Every finding on record at Gifted Hearts Hospice. LLC

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 medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. 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 clinical record review and interview. In 2 of 3 (67%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. CLINICAL RECORD 3/HOME VISIT 1: The patient’s election of benefit was dated 07/10/2024. The medication list printed 12/29/2025 revealed Quetiapine 25mg, give 1 tab PO [by mouth] at 1400 (2:00 pm) and 1 tab PO every night for Dementia/agitation; Quetiapine 50 mg 1 tablet PO once a day, (additional directions included: give 2-5 LPM [liters per minute] Nasal once a day PRN [as needed] sob [shortness of breath]/low sats); and Diclofenac 1% get, give one application topical every 4-6 hours per knee pain (did not have available to use). During the home visit with the Registered Nurse (RN) (Personnel Record 5) on 12/30/2025, the medication bottles observed revealed Quetiapine 50 mg tablet, take one at bedtime for insomnia; Acetaminophen 500 mg tablet, one tab by mouth QAM [every morning] and at 1400 for mild pain; Colace (Docusate Sodium) (over the counter box) 100 mg capsule; Ibuprofen (over the counter bottle) 200 mg tablet; Furosemide 20 mg tablet, one by mouth every day, last filled 08/13/2025; a bottle of Ofloxacin Otic solution 0.3% (manufacturer expiration date 03/2027) in a Ziplock bag with cotton balls with no label identifying the patient, date ordered, directions for use, and when to discard the medication; Quetiapine 25 mg tablets, a count of 9 tablets in a Ziplock bag with no printed label identifying the patient, date ordered, directions of use, and when to discard the medication. The RN reported that the Quetiapine 25 mg tablets were kept in case the patient went back to that dose. The RN stated that the patient was not taking the Colace and Ibuprofen, stating that the daughter brought the medications in case the patient needed them. The RN stated that the patient has not taken the Furosemide since at least September when the nurse started seeing the patient. A review of the medication profile in the patient’s record revealed that the Ofloxacin Otic solution was ordered from 10/06/2025 through 10/14/2025, give 8 right ear every day for pain; and the Furosemide was ordered 07/10/2024 and discontinued 09/03/2025. CLINICAL RECORD 6/HOME VISIT 2: The patient’s election of benefit was dated 11/05/2024. The medication list printed 12/29/2025 revealed Magnesium (over the counter bottle), give 2 po once a day Supplement; Omega 3 (over the counter bottle), give 2 QAM and 1 QPM [at night] po Supplement; Vitamin D3 (over the counter bottle), give 2 po once a day Supplement; docusate 100 mg, give 1 soft gel PO as directed Constipation, “not now” is handwritten on the medication card. During the home visit with the Registered Nurse (Personnel Record 5) on 12/30/2025, the medication bottles observed revealed Triamcinolone 0.1% cream 30 gm, apply to rash on scalp and ears every other day PRN, dated 04/22/2025; Loperamide 2mg, take 1 cap by mouth twice a day for diarrhea, with a use by 09/10/2025; Ondansetron 4 mg, give one tablet every 6 hours as needed for nausea/vomiting, dispensed 09/10/2024, with a use by 09/10/2025, “as needed” was handwritten on the medication card; Clonidine HCl 0.1 mg, give one tablet every 12 hours as needed, dispensed date of 09/11/2024, order after 09/22/2024, without a medication discard date, “do not use” is handwritten on the medication card; and a medication card with Benzonatate 100mg, dispensed on 09/09/2024, order after 09/20/2024, without a discard by date. The RN reported the patient takes the Magnesium one tablet daily; the Omega 3 one capsule daily; and the Vitamin D3 one capsule daily. The RN stated that the medications not use were kept in the event the patient needs the medication in the future. The was no evidence that the medications were not reviewed for expired medications and disposed. A review of the medication profile in the patient’s record revealed the Loperamide was discontinued on 12/12/2025; the Clonidine HCl was discontinued on 02/28/2025; and the Ondansetron was not found with the active medications or the discontinued medications. During a joint record review and interview on 12/30/2025, the Director of Clinical Services (Personnel Record 2) confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile. The Director of Clinical Services confirmed that the expired medications should have been removed along with any other medications that were not on the current medication list.