition. Review of 10/1/2025 POC revealed skilled nurse (SN) services were discontinued on 10/28/2025. Aide services were discontinued on 11/25/2025. Review of interdisciplinary visits for Patient #2 revealed SN visits were made on 11/11/2025, 11/19/2025,11/28/2025 and 12/2/2025. Aide visits were made on 11/28/2025, 12/2/2025 and 12/5/2025 In an interview on 12/16/2025 at 3:00 PM, the Vice President (VP) of Clinical Education verified there were no physician orders for the SN visits that occurred after 10/28/2025 and no physician orders for the aide visits that occurred after 11/25/2025.          4. Medical record review for Patient #3 revealed elderly female with admission date of 9/17/2025 with diagnosis of Cerebrovascular disease. Review of 11/4/2025 POC revealed skilled nurse (SN) services were discontinued on 11/9/2025. Aide services were discontinued on 11/9/2025. Review of interdisciplinary visits for Patient #3 revealed SN visits were made on 11/11/2025, 11/17/2025,11/24/2025 and 12/2/2025, 12/10/2025 and 12/16/2025. Aide visits were made on 11/13/2025, 11/17/2025, 11/20/2025, 11/24/2025, 12/1/2025, 12/4/2025, 12/8/2025, 12/11/2025, 12/15/2025. 5. Medical record review for Patient #5 revealed elderly female with admission date of 8/24/2024 with diagnosis of Malignant Neoplasm of Endometrium. Review of 10/22/2025 POC revealed SN services were discontinued on 10/28/2025. Aide services were discontinued on 10/24/2025. Review of interdisciplinary visits for Patient #5 revealed SN visits were made on 11/7/2025, 11/12/2025, 11/20/2025, 11/28/2025, 12/4/2025, 12/11/2025. Aide visits were made on 10/27/2025, 10/29/2025, 11/3/2025, 11/10/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/24/2025, 11/26/2025, 12/1/2025, 12/3/2025, 12/10/2025, 12/12/2025 and 12/15/2025. In an interview on 12/16/2025 at 3:10 PM, the facility’s Clinical Director verified there were no physician orders for the SN visits that occurred after 10/28/2025 and no physician orders for the aide visits that occurred after 10/24/2025.  6. Medical record review for Patient #8 revealed elderly female with admission date of 10/17/2025 with diagnosis of senile degeneration of brain. Review of 10/17/2025 POC revealed SN and aide services were discontinued on 11/13/2025. Review of interdisciplinary visits for Patient #8 revealed SN visits were made on 11/25/2025, and 12/4/2025. Aide visits were made on 11/17/2025, 11/19/2025, 11/26/2025, 11/28/2025, 12/2/2025, 12/5/2025, 12/9/2025, 12/12/2025 and 12/16/2025. In an interview on 12/17/2025 at 10:47 AM, VP of Clinical Education verified there were no physician orders for the SN and aide visits that occurred after 11/13/2025. 7. Medical record review for Patient #11 revealed elderly female with admission date of 11/5/2024 with diagnosis of Dementia. Review of 10/31/2025 POC revealed SN and aide services were discontinued on 11/11/2025. The POC revealed no order for Chaplain services. Review of the interdisciplinary visits for Patient #11 revealed SN visits were made on 11/14/2025, 11/21/2025, 12/5/2025, 12/12/2025. Aide visits were made on 11/12/2025, 11/14/2025, 11/19/2025, 11/21/2025, 11/26/2025, 11/28/2025, 12/3/2025, 12/5/2025, 12/10/2025 and 12/12/2025. Chaplain visits were made on 11/4/2025, 11/18/2025 and 12/2/2025. In an interview on 12/17/2025 at 10:58 AM, VP of Clinical Education verified there were no physician orders for the SN and aide visits that occurred after 11/11/25 and verified no orders for chaplain visits. 8. Medical record review for Patient #12 revealed elderly male with admission date of 7/16/2025 with diagnosis of Chronic Obstructive Pulmonary Disease. Review of 10/14/2025 POC revealed no orders for Aide visits from 10/27/2025 through 11/20/2025. The POC revealed no orders for Chaplain visits after 10/15/2025. Review of the interdisciplinary visits for Patient #12 revealed aide visits were made on 10/29/2025, 11/3/2025, 11/6/2025, 11/10/2025, 11/13/2025, 11/17/2025 and 11/19/2025. Chaplain visits were made on 11/11/2025 and 12/8/2025. In an interview on 12/17/2025 at 12:08 PM, VP of Clinical Education verified there were no orders to cover the aide visits between 10/27/2025 and 11/20/2025 and no orders for the Chaplain visits on 11/11/2025 and 12/8/2025.     