Every finding on record at Hospice Care of the West LLC

It is required that the comprehensive assessment identify the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness and address them to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records of patients who required oxygen support at the time of hospice admission, the agency did not ensure that the comprehensive assessment documented all medical equipment and oxygen requirements for patients receiving oxygen therapy. In 1 of 1 (100%) clinical records reviewed of a patient with multiple wounds and skin tears on admission, the agency did not ensure the comprehensive assessment documented wound measurements and characteristics. CLINICAL RECORD 2: MRN # 77216206. The patient elected hospice on 11/10/2025. The RN completed the initial comprehensive assessment on 11/10/2025; however, the documentation did not indicate that the patient required two oxygen concentrators to deliver 8 liters of oxygen per minute. Omitting details on oxygen delivery and the required equipment did not ensure an accurate and complete assessment to support safe care planning and service coordination for oxygen therapy. Additionally, the RN's initial assessment documented wounds: "Large skin tear on shin, large skin tear on posterior calf, very large skin tear on calf, wound R lateral heel, wound R ankle." However, the clinical record lacked documentation of wound measurements, including length, width, and depth. During a joint record review and interview on 02/09/2026, the Administrator/RN agreed that there was no documented evidence of the two (2) oxygen concentrators in the patient's residence and evidence of wound measurements.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: 1. Prescription and over-the-counter (OTC) drugs; 2. Supplements; 3. Herbal remedies; 4. Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: (L530) 5. The effectiveness of drug therapy; 6. Drug side effects; 7. Actual or potential drug interactions; 8. Duplicate drug therapy; 9. 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 a minimum, at the time of each comprehensive assessment and/or when a 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 1 of 2 (50%) clinical records reviewed of patients who required oxygen on admission, the agency did not ensure that the comprehensive assessment included a complete and accurate drug profile, including oxygen therapy. CLINICAL RECORD 2: The patient elected hospice services on 11/10/2025. The patient was receiving oxygen therapy; however, the medication profile did not include oxygen, rate, route of administration, or frequency. On 02/09/2026, a joint clinical record review and interview with the Administrator, who confirmed that the medication profile did not include oxygen. No further information was provided.

It is required that the written Patient Bill of Rights includes the right to: voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal; Voice grievances regarding treatment or care that is—or fails to be—provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Complaints and Grievances" stated in part, "If a patient or family member voices a complaint regarding hospice services or providers or hospice services to a hospice colleague, the colleague will be responsible for the following actions: Notify the supervisor regarding the complaint voiced by the patient or family member. The Director of Clinical Services or designee will be responsible for the following actions: complete the top portion of the written complaint report, detail the complaint as related by colleagues and/or complainant, begin initial investigation of the complaint, communicate with complainant regarding the progress of the investigation, submit the complaint report to the Area Executive of Clinical Servies or designee within 24 hours of receiving the complaint. The Area Executive of Clinical Services or designee will assign a number to the complaint report and begin recording on the complaint log. Review progress of investigation within five working days. Within 30 days of the receipt of the complaint, contact the complainant either via telephone or with a letter detailing the steps of the resolution. Complete the complaint log." The agency did not ensure that the patient's complaint was documented, investigated, and resolved in accordance with the hospice's Complaints and Grievances policy. A review of the agency's complaint logs and administrative documents on 12/30/2025 and 12/31/2025 revealed that complaints documented in the clinical record were not reported with complaints. The patient's clinical record documented, "The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." For the same clinical record, the RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night... hospice using family's personal items to bathe patient when hospice should be providing those items, Director of Clinical Services (DCS) notified. "Family remains irritable and states, "You guys always say that, but okay." There was no documented evidence that the DCS followed up on or documented the complaint in accordance with agency policy. During an interview on 12/31/2025, the Administrator stated, "I think she didn't realize the follow-through process of documentation." Additionally, the Administrator agreed there was no evidence that the agency documented the received complaint(s) or handled them in accordance with the agency's Complaints and Grievances policy. During an interview on 12/30/2025, the DCS (Team D) stated, "I heard from on call about medications and that the family was upset about delays. ...I recall the staff told me that the family wasn't happy with delays in medications and supplies. I called the daughter; she asked about the medications and why they weren't ready... " Additionally, the DCS (Team D) stated, "I did not document anything about the complaint or follow-up."