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by document review and interview which revealed that the IDG in its entirety did not supervise the care and services provided to the patient and family when the social worker did not participate in the IDG meetings. Upon reviewing the agency sign-in forms for the interdisciplinary group (IDG) meetings, there was no documented evidence that a social worker was present in person or by phone for the following IDG meeting dates: 09/03/2025, 09/18/2025, 10/16/2025, 10/30/2025, 11/13/2025, 11/26/2025, 12/11/2025, and 12/23/2025. When reviewing the clinical documentation, the social worker completed documentation for frequency visits as ordered per the plan of care. The social worker completed documentation for the IDG meeting documentation. During a discussion with the Administrator and the Director of Clinical Services, it was agreed that the social worker was not present in person or by phone, but did complete the IDG meeting documentation and was compliant with the patient frequencies. The Executive Director stated that the social worker had another job that was full time and this employment was as needed/per diem. There was a discussion of which disciplines were required to attend each IDG meeting. During a joint clinical record and document review and interview on 12/31/2025, the Executive Director (Personnel Record 1) confirmed that the social worker did not meet the requirement for attending the IDG meetings. During a joint clinical record and document review and interview on 12/31/2025, the Director of Clinical Services (Personnel Record 2)confirmed that the social worker did not meet the requirement for attending the IDG meetings. Upon reviewing the agency sign-in forms for the interdisciplinary group (IDG) meetings, there was no documented evidence that a social worker was present in person or by phone for the following IDG meeting dates: 09/03/2025, 09/18/2025, 10/16/2025, 10/30/2025, 11/13/2025, 11/26/2025, 12/11/2025, and 12/23/2025. When reviewing the clinical documentation, the social worker completed documentation for frequency visits as ordered per the plan of care. The social worker completed documentation for the IDG meeting documentation. During a discussion with the Administrator and the Director of Clinical Services, it was agreed that the social worker was not present in person or by phone, but did complete the IDG meeting documentation and was compliant with the patient frequencies. The Executive Director stated that the social worker had another job that was full time and this employment was as needed/per diem. There was a discussion of which disciplines were required to attend each IDG meeting.

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient's date of election was 10/08/2025. The primary hospice diagnosis was Corticobasal degeneration. The nursing admission note dated 10/08/2025 documented that the patient had a suprapubic catheter that the wife changes and a fall risk score of 19 for bed/chairbound, uncooperative or unable to follow directions, sensory impairment, mostly/always incontinent, narcotic, seizure disorder, weakness or paralysis of extremities, Parkinson's, chronic debilitating illness, and dementia. Point Summary: 10 or more points - High Risk. The HUV1 registered nurse (RN) routine note dated 10/15/2025 documented that the patient had a SP [suprapubic] catheter draining clear yellow urine, had contractures to all extremities, and used a Hoyer lift for showers and to make the bed. The nursing routine visit note dated 11/19/2025 documented that the patient had contractures to all extremities, transferred using a Hoyer lift, and the wife changed the SP catheter around the 25th of October. The Initial Plan of Care dated 10/08/2025-12/06/2025 and the Updated Comprehensive Patient Plan of Cares dated 11/11/26/2025 and 12/23/2025 lacked problems, interventions, and goals related to the anticipated risk of injury and for suprapubic catheter. CLINICAL RECORD 10: The patient's date of election was 11/19/2025. The primary hospice diagnosis was traumatic subdural hematoma with loss of consciousness of unspecified duration. The medication profile revealed Lacosamide since admission on 11/19/2025. The nursing admission note dated 11/19/2025 documented that the patient developed seizures after the craniotomy, had hemiparesis in the right leg and arm, and had a fall risk score of 14 for more than 2 falls in the past 6 months, intermittent confusion, bed/chairbound, mostly/always incontinent, narcotic, seizure disorder, and weakness or paralysis of extremities. Point Summary: 10 or more points - High Risk. The HUV1 RN routine note dated 11/25/2025 documented seizure activity, hemiparesis of the right leg/arm, and contractures of the right hand. The Initial Plan of Care dated 11/19/2025-02/16/2026 and the Updated Comprehensive Patient Plan of Care dated 12/23/2025 lacked problems, interventions, and goals related to the anticipated risk of injury. During a joint review of the record and an interview on 12/31/2025, the Director of Clinical Services(Personnel 2) confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.