9. Medical record review for Patient #13 revealed elderly female with admission date of 5/29/2025 with diagnosis of Senile Degeneration of the brain. Review of interdisciplinary visits for Patient #13 revealed SN visits were made on 11/25/2025, 12/2/2025, 12/11/2025 and 12/15/2025. Aide visits were made on 11/25/2025, 11/26/2025, 12/2/2025, 12/4/2025, 12/9/2025, 12/12/2025, and 12/16/2025. In an interview on 12/27/2025 at  12:15 PM, the VP of Clinical Education verified there were no documented physician orders or Interdisciplinary Group (IDG) Meeting documents for the SN or Aide visits. 10. Medical record review for Patient #14 revealed elderly female with admission date of 5/3/2025 with diagnosis of senile degeneration of brain. Review of 10/30/2025 POC revealed SN and aide visits were discontinued on 11/3/2025. Review of the interdisciplinary visits for Patient #14 revealed SN visits were made on 11/4/2025, 11/13/2025, 11/21/2025, 12/1/2025, 12/2/2025, 12/5/2025, 12/8/2025 and 12/14/2025. Aide visits were made on 11/5/2025, 11/10/2025, 11/12/2025, 11/17/2025, 11/19/2025, 11/24/2025, 12/3/2025, 12/10/2025 and 12/15/2025. In an interview on 12/17/2025 at 12:08 PM, VP of Clinical Education verified there were no orders for the SN and aide visits made after 11/3/2025. 11. Medical record review for Patient #15 revealed elderly female with admission date of 11/19/2025 with a diagnosis of Acute on Chronic Congestive Heart Failure. Review of a physician order dated 11/19/2025 revealed SN one visit every week for 4 weeks with 1 PRN [as needed] visit. Review of interdisciplinary visits for Patient #15 revealed 3 SN visits were made the week of 11/30/2025 (12/3/2025, 12/5/2025 and 12/6/2025). In an interview on 12/17/2025 at 11:50 AM, the VP of Clinical Education verified the nurse made an extra PRN visit without a physician order and without approval of the IDG. 12. Medical record review for Patient #16 revealed elderly male with admission date of 9/23/2025 with diagnosis of neurocognitive disorder with lewy bodies. Review of 9/23/2025 POC revealed SN and aide visits were discontinued on 10/20/2025. Review of the interdisciplinary visits for Patient #16 revealed SN visits were made on 10/22/2025, 10/29/2025, 11/5/2025, 11/12/2025, 11/19/2025, 11/26/2026, and 12/3/2025. Aide visits were made on 11/3/2025, 11/7/2025, 11/10/2025, 11/21/2025, 11/24/2025, 11/28/2025, 12/1/2025 and 12/5/2025. In an interview on 12/17/2025 at 12:08 PM, VP of Clinical Education verified there were no orders for the SN and aide visits made after 10/20/2025. 13. Medical record review for Patient #17 revealed elderly female with admission date of 12/19/2023 with a diagnosis of Congestive Heart Failure. Review of a physician order dated 9/10/2025 revealed Hospice aide visits 2 times per week for 14 weeks, through 12/16/2025. Review of Aide visits for Patient #17 revealed one visit was documented on 12/10/2025, with no second aide visit documented the week of 12/7/2025. In an interview on 12/17/2025 at 12:19 PM, the VP of Clinical Education verified there was no documentation in the medical record to explain the missed aide visit and failure to follow the POC. 14. Medical record review for Patient #18 revealed male with admission date of 12/09/2025 with a diagnosis of malignant neoplasm of lung. Review of a physician order dated 12/9/2025 revealed Hospice aide visits 2 times per week for 2 weeks. Review of Aide visits for Patient #18 revealed only one visit was documented the week of 12/9/2025. In an interview on 12/17/2025 at 12:19 PM, the VP of Clinical Education verified there was no documentation in the medical record to explain the missed aide visit and failure to follow the POC.