It is required that the written Patient Bill of Rights includes the right to: receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interviews. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the patient received effective pain management and symptom control for conditions related to the terminal illness. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/03/2025 with a terminal diagnosis of malignant neoplasm of the gallbladder. On 12/10/2025, the Registered Nurse (RN) documented a telephone call with the patient's wife, "She reports he felt nauseated and had pain all night. He did take ondansetron 4mg twice and Roxanol 5mg/0.25ml once." The RN conducted a visit on 12/10/2025 at 11:40 am following this phone call. The RN visit note dated 12/10/2025 documented, "Severe nausea/vomiting, patient (pt) unable to keep any foods/medications down, multiple times daily, and lasts all day... symptom screening, symptom impact: over the past 2 days how has the patient been affected by each of the following symptoms: symptom impact nausea SEVERE, symptom impact vomiting SEVERE. Informed Registered Nurse Case Manager (RNCM) of stomach discomfort from nausea. Pt attempts to eat, and intake is bites of food offered, but the patient is unable to hold food down, and has multiple episodes of vomiting daily. RNCM reviewed the nausea medications the patient has on hand with the patient and spouse. Per spouse, pt will take medications and vomit. Pt asking for intravenous (IV) fluids, insisting on going into ER for IV hydration. RNCM attempted to encourage the patient to manage symptoms at home, but the patient was indecisive. Spouse is very receptive to the education provided. RNCM reviewed comfort kit medications with pt. RNCM will follow up with MD for recommendations for nausea/vomiting (N/V). Spouse and pt informed. RNCM attempted to call the patient's spouse to follow up on whether the patient had an ER visit. No answer, and unable to leave a message, will attempt follow-up again on 12/11." A coordination note dated 12/12/2025 at 2:35 pm documented, "Pt is at the hospital. Pt does have N/V." The patient was discharged from hospice care for leaving the service area on 12/12/2025. There was no documented evidence that the RN followed up on 12/11/2025. There was no documented evidence that the RN notified the physician of the severe nausea and vomiting, the patient's inability to keep medications down, and the patient's request to go to the ER, or provided any interventions for the severe nausea/vomiting during the visit. A coordination note dated 12/15/2025 documented, "pt still admitted at hospital, admitted dx: acute gastric outlet obstruction with vomiting." The patient was readmitted to hospice care on 12/18/2025 and died on 12/25/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, and co-morbidities: end-stage heart failure, fibromyalgia, and emphysema. The Registered Nurse (RN) start of care visit note dated 10/20/2025 at 6:11pm documented, "pain an active problem YES, mild pain to lower extremity, aching stabbing tender, intermittent, daily but not constantly, medications relieve pain, effect on quality of life YES-sleep/rest disturbance, patient self-identified threshold for pain 2, acuity level: level 2 moderate level of support needed, changes in symptoms or high-risk situations encountered (new onset of symptoms), symptom screening: symptom impact pain-slight, wound left lower extremity (LLE), keratotic skin flaky black in color wrapped with dry dressing, thrush noted in mouth/throat causing pain upon swallowing, will get orders to start nystatin, currently all medications stopped only on comfort medications and oxycodone for pain in his legs, left knee status post (s/p) arthroplasty developed a hematoma and infection, reviewed medications and all home medications (meds) were discontinued... patient agreed, comfort medications only and to be ordered at pharmacy for family to pick up, teaching discussed comfort medications, patient has adequate supply of medications on hand YES, patient has 7 days of medications on hand YES, no refills are needed." A clinical record review revealed no documented evidence that oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." The Chaplain's visit note dated 10/21/2025 documented that the patient was "having pain all over." The RN visit note dated 10/21/2025 at 11:29 am documented that the "patient states that pain is all over his body, 7/10, family picking up comfort kit not in home at this time, called pharmacy and comfort kit was being prepped and would be given to patient's family member to take home." A clinical review revealed no documented evidence that the RN notified the physician of the 7/10 pain above the patient's self-identified threshold for pain (2/10) or that the RN provided any interventions for the pain during the visit. There was no documented evidence that the oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The pharmacy receipt provided by the hospice revealed that the family picked up the morphine and Magic Mouthwash on 10/21/2025 at 12:20 pm. The RN visit note dated 10/22/2025 documented "no BM (bowel movement) for approximately one month, 0/10 pain, received fentanyl patches and applied the first one approximately 30 minutes ago." There was no documented evidence that the RN notified the physician about the no BM for approximately one month or provided any interventions for the constipation during the visit. The SW visit documentation on 10/22/2025 documented family shows signs of grief and anger. The pharmacy receipt provided by the hospice revealed that the family picked up Fentanyl on 10/22/2025 at 11:28 am. The morning call report dated 10/23/2025 