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. In 2 of 3 (67%) home visit observations revealed the agency did not ensure the staff followed the agency hand hygiene policy. Agency policy, Hand Hygiene, dated 04/27/2023, stated in part, "When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations or wash hands with antimicrobial soap and water. Decontaminate hands before having direct contact with clients... Decontaminate hands after contact with a client’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a client. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. Decontaminate hands after removing gloves, and between glove changes." HOME VISIT 1: During the home visit on 12/30/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN was observed to go to a closet that was in the kitchen to retrieve a basket of dressing supplies. The RN stated, the patient "gets skin tears a lot, so we keep dressings here; a little of everything, because we never know what we will need." The RN used alcohol and retrieved gloves from the nursing bag. The RN used wound cleanser and gauze to clean off the wound on the right outer forearm. The RN removed some triple antibiotic ointment from the basket, used it on the patient, and returned it back to the basket. The RN looked through the basket at the different supplies and took out a piece of Telfa and placed on the wound. The RN removed some Coban, wrapped the arm, and returned the remainder of the Coban to the basket. The RN removed the gloves and picked up the basket of dressing supplies and returned it to the closet. The RN threw away the gloves and used alcohol. The RN spoke with the group -home owner on the phone and then proceeded with wiping down the equipment and placed them on the other barrier. The RN moved on to the next patient at the group home that was also in the common living area. The RN did not decontaminate the hands after cleaning the wound and before looking through the basket of clean dressing supplies. The RN did not disinfect the hands after removing the gloves and before returning the basket of dressings to the closet in the kitchen. HOME VISIT 2: During the home visit on 12/30/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN had finished cleaning the assessment equipment from the previous patient, placed them on the clean barrier that was initially place at the beginning of the previous patient visit. The RN completed the patient's visit. The RN did not disinfect the hands between patients. During an interview on 05/22/2024, the Director of Clinical Services agreed the staff did not follow the agency hand hygiene policy.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse (RN) of the changes in the patient’s plan of care. CLINICAL RECORD 3: The hospice aide care plan dated 06/26/2025 included task of apply lotion, assist with dressing, brush teeth/dentures, clean/file fingernails weekly, clean/file toenails weekly, comb hair, perineal care, shampoo hair weekly, shower, assist to toilet, change briefs, encourage fluids, snack, ambulate only with assistance, reposition Geri chair, fall precautions, oxygen precautions, change bed linens, make bed, straighten room. The hospice aide missed/rejected/rescheduled visit note dated 09/03/2025 documented, "Reason Missed: Missed. Explanation: PCG [paid caregiver] rescheduled... Administrator Notified Date: 09/03/2025. The hospice aide missed/rejected/rescheduled visit note dated 09/08/2025 documented, "Reason Missed: Missed. Explanation: (patient) lives in a PCH [private care home], this morning I went to see the patient as routine visit (M-W-F [Monday, Wednesday, Friday]). I was at... Administrator Notified Date: 09/08/2025." The documentation lacked evidence that the registered nurse was notified of changes to the plan of care. CLINICAL RECORD 4: The hospice aide care plan dated 11/09/2025 included task of lotion, assist with dressing, brush teeth/dentures, clean/file fingernails weekly, clean/file toenails weekly, comb hair, perineal care, shampoo hair, shower, change briefs, encourage fluids, ambulate with assistance, fall precautions, change bed linens weekly unless soiled then per visit, make bed, straighten