Based on policy review, record review, and interview, the facility failed to ensure the Plan of Care (POC) included measurable outcomes for 4 of 18 (Patient #1, #2, #5, and #6) sampled patients. --- The findings included: 1. Review of the facility policy ";IDG [Interdisciplinary Group] HOSPICE PLAN OF CARE, COORDINATION AND CONTINUITY OF CARE-..." renewed 5/23/2022 revealed, ";...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...The Plan of Care interventions must include measurable outcomes with data collected during the comprehensive assessment and updates..." 2. Medical record review for Patient #1 revealed a Start of Care (SOC) date of 8/23/2022 and a Recertification (RC) date of 11/10/2022 – 2/19/2023, with diagnoses which included Alzheimers Disease. The IDG Meeting Notes dated 1/26/2023 at 11:51 AM, revealed Patient #1 required Seroquel and Ativan due to confusion, anxiety, and agitation. Had reddened areas to bilateral hips and knees. Also had difficulty swallowing and pocketed food. Review of the Comprehensive Care Plan dated 2/15/2023 revealed, ";...Issue...Fecal Incontinence...Goal...Patient should exhibit optimal comfort and dignity related to incontinence... Issue...Urinary Incontinence...Goal...Patient should exhibit optimal comfort and dignity related to incontinence...Issue...Generalized Weakness... patient should receive personal care safely and effectively and maintain dignity..." The Comprehensive POC did not address medications, skin integrity and did not include measurable outcomes for Patient #1. 3. Medical record review for Patient #2 revealed a SOC date of 1/15/2021 and a RC date of 1/5/2023 – 3/6/2023, with diagnoses which included Cerebrovascular Accident. The IDG Meeting Notes dated 1/30/2023 at 4:52 PM, revealed Patient #2 was visibly losing weight, urine was very strong and continued to display increasing weakness. Review of the Comprehensive Care Plan dated 2/15/2023 revealed, ";...Issue...Urinary Incontinence...Goal...Patient should exhibit optimal comfort and dignity related to incontinence...Issue...PO [by mouth] Intake...Patient should maintain optimal PO intake within the disease process...Issue...Diminished Strength...Weakness will be tolerated..." The Comprehensive POC did not include measurable outcomes for Patient #2. 4. Medical record review for Patient #5 revealed a SOC date of 1/9/2023 with diagnoses which included Senile Degeneration of the Brain. The IDG Meeting Notes dated 1/30/2023 at 8:13 PM, revealed Patient #5 continued to placed items into the toilet causing it to clog. The patients gait was unsteady and often forgot to use the cane. Review of the Comprehensive Care Plan dated 2/15/2023 revealed, ";...Issue...Impaired Balance...Patient will remain comfortable and safe...Issue...Generalized Weakness...Weakness will be tolerated...Issue...Diminished Strength...Weakness will be tolerated..." The Comprehensive POC did not include measurable outcomes for Patient #5. 5. Medical record review for Patient #6 revealed a SOC date of 12/24/2021 and a RC date of 12/19/2022 – 2/16/2023, with diagnoses which included Stomach Cancer. The IDG Meeting Notes dated 1/31/2023 at 2:47 PM, revealed Patient #6 took scheduled and as needed (PRN) oxycodone. The patient continued to have pain in chest and back that patient reported traveled all over her body. Review of the Comprehensive Care Plan dated 2/15/2023 revealed, ";...Issue...Anxiety... Patient should exhibit decrease signs and symptoms of anxiety...Agitation... patient will exhibit decreased signs and symptoms of agitation..." The Comprehensive POC did not address pain management or include measurable outcomes for Patient #6. 6. In an interview on 2/14/2023 at 3:25 PM, the Site Educator revealed the goals and interventions on the POC were auto-generated by the facilitys computer system. The Site Educator verified the POC goals for Patients #1, #2, #5, and #6 were not measurable.