at 7:58 am documented a call from the patient's family stating, "He is in a great deal of pain, and no one has called back all night." The RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night for med refills at 2:30 am in which have not been completed until this morning, and hospice using family's personal items to bathe patient when hospice should be providing those items, Director of Clinical Services (DCS) notified. Patient (Pt) complaining of (c/o) pain in the abdomen. Family reports Morphine 0.50 ml to have been administered prior to this Registered Nurse Case Manager's (RNCM) arrival. (Face, Legs, Activity, Cry, Consolability- interprets pain in non-verbal individuals) FLACC score 2. Labored breathing and intermediate moaning. Fentanyl patch in place and scheduled to be changed tomorrow. Last bowel movement yesterday, reported to be 'a little bit.' SOB observed with conversation. Family informed pt oxygen (O2) levels can be increased to 4 liters per minute (LPM) or higher for comfort. Family reports new refills are being picked up now. Family denies further needs at this time, and RNCM informs to call hospice with additional concerns." The pharmacy receipt provided by the hospice revealed that the family picked up medications on 10/23/2025 at 12:49 pm. During an interview on 12/31/2025, the Administrator agreed there was no documented evidence that the RN notified the physician or provided interventions for the severe nausea and vomiting documented in clinical record 3 on 12/10/2025. Additionally, the Administrator agreed there was no documented evidence that pain medication was available in the home for clinical record 5 prior to the day after admission, when the family called in urgently. During an interview on 12/31/2025, the DCS (parent location & covering other locations) agreed there was no documented evidence that the RN notified the physician or provided any interventions for the severe nausea/vomiting during the visit on 12/10/2025 for clinical record 3. Additionally, the Administrator agreed there was no documented evidence that pain medications were available in the home for clinical record 5 before the day after admission, when the family called in urgently. During an interview and joint review of clinical records 3 and 5 on 12/31/2025, the Hospice Medical Director (HMD) stated, "Those rural ones are followed by the other doctors, so I am not familiar with them." When the HMD was asked about patients having symptoms or a crisis where the patient is uncomfortable after hours, the HMD stated, "The nurses call if they aren't comfortable so that we can make changes. It's hard being that rural, so we try to provide comfort kits on admission. There are no 24/7 pharmacies. Patients have to tough it out till the morning or go to the hospital."

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the Registered Nurse implemented the plan of care and coordinated care with the physician to address changes in the patient's condition and needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/03/2025 with a terminal diagnosis of malignant neoplasm of the gallbladder. On 12/10/2025, the Registered Nurse (RN) documented a telephone call with the patient's wife, "She reports he felt nauseated and had pain all night. He did take ondansetron 4mg twice and Roxanol 5mg/0.25ml once." The RN conducted a visit on 12/10/2025 at 11:40 am following this phone call. The RN visit note dated 12/10/2025 documented, "Severe nausea/vomiting, patient (pt) unable to keep any foods/medications down, multiple times daily, and lasts all day... symptom screening, symptom impact: over the past 2 days how has the patient been affected by each of the following symptoms: symptom impact nausea SEVERE, symptom impact vomiting SEVERE. Informed Registered Nurse Case Manager (RNCM) of stomach discomfort from nausea. Pt attempts to eat, and intake is bites of food offered, but pt unable to hold food down, is having multiple episodes of vomiting daily. RNCM reviewed nausea medications pt has on hand with pt and spouse. Per spouse pt will take medications and vomit. Pt asking for intravenous (IV) fluids, insisting on going into ER for IV hydration. RNCM attempted to encourage pt to manage symptoms at home and pt undecisive. Spouse very receptive of education provided. RNCM reviewed comfort kit medications with pt. RNCM will follow up with MD for recommendations for nausea/vomiting (N/V). Spouse and pt informed. RNCM attempted to call pt spouse to follow up on if ER visit was made, no answer, and unable to leave message will attempt follow up again on 12/11." A coordination note dated 12/12/2025 at 2:35 pm documented, "Pt is at the hospital. Pt does have N/V." The patient was discharged from hospice care for leaving the service area on 12/12/2025. There was no documented evidence that the RN followed up on 12/11/2025. There was no documented evidence that the RN notified the physician of the severe nausea and vomiting, the patient's inability to keep medications down, and the patient's request to go to the ER, or provided any interventions for the severe nausea/vomiting during the visit. A coordination note dated 12/15/2025 documented, "pt still admitted at hospital, admitted dx: acute gastric outlet obstruction with vomiting." The patient was readmitted to hospice care on 12/18/2025 and died on 12/25/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, and co-morbidities: end-stage heart failure, fibromyalgia, and emphysema. The Registered Nurse (RN) start of care visit note dated 10/20/2025 at 6:11pm documented, "pain an active problem YES, mild pain to lower extremity, aching stabbing tender, intermittent, daily but not constantly, medications