room. The hospice aide missed/rejected/rescheduled visit note dated 11/11/2025 documented, "Reason Missed: Patient and/or caregiver declined an in-person visit. Explanation: Patient refused shower. I was at... Administrator Notified Date:11/11/2025." . The hospice aide missed/rejected/rescheduled visit note dated 11/27/2025 documented, "Reason Missed: Patient Cancelled. Explanation: Patient’s daughter cancelled visit because she will be picking the patient up from the nursing facility... Administrator Notified Date: 11/27/2025." The documentation lacked evidence that the registered nurse was notified of changes to the plan of care. CLINICAL RECORD 5: The hospice aide care plan dated 09/22/2025 included task of apply lotion, assist with dressing, clean/file fingernails weekly, clean/file toenails weekly, comb hair, shampoo hair, shave weekly, shower, assist to toilet, change briefs, encourage fluids, ambulate with assistance, chair/bed, fall precautions, change bed linens, make bed, straighten room. The hospice aide care plan dated 11/21/2025 included task of apply lotion, assist with dressing, clean/file fingernails weekly, clean/file toenails weekly, comb hair, perineal care, shampoo hair, shave weekly, shower, assist to toilet, change briefs, encourage fluids, ambulate with assistance, chair/bed, fall precautions, change bed linens, make bed, straighten room. The hospice aide missed/rejected/rescheduled visit note dated 11/13/2025 documented, "Reason Missed: Patient not home. Explanation: Patient Caregiver notified they wouldn't be home; patient had an appointment at the social security... Administrator Notified Date:11/13/2025." The hospice aide missed/rejected/rescheduled visit note dated 11/20/2025 documented, "Reason Missed: Rescheduled. Explanation: Daughter called to cancel visit for today... Administrator Notified Date:11/20/2025." The hospice aide missed/rejected/rescheduled visit note dated 12/16/2025 documented, "Reason Missed: Rescheduled. Explanation: Daughter rescheduled... Administrator Notified Date: 12/15/2025." The documentation lacked evidence that the registered nurse was notified of changes to the plan of care. During a joint clinical record review and interview on 12/31/2025, the Director of Clinical Services(DCS) (Personnel Record 2) confirmed that the documentation lacked evidence that an RN was notified of the changes to the plan of care or missed visits. The DCS stated that the hospice aides will notify the Administrator, who is not clinical, and they will notify the DCS or RN.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records that had aide services reviewed revealed that the agency did not that the registered nurse did not make an on-site supervisory visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 7: The patient's date of election was 09/04/2025. The hospice aide services started 09/08/2025. There were supervisory visits on 10/14/2025 and 10/31/2025, 17 days apart. There was an registered nurse (RN) visit on 10/21/2025 that did not include a supervisory visit. CLINICAL RECORD 8: The patient's date of election was 01/30/2025. The hospice aide services started 01/31/2025. There were supervisory visits on 12/05/2025 and 12/26/2025, 21 days apart. There was an RN visit on 12/12/2025 that did not include a supervisory visit. During a joint clinical record review and interview on 12/31/2025, the Director of Clinical Services confirmed that the registered nurse did not make on-site supervisory visits.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence of sufficient efforts to retain volunteers. The documentation contained one email from February 2024 for recruitment. There were no efforts documented from December 2024 through November 2025. During an interview on 12/31/2025, the Executive Director (Personnel Record 1) confirmed that the retention efforts were not documented from December 2024 through November 2025. Upon reviewing the volunteer program, the documentation lacked evidence of sufficient efforts to retain volunteers. The documentation contained one email from February 2024 for recruitment. There were no efforts documented from December 2024 through November 2025.

