Every finding on record at First State Hospice Care Inc

It is required that bereavement services are supervised by a qualified professional with experience or education in grief or loss counseling. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 1 (100%) personnel records reviewed for the Bereavement Coordinator revealed that the agency did not ensure that bereavement services were supervised by a qualified professional with experience or education in grief or loss counseling. DOCUMENT 1: The document titled, Bereavement Coordinator Job Description, stated in part, "Bachelor's degree or equivalent theological degree from a college, university, or experience with patients/families with death and dying issues." PERSONNEL RECORD 4: The Bereavement Coordinator was hired on 10/13/2025. A review of the personnel record included a signed Bereavement Coordinator Job description dated 10/13/2025. The personnel record did not provide evidence of a bachelor’s degree or theological degree from a university and did not provide evidence of experience with grief or loss counseling. During an interview and joint record with the Administrator (Personnel Record 1) and Hospice Manager (Personnel Record 15), confirmed that the current Bereavement Coordinator did not have the qualifications for the position. Furthermore, the Hospice Manager did not have a job description in her personnel file for Bereavement Coordinator and stated, “they should have completed this previously.”

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 clinical record review, document review, and interview. In 1 of 14 (7%) records reviewed. the agency did not ensure the drug profile was updated per hospice policy and procedure. Agency policy PC.M60, Medication - Profile, stated in part, "When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over the counter drugs, herbal remedies and alternative supplements tat could affect drug therapy. The patient's medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum every 15 days. The patient medication profile review includes but is not limited to: determining accuracy and completeness of the profile." Clinical Record 1: The updated hospice plan of care dated 6/28/23 read in part, "O2 @ 2-4L via NC." The licensed practical nurse visit note dated 7/5/23, and the registered nurse visit note dated 6/27/23, stated oxygen use at "4L via NC." However, oxygen was not included on the medication profile, with documented review dates by the registered nurse on 6/28/23 and 7/1/23. During an interview on 7/13/23, the QA Nurse confirmed the finding.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) records reviewed, it was revealed that the agency did not ensure that the written plan of care included a detailed scope and frequency of services necessary to meet specific patient needs. Clinical Record 1: The updated hospice plans of care dated 6/28/23 and 7/1/23, included a social work frequency that read, "MSW prn." However, there was no detailed statement regarding the use of the PRN (as needed) frequency. Clinical Record 3: The updated hospice plans of care dated 5/27/23, 6/14/23, and 6/28/23, included a social work frequency that read, "MSW prn." However, there was no detailed statement regarding the use of the PRN (as needed) frequency. Clinical Record 9: The updated hospice plans of care dated 5/27/23, 6/14/23, and 6/28/23, included a social work frequency that read, "MSW prn." However, there was no detailed statement regarding the use of the PRN (as needed) frequency. Clinical Record 13: The updated hospice plans of care dated 5/17/23 and 5/31/23, included a social work frequency that read, "MSW prn." However, there was no detailed statement regarding the use of the PRN (as needed) frequency. During a joint record review and interview on 7/13/23, the QA Nurse confirmed the finding.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) records reviewed, it was revealed that the agency did not ensure the plan of care included complete treatment orders necessary to meet the patient's needs. Clinical Record 2: The physician's order dated 5/23/23 read, "May irrigate foley with NS prn and may change foley q month and prn." There was no specified amount of NS solution. Nor were there indications for use of the prn (as needed) frequencies. Clinical Record 9: The physician's order dated 5/11/23 read, "May irrigate foley with NS prn and may change foley q month and prn." There was no specified amount of NS solution. Nor were there indications for use of the prn (as needed) frequencies. The physician's order dated 6/28/23 read, "L great toe, cleanse with NS, pat dry, wrap with 4x4 and secure with Coban." There was no frequency. The skilled nursing visit note dated 6/30/23, documented the wound care was to be completed three times per week until the wound healed. Clinical Record 13: The physician's order dated 4/26/23 read, "May irrigate foley with NS prn and may change foley q month and prn." There was no specified amount of NS solution. Nor were there indications for use of the prn (as needed) frequencies. During a joint record review and interview on 7/13/23, the QA Nurse confirmed the finding.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by clinical record review, document review, and interview. In 14 of 14 (100%) records reviewed, it was revealed that the agency did not ensure that a copy of the agency's policy and procedure for managing and disposal of controlled drugs was provided to the patient or family or patient’s legal representative(s). Agency policy PC.M70, Medications - Use and Disposal of Controlled Substances, stated in part, "At the time when controlled substances are first ordered the hospice nurse: provides a copy of the hospice's written policies and procedures on the management and disposal of controlled drugs to the patient or the patient representative and family." Clinical Record 1: On 1/7/22, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 2: On 5/12/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 3: On 6/1/22, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 4: On 6/13/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 5: On 6/9/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 6: On 4/25/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 7: On 4/28/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 8: On 4/6/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 9: On 5/8/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 10: On 6/30/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 11: On 5/26/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 12: On 6/8/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 13: On 4/26/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 14: On 6/13/23, education was provided to the patient/family on medication management and disposal in the patient admission booklet. However, there was no evidence that a copy of the agency's policy for the management and disposal of controlled medications was provided to the patient/family. During an interview on 7/13/23, the QA Nurse confirmed the finding.