relieve pain, effect on quality of life YES-sleep/rest disturbance, patient self-identified threshold for pain 2, acuity level: level 2 moderate level of support needed, changes in symptoms or high-risk situations encountered (new onset of symptoms), symptom screening: symptom impact pain-slight, wound left lower extremity (LLE), keratotic skin flaky black in color wrapped with dry dressing, thrush noted in mouth/throat causing pain upon swallowing, will get orders to start nystatin, currently all medications stopped only on comfort medications and oxycodone for pain in his legs, left knee status post (s/p) arthroplasty developed a hematoma and infection, reviewed medications and all home medications (meds) were discontinued... patient agreed, comfort medications only and to be ordered at pharmacy for family to pick up, teaching discussed comfort medications, patient has adequate supply of medications on hand YES, patient has 7 days of medications on hand YES, no refills are needed." A clinical record review revealed no documented evidence that oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." The Chaplain's visit note dated 10/21/2025 documented that the patient was "having pain all over." The RN visit note dated 10/21/2025 at 11:29 am documented that the "patient states that pain is all over his body, 7/10, family picking up comfort kit not in home at this time, called pharmacy and comfort kit was being prepped and would be given to patient's family member to take home." A clinical review revealed no documented evidence that the RN notified the physician of the 7/10 pain above the patient's self-identified threshold for pain (2/10) or that the RN provided any interventions for the pain during the visit. There was no documented evidence that the oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The pharmacy receipt provided by the hospice revealed that the family picked up the morphine and Magic Mouthwash on 10/21/2025 at 12:20 pm. The RN visit note dated 10/22/2025 documented "no BM (bowel movement) for approximately one month, 0/10 pain, received fentanyl patches and applied the first one approximately 30 minutes ago, semi difficult to get information, caregivers seem somewhat standoffish. There was no documented evidence that the RN notified the physician about the no BM for approximately one month or provided any interventions for the constipation during the visit. The SW visit documentation on 10/22/2025 documented family shows signs of grief and anger. The pharmacy receipt provided by the hospice revealed that the family picked up Fentanyl on 10/22/2025 at 11:28 am. The morning call report dated 10/23/2025 at 7:58 am documented a call from the patient's family stating, "He is in a great deal of pain, and no one has called back all night." The RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night for med refills at 2:30 am in which have not been completed until this morning, and hospice using family's personal items to bathe patient when hospice should be providing those items, Director of Clinical Services (DCS) notified. Patient (Pt) complaining of (c/o) pain in abdomen. Family reports 0.50 ml to have been administered prior to this Registered Nurse Case Manager's (RNCM) arrival. (Face, Legs, Activity, Cry, Consolability- interprets pain in non-verbal individuals) FLACC score 2. Labored breathing and intermediate moaning. Fentanyl patch in place and scheduled to be changed tomorrow. Last bowel movement yesterday, reported to be 'a little bit.' SOB observed with conversation. Family informed pt oxygen (O2) levels can be increased to 4 liters per minute (LPM) or higher for comfort. Family reports new refills are being picked up now. Family denies further needs at this time, and RNCM informs to call hospice with additional concerns. Family remains irritable and states, "You guys always say that, but okay." The pharmacy receipt provided by the hospice revealed that the family picked up medications on 10/23/2025 at 12:49 pm. During an interview on 12/31/2025, the Administrator agreed there was no documented evidence that the RN notified the physician or provided interventions for the severe nausea and vomiting documented in clinical record 3. Additionally, the Administrator agreed there was no documented evidence that pain medications were available to the patient upon admission, prior to the family calling to report that the patient was in pain and had none. During an interview on 12/31/2025, the DCS (parent location & covering other locations) agreed there was no documented evidence that the RN notified the physician of the patient's severe nausea and vomiting, inability to keep medications down, and the patient's request to go to the emergency room (ER), or provided any interventions for the severe nausea/vomiting during the visit. Additionally, the DCS agreed there was no documented evidence that the patient had pain medications available prior to an urgent call from the family. During an interview on 12/30/2025, the DCS (Team D) stated, "I heard from on call about medications and that the family was upset about delays. The comfort kit was ordered by my on-call nurse in the morning, after receiving a call that the patient did not have medications. We ordered it for the family to pick up, and then we sent a nurse out that morning. I recall the staff told me that the family wasn't happy with delays in medications and supplies. I called the daughter; she asked about the medications and why they weren't ready. They were admitted after the pharmacy closed. The nurse was going to put it in the next morning, but the pharmacy was not available at night. We do not have a pharmacy available 24/7 in that area."