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. Upon reviewing the volunteer program, the documentation revealed that the number of direct care staff hours (1522.75) and the number of volunteer hours (48.45) equaled 3.18% from December 2024 through November 2025. During a joint review of the volunteer program records and interview on 12/31/2025, the Executive Director (Personnel Record 1) confirmed that the agency did not provide 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 from December 2024 through November 2025. Upon reviewing the volunteer program, the documentation revealed that the the number of direct care staff hours (1522.75) and the number of volunteer hours (48.45) equalled 3.18% from December 2024 through November 2025.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed with recertification period revealed the agency did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. CLINICAL RECORD 3: The patient's date of election was 07/01/2024. The Physician's Certification for Medicare Hospice Benefit document for the 10th certification period, from 12/28/2024-03/25/2025, was signed and dated 11/28/2024, which was 30 days before the next benefit period began. The Physician's Certification for Medicare Hospice Benefit document for the 13th certification period, from 06/26/2025-08/24/2025, was signed and dated 06/10/2025, which was 16 days before the next benefit period began. During a joint review of the record and an interview on 12/31/2025, the Director of Clinical Services (Personnel Record 2) agreed there was no documented evidence the recertification was completed no more than fifteen (15) days before the next benefit period begins.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 11: The patient's care was transferred to another Hospice provider on 09/15/2025. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 12/31/2025, the Director of Clinical Services (Personnel Record 2) confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 12: The discharge summary dated 12/15/2025 lacked documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 12/31/2025, the Director of Clinical Services (Personnel Record 2) confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary included at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. CLINICAL RECORD 11: The patient’s election of benefits (EOB) was 06/10/2025. The patient's care was transferred to another Hospice provider on 09/15/2025. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 12: The date of the revocation was 12/15/2025. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 12/31/2024, the Director of Clinical Services (Personnel Record 2) confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the patient’s full name; generic, trade, or brand name of the medication, as well as amount dispensed; directions for use, including route, rate, frequency, and method of administration; prescriber’s name; expiration date; and cautionary instructions. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure that drugs and biologicals were labeled including the patient's full name; generic, trade, or brand name of the medication, as well as amount dispensed; directions for use, including route, rate, frequency, and method of administration; prescriber's name; expiration date; and cautionary instructions. HOME VISIT 1: The patient's date of election was 07/10/2024. The patient resided in a group home. During the home visit with the Registered Nurse (RN) (Personnel Record 5) on 12/30/2025, the medication bottles observed revealed a bottle of Ofloxacin Otic solution 0.3% with manufacturer expiration date 03/2027 in a Ziplock bag with cotton balls and Quetiapine 25 mg tablets, a count of 9 tablets in a Ziplock bag. The Ofloxacin bottle and the Quetiapine tablets did not have labels identifying the patient, the medication with dispensed amount, directions for use, the prescriber's name, the expiration date, and any cautionary instructions. The RN reported that the Quetiapine 25 mg tablets were kept in case the patient went back to that dose. During a joint clinical record review and interview on 12/30/2025, the Director of Clinical Services (Personnel Record 2) confirmed that the medications were not labeled including the patient's full name; generic, trade, or brand name of the medication, as well as amount dispensed; directions for use, including route, rate, frequency, and method of administration; prescriber's name; expiration date; and cautionary instructions.

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 interviews. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure that the initial psychosocial assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 1/5/23. A clinical record review revealed no evidence that an initial psychosocial assessment was completed. No communication was documented to support why the assessment was not completed. Clinical Record 11: The patient elected the hospice benefit on 6/17/22. A clinical record review revealed that the Social Worker (SW) completed the initial psychosocial assessment on 6/23/22, six days after the election of hospice care. No communication was documented to support why the assessment was completed later than five (5) calendar days after the election of hospice care. During an interview, the Director of Clinical Services (DCS) confirmed that Record 4 had no initial psychosocial assessment completed and that Record 6 had the assessment completed late.

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 is a CMS CONDITION level finding. This CONDITION was not met as evidenced by a review of clinical records and interviews. The hospice failed to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care [HCPC.9.1.I/L543]; failed to ensure that the patient’s plan of care identified planned interventions based on problems identified in the comprehensive assessment [HCPC.21.I/L545]; failed to implement an interdisciplinary plan of care including all medications and treatments to meet the needs of the patient [HCPC.21.I/L549]; failed to ensure that the patient’s individualized written plan of care included interventions to manage pain and symptoms [HCPC.21.I/L546]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality patient care in a safe environment.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure that hospice care and services provided to the patient/caregiver followed the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 12/5/22. The plan of care (POC) dated 12/5/22 through 2/2/23 ordered one skilled nursing visit weekly. There was no evidence that a nursing visit was completed for the week of 1/22/23 through 1/28/23. There was no evidence of a documented missed visit or communication with the physician changing the skilled nursing visit frequency. Clinical Record 3: The patient elected the hospice benefit on 1/7/23. The plan of care (POC) dated 1/7/23 to 4/6/23 ordered one skilled nursing visit weekly. There was no evidence that a nursing visit was completed for the week of 1/22/23 through 1/28/23. There was no evidence of a documented missed visit or communication with the physician changing the skilled nursing visit frequency. During an interview and joint record review on 2/23/22, the Director of Clinical Services (DCS) confirmed the POC had not been followed for skilled nursing.

