Every finding on record at Gaffey Home Nursing & Hospice Inc.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: Development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment; The documented discussion of the plan provided to the patient/family and maintained by the hospice; Follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. This standard was not met as evidenced by clinical record review and interview. In 12 of 12 (100%) clinical records reviewed of patients residing at home it was revealed that the agency did not ensure there was documented evidence of an individualized emergency plan. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/20/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/21/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/25/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged on 07/24/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/22/2025 and discharged on 01/07/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/30/2025 and discharged on 10/20/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged on 04/23/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/19/2025 and discharged on 04/19/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/21/2025 and discharged on 06/14/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/21/2025 and discharged on 08/02/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/29/2025 and discharged on 10/07/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. During an interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the patient's emergency plan was individualized and reviewed with the patient. Additionally, the Administrator stated, "I have a new form with all the required information that we will start using." During a joint record review and interview on 03/11/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the patient's emergency plan was individualized.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 7 (14%) clinical records reviewed of patients receiving hospice aide services it was revealed that the hospice did not ensure the Registered Nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 5/HOME VISIT 1: The hospice aide care plan dated 02/25/2025 included for the aide to take temperature, respirations, and blood pressure each visit. Additionally, "report abnormal vital signs to nurse" was included for each visit. During the home visit with the hospice aide (Personnel Record 8) on 03/11/2026, the hospice aide was observed taking the patient's temperature, respirations, and blood pressure. The hospice aide visit documentation on 3/11/2026 revealed a temperature 97F, respirations 22, and blood pressure 168/92. There was no documented evidence that the hospice aide care plan included vital sign parameters for the hospice aide to report. The hospice aide was interviewed about reporting parameters, and the hospice aide stated, "Because he is hospice, we don't do that." During a joint record review and interview on 03/12/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the aide plan of care included specific instructions for the aide including what the parameters were for abnormal vital signs to be reported. Additionally, the Director of Nursing stated, "The nurses need to type the parameters in the care plan. It wasn't done."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer hours log detailing the staff hours and volunteer hours revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator provided a volunteer hours log that documented total staff hours and volunteer hours. The volunteer hours log for 01/01/2024-12/31/2024 revealed that the volunteer hours were at 1.04%. The volunteer hours log for 01/01/2025-12/31/2025 revealed that the volunteer hours were at 0.4%. There was no documented evidence that the volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2024 and 2025. During an interview with the Volunteer Coordinator (Personnel Record 6) on 03/12/2026, the Volunteer Coordinator stated, "I don't keep track of the hours, the Administrator does." During a joint review of the documentation and interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Administrator stated, "There is lack of follow up by the volunteer coordinator. We need to have additional education for the volunteer coordinator and monthly follow up with supervision." A review of the volunteer hours log detailing the staff hours and volunteer hours revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed it was revealed that the hospice did not ensure that the hospice election form informed the patient or representative of their right to request the covered/non covered addendum. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/04/2026. The Medicare Benefit Election Form dated 02/04/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 2:The patient elected the hospice benefit on 02/20/2026. The Medicare Benefit Election Form dated 02/20/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2026. The Medicare Benefit Election Form dated 02/10/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/21/2025. The Medicare Benefit Election Form dated 11/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/25/2025. The Medicare Benefit Election Form dated 11/25/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged on 07/24/2025. The Medicare Benefit Election Form dated 12/04/2024 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/22/2025 and discharged on 01/07/2026. The Medicare Benefit Election Form dated 12/22/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/30/2025 and discharged on 10/20/2025. The Medicare Benefit Election Form dated 04/30/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged on 04/23/2025. The Medicare Benefit Election Form dated 02/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/19/2025 and discharged on 04/19/2025. The Medicare Benefit Election Form dated 02/19/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/21/2025 and discharged on 06/14/2025. The Medicare Benefit Election Form dated 05/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/21/2025 and discharged on 08/02/2025. The Medicare Benefit Election Form dated 07/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/29/2025 and discharged on 10/07/2025. The Medicare Benefit Election Form dated 09/29/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/18/2025 and discharged on 04/22/2025. The Medicare Benefit Election Form dated 04/18/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. During a joint record review and interview on 03/11/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the election form informed the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. During an interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the election form informed the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. Additionally, the Administrator stated, "We missed this. I will get this form updated and update the admission books."