Based on policy review, record review, and interview, the facility failed to ensure care and services were provided accorded to the plan of care (POC) for 2 of 18 (Patient #7 and #18) sampled patients. --- The findings included: 1. Review of the facility policy ";IDG [Interdisciplinary Group] HOSPICE PLAN OF CARE, COORDINATION AND CONTINUITY OF CARE-..." renewed 5/23/2022 revealed, ";... The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family..." Review of the facility policy ";MISSED VISITS/RESCHEDULED VISITS/REFUSED VISITS" renewed 5/9/2022 revealed, ";... If a visit has been missed and has not been rescheduled or performed within the said work week/time period, this will be considered a ";missed visit" and will be reported to supervisor and will be recorded on the appropriate missed visit report log and will ultimately reported to the QAPI committee for review/discussion at the next scheduled QAPI committee meeting..." 2. Medical record review for Patient #7 revealed a Start of Care (SOC) date of 3/22/2019 and a Recertification (RC) date of 12/31/2022 – 2/28/2023, with diagnoses which included Lung Cancer. Patient #7 was scheduled for Nursing visits 1 x per month with 1 PRN visit and visits from the Hospice Aide 2 x week. Review of the visit notes from January 1, 2023 – February 11, 2023, revealed the Hospice Aide visited Patient #7 1x per week, for 6 weeks. The IDG Meeting Notes dated 1/26/2023 at 11:31 PM, revealed the Hospice Aide followed the POC. The IDG Meeting Notes dated 2/2/2023 at 4:38 PM, revealed the Hospice Aide followed the POC. The IDG Meeting Notes dated 2/8/2023 at 7:49 PM, revealed the Hospice Aide followed the POC. The facility was unable to provide documentation for the missed visits for Patient #7. 3. Medical record review for Patient #18 revealed a SOC date of 3/17/2022 and a RC date of 1/11/2023 – 3/11/2023, with diagnoses which included End Stage Renal Disease. Patient #18 was scheduled for Hospice Aide visits 2 x week. Review of the visit notes from January 11, 2023 – February 11, 2023, revealed the Hospice Aide visited Patient #18 1x during week 5. The facility was unable to provide documentation for the missed visits for the week of 2/5/2023-2/11/2023. 4. In an interview on 2/16/2023 at 12:29 PM, in the conference room, the Team Leader for Patient #7 verified the missed Hospice Aide visits. The Team Leader revealed the nurse entered the orders into the system wrong.

Based on document review and interview, the facility failed to measure, analyze and track quality indicators since departure of previous management. --- The findings included: 1. In an interview on 2/13/2023 at 11:12 AM, in the conference room, the Executive Director (ED) revealed the facility had not had a QAPI meeting ";in a year." The ED revealed he was hired 7 months ago and had been in training. In November 2022, we could not locate the QAPI documents from the previous managers. The ED sent out a Process Documentation to address the Plan of Action. The ED revealed the QAPI was scheduled to meet on 2/21/2023. 2. Review of the Process Documentation dated 11/2/2022 revealed, ";...Discovery of need for QAPI data gathering/reporting...Immediate establishment of QAPI committee at this location...Assignment of Clinical Director as Chairperson...First Report Date...February, 2023..."

Based on policy review, record review and interview, the facility failed to follow the plan of care related to nursing and aide visits for 2 of 3 (Patient #1 and #3) sampled patients reviewed. The findings included: 1. Review of the facility's "POLICY: GENERAL INPATIENT CARE-INPATIENT CARE FOR SYMPTOM CONTROL RELATED TO THE TERMINAL ILLNESS (GENERAL INPATIENT-GIP)" policy (updated 5/23/22) revealed, " ...When GIP has been deemed appropriate, the staff will ...Perform daily nursing visits for any patient admitted to general inpatient level of care ...Complete appropriate clinical documentation/clinical notes within the EMR [Electronic Medical Record]/clinical record for each visit made to patients in inpatient setting ..." 2. Medical record review for Patient #1 revealed an admission date of 3/25/22 to GIP care. Review of the "General Inpatient Admit Orders & [and] Initial and Comprehensive Care Plan" dated 3/25/22 revealed a Registered Nurse (RN) frequency of 1x daily, and Aide frequency of 1x daily. Review of RN visit notes from 3/25/22 through 4/7/22 revealed no documentation of RN visits on 3/26/22 and 3/27/22. Review of Aide visit notes from 3/25/22 through 4/7/22 revealed no documentation of Aide visits on 4/2/22 and 4/3/22. 3. Medical record review for Patient #3 revealed an admission date of 5/1/22 to GIP care. Review of the "General Inpatient Admit Orders & Initial and Comprehensive Care Plan" dated 5/1/22 revealed an Aide frequency of daily visits. Review of Aide visit notes from 5/1/22 through 5/12/22 revealed no documentation of Aide visits on 5/7/22 and 5/8/22. In an interview on 6/3/2022 at 4:30 PM, RN #1 verified the RN visit notes and Aide visit notes could not be found.