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. 1 of 11 (9%) clinical records reviewed revealed the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 10/14/22. The skilled nursing visit notes dated 1/6/23 and 1/17/23 documented "Dyspnea-2-Walks slower than most people of the same age on the level because of breathlessness". In addition, the nursing visit note completed by the Licensed Vocational Nurse (LVN) on 1/11/23 documented that the patient had " Dyspnea-1-Troubled by shortness of breath when hurrying on the level or walking up a slight hill". The plans of care dated 10/4/22 through 1/11/23 and 1/12/23 through 4/11/23 did not identify dyspnea as a problem with goals and interventions. During an interview on 2/22/23, the Director of Clinical Services (DCS) confirmed that there were no goals, problems, or interventions to address the patient's dyspnea.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: interventions to manage pain and symptoms. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure that the patient’s individualized written plan of care included interventions to manage pain and symptoms. Clinical Record 2: The patient elected the hospice benefit on 10/14/22. The assessment completed by the Registered Nurse (RN) during the visit dated 2/20/23 documented, "...patient is having intermittent aching...His pain intensity before meds is 5...His pain intensity after meds is 2...Denies pain today." The plans of care (POC) dated 10/4/22 through 1/11/23 and 1/12/23 through 4/11/23 did not include the patient's pain as a problem and did not include interventions to manage pain and symptoms. During an interview on 2/22/23, the Director of Clinical Services (DCS) confirmed that there were no goals, problems, or interventions to address the patient's pain.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, document review, and interview. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure that the plan of care (POC) included drugs and treatment necessary to meet the needs of the patient. The agency policy "Medication Management Policy" (undated) stated in relevant part; "Administration of Medications...The Hospice will...Provide education to patient or caregiver, which may include, but is not limited to... Medication Name, indication... Dose... Frequency... Treatment Length... Side Effects." Clinical Record 3: The patient elected the hospice benefit on 1/7/23. The plan of care dated 1/7/23 ordered "Meclizine 25mg for nausea 1 PO ad lib". The POC did not include instructions/indications for using the "ad lib" medication. Clinical Record 4: The patient elected the hospice benefit on 1/5/23. The plan of care dated 1/5/23 ordered "Ipratropium Sol for asthma 0.02% inhaled as directed". The POC did not include instructions/indications for using the "as directed" medication. Clinical Record 7: The patient elected the hospice benefit on 12/15/22. The plans of care dated 12/15/22 and 2/13/23 ordered "Meclizine 25mg for nausea 1 PO ad lib". The POC did not include instructions/indications for using the "ad lib" medication. Clinical Record 8: The patient elected the hospice benefit on 5/12/2020. For the benefit period dated 12/28/22 to 2/25/23, the plan of care included an order dated 1/7/21 for "Oxygen at 2-4 liters inhalant nasal as directed", an order dated 1/7/21 for "Ibuprofen 600mg, for pain, PO, as directed...Morphine Concentrate 20mg/ml dose 0.25mg for pain PO/SL as directed", an order dated 1/21/21 for "Psyllium Powder 3.4G/11G one PO as directed." In addition, the record included an order dated 3/11/21 for "Magnesium Citrate 1.745 GM as directed" and an order dated 3/17/21 for Bisacodyl Supp 10mg suppository, rectally as directed". The POC and medication orders did not include instructions/indications for the use of the "as directed" medications. Clinical Record 9: The patient elected the hospice benefit on 7/11/22. The plan of care dated 7/11/22 ordered: "Bisacodyl supp for constipation rectally, as directed." The POC did not include instructions/indications for using the "as directed" medication. During an interview and a joint clinical record review on 2/22/22, the Director of Clinical Services confirmed that the plans of care and medication orders identified in records 3,4,7,8 and 9 did not include instructions for medication administration, and they should have been corrected.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure that the Interdisciplinary Group (IDG) documented the individualized care plan no less frequently than every 15 calendar days. Clinical Record 1: The patient elected the hospice benefit on 12/5/22. A review of the clinical record revealed that for the benefit period dated 2/3/23 to 4/3/23, the IDG documented the review of the patient's plan of care (POC) on 1/3/23 and 1/31/23, 28 days later. The hospice held an IDG team meeting on 1/17/23. There was no evidence that the patient's POC was reviewed on 1/17/23. During an interview with the Director of Clinical Services (DCS) conducted on 1/21/23, the DCS confirmed the finding.