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interviews. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the patient's nursing needs were met as identified in the assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/03/2025 with a terminal diagnosis of malignant neoplasm of the gallbladder. On 12/10/2025, the Registered Nurse (RN) documented a telephone call with the patient's wife, "She reports he felt nauseated and had pain all night. He did take ondansetron 4mg twice and Roxanol 5mg/0.25ml once." The RN conducted a visit on 12/10/2025 at 11:40 am following this phone call. The RN visit note dated 12/10/2025 documented, "Severe nausea/vomiting, patient (pt) unable to keep any foods/medications down, multiple times daily, and lasts all day... symptom screening, symptom impact: over the past 2 days how has the patient been affected by each of the following symptoms: symptom impact nausea SEVERE, symptom impact vomiting SEVERE. Informed Registered Nurse Case Manager (RNCM) of stomach discomfort from nausea. Pt attempts to eat, and intake is bites of food offered, but pt unable to hold food down, is having multiple episodes of vomiting daily. RNCM reviewed nausea medications pt has on hand with pt and spouse. Per spouse pt will take medications and vomit. Pt asking for intravenous (IV) fluids, insisting on going into ER for IV hydration. RNCM attempted to encourage pt to manage symptoms at home and pt undecisive. Spouse very receptive of education provided. RNCM reviewed comfort kit medications with pt. RNCM will follow up with MD for recommendations for nausea/vomiting (N/V). Spouse and pt informed. RNCM attempted to call pt spouse to follow up on if ER visit was made, no answer, and unable to leave message will attempt follow up again on 12/11." A coordination note dated 12/12/2025 at 2:35 pm documented, "Pt is at the hospital. Pt does have N/V." The patient was discharged from hospice care for leaving the service area on 12/12/2025. There was no documented evidence that the RN followed up on 12/11/2025. There was no documented evidence that the RN notified the physician of the severe nausea and vomiting, the patient's inability to keep medications down, and the patient's request to go to the ER, or provided any interventions for the severe nausea/vomiting during the visit. A coordination note dated 12/15/2025 documented, "pt still admitted at hospital, admitted dx: acute gastric outlet obstruction with vomiting." The patient was readmitted to hospice care on 12/18/2025 and died on 12/25/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, and co-morbidities: end-stage heart failure, fibromyalgia, and emphysema. The Registered Nurse (RN) start of care visit note dated 10/20/2025 at 6:11pm documented, "pain an active problem YES, mild pain to lower extremity, aching stabbing tender, intermittent, daily but not constantly, medications relieve pain, effect on quality of life YES-sleep/rest disturbance, patient self-identified threshold for pain 2, acuity level: level 2 moderate level of support needed, changes in symptoms or high-risk situations encountered (new onset of symptoms), symptom screening: symptom impact pain-slight, wound left lower extremity (LLE), keratotic skin flaky black in color wrapped with dry dressing, thrush noted in mouth/throat causing pain upon swallowing, will get orders to start nystatin, currently all medications stopped only on comfort medications and oxycodone for pain in his legs, left knee status post (s/p) arthroplasty developed a hematoma and infection, reviewed medications and all home medications (meds) were discontinued... patient agreed, comfort medications only and to be ordered at pharmacy for family to pick up, teaching discussed comfort medications, patient has adequate supply of medications on hand YES, patient has 7 days of medications on hand YES, no refills are needed." A clinical record review revealed no documented evidence that oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." The Chaplain's visit note dated 10/21/2025 documented that the patient was "having pain all over." The RN visit note dated 10/21/2025 at 11:29 am documented that the "patient states that pain is all over his body, 7/10, family picking up comfort kit not in home at this time, called pharmacy and comfort kit was being prepped and would be given to patient's family member to take home." A clinical review revealed no documented evidence that the RN notified the physician of the 7/10 pain above the patient's self-identified threshold for pain (2/10) or that the RN provided any interventions for the pain during the visit. There was no documented evidence that the oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The pharmacy receipt provided by the hospice revealed that the family picked up the morphine and Magic Mouthwash on 10/21/2025 at 12:20 pm. The RN visit note dated 10/22/2025 documented "no BM (bowel movement) for approximately one month, 0/10 pain, received fentanyl patches and applied the first one approximately 30 minutes ago, semi difficult to get information, caregivers seem somewhat standoffish. There was no documented evidence that the RN notified the physician