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. In 2 of 3 (67%) clinical records reviewed of patients that had a live discharge it was revealed that the hospice did not ensure that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged due to no longer terminally ill on 07/24/2025. A discharge summary was documented on 07/24/2025. There was no documented evidence that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged due to moved out of service area-went to hospital on 04/23/2025. A discharge summary was documented on 04/23/2025. There was no documented evidence that the discharge summary was sent to the patient's attending physician or hospital. During a joint record review and interview on 03/12/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the discharge summaries were provided to the patient's attending physician or hospital. Additionally, the Director of Nursing stated, "These were missed. We need to educate the staff."

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, supplements, herbal remedies, other alternative treatments that could affect drug therapy. 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 document review, interview, and observation. 3 of 3 (100%) home visits revealed the hospice did not ensure that the drug profile included the patient's current prescriptions. The hospice's policy # 2-004, "Medication Profile" (revised December 2018), stated in part, "Upon admission, the admitting nurse will initiate a medication profile to document current medication regimen, including name, dose, strength, route, frequency, date and time... A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." Home Visit 1: The patient elected hospice care on 07/18/22. During the home visit at an assisted living facility on 04/11/23, the hospice's drug profile was compared to the facility's drug profile. The hospice's drug profile included the medication "promethazine vc/codeine oral syrup 6.25-5019 mg/5ml take ten (10) ml every 6 hours as needed for cough." The facility's drug profile did not include the medication "promethazine vc/codeine." The hospice's drug profile included the medication "prochlorperazine maleate oral tablet, ten (10) mg take one (1) tablet every six (6) hours as needed for nausea/vomiting." The facility's drug profile did not contain the medication "prochlorperazine maleate." The facility's nurse confirmed that the patient was not taking the medications. The hospice's drug profile was not updated to include the patient's current medications. Home Visit 2: The patient elected hospice care on 11/02/22. During the home visit on 04/12/23, the hospice's drug profile was compared to the patient's medications. The patient and caregiver reported that the patient was taking one medication daily, "Norco oral tablet 5-325 mg one (1) tablet every eight (8) hours." The hospice's drug profile included the medications "Norco oral tablet 5-325 take one (1) tablet every four (4) to six (6) hours, Allopurinol three hundred (300) mg take one (1) tablet daily, Atorvastatin ten (10) mg take one (1) tablet daily, Folic Acid one (1) mg take one (1) tablet daily, and Methotrexate two and a half (2.5) mg take four (4) tablets weekly." The patient reported they had not taken the listed medications, Allopurinol, Atorvastatin, Folic Acid, or Methotrexate, for several weeks. The hospice's drug profile was not updated to include the patient's current medications. Home Visit 3: The patient elected hospice care on 01/17/23. During the home visit on 04/12/23, the hospice's drug profile was compared to the patient's medications. The patient reported taking the medication "Benzonatate one hundred (100) mg take one (1) tablet two (2) times daily." The hospice's drug profile did not include the medication Benzonatate. The RN present confirmed the drug profile did not include the medication Benzonatate. The hospice's drug profile was not updated to include the patient's current medications. During an interview and a joint record review on 04/12/23, the Director of Nursing confirmed the hospice agency did not have an accurate active medication profile for the patient (record 2).

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN responsible for supervising the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 4 (25%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that the aide care plan provided specific written patient care instructions that allowed the aide to effectively complete all necessary patient care within their scope of practice. Clinical Record 2: The patient elected hospice care on 11/02/22 with the diagnosis of "Merkle cell carcinoma." The hospice aide care plan dated 11/02/22 through 01/30/23 assigned the aide the tasks, "assist in ambulation as needed...assist in transfer as needed...incontinent care as needed...complete bed bath per request...complete shower per patient request...comb hair per request...shampoo hair per patient request." In addition, the aide care plan dated 11/21/22 stated in part, "may cover tumor lesions with gauze and kerlix for drainage as needed." The care plans did not provide the hospice aide with specific patient instructions regarding the frequency of the assigned tasks leaving the hospice aide to make decisions outside their scope of practice. During an interview and a joint record review on 04/11/23, the Director of Nursing confirmed that the aide care plan did not provide specific instructions to the hospice aide, thus leaving the hospice aide to make decisions outside the scope of practice.