It is required that medical social services must be provided by a qualified social worker, under the direction of a physician. Social work services must be based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of these services. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure that the social worker provided care based on the psychosocial assessment and the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 12/5/22. A review of the clinical record revealed that for the benefit period dated 12/5/22 to 2/2/23, an initial psychosocial assessment was completed on 12/9/22. The Social Worker (SW) documented that SW would continue "emotional support and community resource planning." The SW care plan dated 12/9/22 documented goals included "Emotional support goals....helping patient deal with decline....active listening". There was no evidence that further SW visits were completed as of 2/23/23. There was no documentation of social worker visit refusal. Clinical Record 5: The patient elected the hospice benefit on 8/31/22. The plan of care (POC) dated 11/30/22 to 2/27/23 ordered one Social Worker (SW) visit monthly. There was no evidence that SW visits were completed for the months of December and January. There was no evidence of a documented missed visit or communication with the physician changing the SW visit frequency. Clinical Record 7: The patient elected the hospice benefit on 12/15/22. The plan of care (POC) dated 12/15/22 to 2/12/23 ordered one Social Worker (SW) visit monthly. There was no evidence that a SW visit was completed for January. There was no evidence of a documented missed visit or communication with the physician changing the SW visit frequency During an interview and joint clinical record review on 2/21/23, the Director of Clinical Services (DCS)confirmed that the SW did not provide service based on the psychosocial assessment and goals outlined in the POC.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group [and] included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 10 (10%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group. Clinical Record 6: The patient elected the hospice benefit on 9/28/22. The plan of care for the benefit period dated 12/27/22 through 3/26/23 included the order dated 1/1/23 for hospice aide visits "3 times" a week through 3/27/23. A review of the clinical record revealed that for the weeks of 1/1/23 through 2/4/23, the hospice aide completed two (2) visits per week. The clinical record did not include evidence of documented missed hospice aide visits or communication with the physician changing the hospice aide visit frequency.. During an interview on 2/23/22, the Director of Clinical Services (DCS) confirmed that the hospice aide did not complete patient visits as ordered. The DCS stated that a new order should have been obtained to reflect the current frequency of health aide visits required by the patient.

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, physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed that the hospice did not ensure a physician order was present for all medications. Clinical Record 1: The patient elected the hospice benefit on 12/5/22. A clinical record review revealed that the nursing visit notes dated 2/6/23, 2/15/23, and 2/20/23 each documented "... O2 @ 2L via N/C continuously." The plan of care dated 2/3/23 through 4/3/23 did not include a physician's order for oxygen. During an interview on 2/21/23, the Director of Clinical Services (DCS) confirmed that there was no oxygen order.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the most recent hospice plan of care. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 1 of 1 (100%) home visits conducted to a patient residing in a skilled nursing facility (SNF) revealed the hospice did not ensure that the SNF was provided with the patient's most recent hospice plan of care. Home Visit 1: The patient that elected the hospice benefit on 2/5/22 resided at a SNF. During a home visit conducted on 2/22/23, a record review revealed no evidence that the patient's most recent POC, dated 2/3/23 to 4/3/23, was included in the documentation provided to the SNF. During an interview on 2/22/23, the Director of Clinical Services (DCS) confirmed that the SNF was not provided with the current POC.