about the no BM for approximately one month or provided any interventions for the constipation during the visit. The SW visit documentation on 10/22/2025 documented family shows signs of grief and anger. The pharmacy receipt provided by the hospice revealed that the family picked up Fentanyl on 10/22/2025 at 11:28 am. The morning call report dated 10/23/2025 at 7:58 am documented a call from the patient's family stating, "He is in a great deal of pain, and no one has called back all night." The RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night for med refills at 2:30 am in which have not been completed until this morning, and hospice using family's personal items to bathe patient when hospice should be providing those items, Director of Clinical Services (DCS) notified. Patient (Pt) complaining of (c/o) pain in abdomen. Family reports 0.50 ml to have been administered prior to this Registered Nurse Case Manager's (RNCM) arrival. (Face, Legs, Activity, Cry, Consolability- interprets pain in non-verbal individuals) FLACC score 2. Labored breathing and intermediate moaning. Fentanyl patch in place and scheduled to be changed tomorrow. Last bowel movement yesterday, reported to be 'a little bit.' SOB observed with conversation. Family informed pt oxygen (O2) levels can be increased to 4 liters per minute (LPM) or higher for comfort. Family reports new refills are being picked up now. Family denies further needs at this time, and RNCM informs to call hospice with additional concerns. Family remains irritable and states, "You guys always say that, but okay." The pharmacy receipt provided by the hospice revealed that the family picked up medications on 10/23/2025 at 12:49 pm. During an interview on 12/31/2025, the Administrator agreed there was no documented evidence that the RN notified the physician or provided interventions for the severe nausea and vomiting documented in clinical record 3. Additionally, the Administrator agreed there was no documented evidence that pain medications were available to the patient upon admission, prior to the family calling to report that the patient was in pain and had none. During an interview on 12/31/2025, the DCS (parent location & covering other locations) agreed there was no documented evidence that the RN notified the physician of the patient's severe nausea and vomiting, inability to keep medications down, and the patient's request to go to the emergency room (ER), or provided any interventions for the severe nausea/vomiting during the visit. Additionally, the DCS agreed there was no documented evidence that the patient had pain medications available prior to an urgent call from the family. During an interview on 12/30/2025, the DCS (Team D) stated, "I heard from on call about medications and that the family was upset about delays. The comfort kit was ordered by my on-call nurse in the morning, after receiving a call that the patient did not have medications. We ordered it for the family to pick up, and then we sent a nurse out that morning. I recall the staff told me that the family wasn't happy with delays in medications and supplies. I called the daughter; she asked about the medications and why they weren't ready. They were admitted after the pharmacy closed. The nurse was going to put it in the next morning, but the pharmacy was not available at night. We do not have a pharmacy available 24/7 in that area."

HCDT.15.I - Hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. (L625) 1. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. 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 2 (50%) home visits observed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient instructions to meet the patient's needs. HOME VISIT 1/CLINICAL RECORD 1: The patient elected hospice care on 11/26/2025 with a diagnosis of malignant neoplasm of the anterior mediastinum. The plan of care dated 11/26/2025 through 02/23/2026 ordered HA services twice weekly, effective 11/30/2025. The HA care plan dated 11/26/2025 ordered the following for every visit: bathing (shower); transport patient (pt) to shower; and clip fingernails as needed. During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 12/31/2025, the patient's son reported that the HA had been "helpful by putting the oxygen on when my mom looked short of breath and told me to keep it on." A whiteboard in the patient's living room between the kitchen and shower had a written note from one of the patient's sons, "Do not use walker. Mom cannot walk behind walker. She loses her balance and almost fell down." The HA care plan did not include specific instructions for the HA on how to transport the patient to the shower, when to clip the patient's fingernails, or for oxygen/oxygen precautions. During a joint record review and interview on 12/31/2025, the Director of Clinical Services (DCS) agreed there was no documented evidence that the HA was provided with specific written instructions for how the HA was to transport the patient to the shower, when to clip the fingernails, and instructions for the oxygen or oxygen precautions. Additionally, the DCS stated, "They should not be using as needed. The aides need specific instructions."

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; [and] included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 2 (100%) home visits observed for patients who received Hospice Aide (HA) services, the agency did not ensure that HA services were provided as ordered and included in the plan of care. HOME VISIT 1/CLINICAL RECORD 1: The patient elected hospice care on 11/26/2025 with a diagnosis of malignant neoplasm of the anterior mediastinum. The plan of care dated 11/26/2025 through 02/23/2026 ordered HA services twice weekly, effective 11/30/2025. The week of 11/30/2025 through 12/06/2025, one HA visit was documented, dated 12/02/2025. There was no documented evidence of a second HA visit or a reason for the missed visit. The HA care plan dated 11/26/2025 ordered the following for every visit: bathing (shower); transport patient (pt) to shower; and clip fingernails as needed. During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 12/31/2025, the HA transferred the patient from the kitchen table to a seated position on a wheeled walker, pushing the walker, on the carpeted floor, with the patient seated, to the bathroom, then transferred the patient to the shower and a shower bench. A whiteboard in the patient's living room between the kitchen and shower had a written note from one of the patient's sons, "Do not use walker. Mom cannot walk behind walker. She loses her balance and almost fell down." The HA care plan did not assign the HA to transfer to patient from the kitchen to the shower bench while seated on a wheeled walker. The HA stated, "Usually, I can walk her behind the walker to the shower. She is usually with it, but not today, so this is different." Additionally, the HA stated, "I just clean under the nails and file if needed. We are not allowed to cut the fingernails." HOME VISIT 2/CLINICAL RECORD 2: The patient elected hospice care on 12/03/2025 with a diagnosis of malignant neoplasm of the bronchus or lung. The plan of care dated 12/03/2025 through 03/02/2026 ordered HA services twice weekly, effective 12/07/2025. During the week of 12/14/2025 through 12/20/2025, one HA visit was documented, dated 12/20/2025. There was no documented evidence of a second HA visit or a reason for the missed visit. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 12/31/2025, the patient's sister reported, "We have had more issues with the aide. We have a hard time getting her here." The patient's son reported, "She is always calling, saying she is stuck across town and wants to come on other days, then doesn't. The other week (son confirmed it was the week of 12/14/2025 through 12/20/2025, and confirmed the only visit that week was 12/20/2025), we had to get my family to come help because we had no one to bathe my mom. It's hard for me, being her son. She was supposed to come yesterday, now it's supposed to be today instead." During an interview, the RN [Personnel Record 2] stated they were not aware of the visit issues and will be following up with the HA and scheduling. During a joint record review and interview on 12/31/2025, the Administrator stated that expectations are that the HA must call the Registered Nurse Case Manager (RNCM) first and, if unable to reach them, call the Director of Clinical Services (DCS). During a joint record review and interview on 12/31/2025, the Director of Clinical Services (DCS) agreed there was no documented evidence that the HA provided services as ordered and included in the plan of care. The DCS stated that she was not aware of the missed visit and concerns expressed about the HA scheduling. The DCS stated that the aide should follow the plan of care and, if unable, notify the Registered Nurse (RN).

It is required that a 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. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 2 (100%) clinical records reviewed and home visits observed for patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes to the patient's plan of care regarding the frequency of HA visits. CLINICAL RECORD 2/HOME VISIT 2: The patient elected hospice care on 12/03/2025 with a diagnosis of malignant neoplasm of the bronchus or lung. The plan of care dated 12/03/2025 through 03/02/2026 ordered HA services twice weekly, effective 12/07/2025. During the week of 12/14/2025 through 12/20/2025, one HA visit was documented, dated 12/20/2025. There was no documented evidence of a second HA visit, a reason for the missed visit, or evidence of communication with the Registered Nurse (RN). During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 12/31/2025, the patient's sister reported, "We have had more issues with the aide. We have a hard time getting her here." The patient's son reported, "She is always calling, saying she is stuck across town and wants to come on other days, then doesn't. The other week (son confirmed it was the week of 12/14/2025 through 12/20/2025, and confirmed the only visit that week was 12/20/2025), we had to get my family to come help because we had no one to bathe my mom. It's hard for me, being her son. She was supposed to come yesterday, now it's supposed to be today instead." During an interview, the RN [Personnel Record 2] stated they were not aware of the visit issues and will be following up with the HA and scheduling. During a joint record review and interview on 12/31/2025, the Administrator stated that expectations are that the HA must call the Registered Nurse Case Manager (RNCM) first and, if unable to reach them, call the Director of Clinical Services (DCS). During a joint record review and interview on 12/31/2025, the Director of Clinical Services (DCS) stated that the aide should follow the plan of care and, if unable, notify the Registered Nurse (RN). The DCS stated that she was not aware of the missed visit and concerns expressed about the HA scheduling.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews and interviews with the Director of Clinical Services (DCS), Administrator, and Hospice Medical Director (HMD), which revealed issues with the hospice organizing, managing and administering its resources to provide hospice care and services to patients, families, and caregivers in the following area: Failed to ensure that the hospice provided care consistent with the patient's and family's needs and goals, prioritizing the patient’s needs and goals in 2 of 5 (40%) clinical records reviewed [HSLG.4.I/L650/418.100(a)]; and Failed to ensure that drugs were available 24/7 to meet the patient's and family's needs in 1 of 5 (20%) clinical records reviewed [HCDT.4.I/L653/418.100(c)(2)]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation, CFR 418.100: Organization and administration of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the management and governing body (or designated persons so functioning) of the hospice is responsible to provide care that: optimizes comfort and dignity; [and] is consistent with patient and family needs and goals, with the patient’s needs and goals as priority. This standard was not met as evidenced by clinical record review and interviews. In 2 of 5 (40%) clinical records reviewed, the agency's management did not ensure that the hospice provided care consistent with the patient's and family's needs and goals, prioritizing the patient’s needs and goals. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/03/2025 with a terminal diagnosis of malignant neoplasm of the gallbladder. On 12/10/2025, the Registered Nurse (RN) documented a telephone call with the patient's wife, "She reports he felt nauseated and had pain all night. He did take ondansetron 4mg twice and Roxanol 5mg/0.25ml once." The RN conducted a visit on 12/10/2025 at 11:40 am following this phone call. The RN visit note dated 12/10/2025 documented, "Severe nausea/vomiting, patient (pt) unable to keep any foods/medications down, multiple times daily, and lasts all day... symptom screening, symptom impact: over the past 2 days how has the patient been affected by each of the following symptoms: symptom impact nausea SEVERE, symptom impact vomiting SEVERE. Informed Registered Nurse Case Manager (RNCM) of stomach discomfort from nausea. Pt attempts to eat, and intake is bites of food offered, but pt unable to hold food down, is having multiple episodes of vomiting daily. RNCM reviewed nausea medications pt has on hand with pt and spouse. Per spouse pt will take medications and vomit. Pt asking for intravenous (IV) fluids, insisting on going into ER for IV hydration. RNCM attempted to encourage pt to manage symptoms at home and pt undecisive. Spouse very receptive of education provided. RNCM reviewed comfort kit medications with pt. RNCM will follow up with MD for recommendations for nausea/vomiting (N/V). Spouse and pt informed. RNCM attempted to call pt spouse to follow up on if ER visit was made, no answer, and unable to leave message will attempt follow up again on 12/11." A coordination note dated 12/12/2025 at 2:35 pm documented, "Pt is at the hospital. Pt does have N/V." The patient was discharged from hospice care for leaving the service area on 12/12/2025. There was no documented evidence that the RN followed up on 12/11/2025. There was no documented evidence that the RN notified the physician of the severe nausea and vomiting, the patient's inability to keep medications down, and the patient's request to go to the ER, or provided any interventions for the severe nausea/vomiting during the visit. A coordination note dated 12/15/2025 documented, "pt still admitted at hospital, admitted dx: acute gastric outlet obstruction with vomiting." The patient was readmitted to hospice care on 12/18/2025 and died on 12/25/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, and co-morbidities: end-stage heart failure, fibromyalgia, and emphysema. The Registered Nurse (RN) start of care visit note dated 10/20/2025 at 6:11pm documented, "pain an active problem YES, mild pain to lower extremity, aching stabbing tender, intermittent, daily but not constantly, medications relieve pain, effect on quality of life YES-sleep/rest disturbance, patient self-identified threshold for pain 2, acuity level: level 2 moderate level of support needed, changes in symptoms or high-risk situations encountered (new onset of symptoms), symptom screening: symptom impact pain-slight, wound left lower extremity (LLE), keratotic skin flaky black in color wrapped with dry dressing, thrush noted in mouth/throat causing pain upon swallowing, will get orders to start nystatin, currently all medications stopped only on comfort medications and oxycodone for pain in his legs, left knee status post (s/p) arthroplasty developed a hematoma and infection, reviewed medications and all home medications (meds) were discontinued... patient agreed, comfort medications only and to be ordered at pharmacy for family to pick up, teaching discussed comfort medications, patient has adequate supply of medications on hand YES, patient has 7 days of medications on hand YES, no refills are needed." A clinical record review revealed no documented evidence that oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." The Chaplain's visit note dated 10/21/2025 documented that the patient was "having pain all over." The RN visit note dated 10/21/2025 at 11:29 am documented that the "patient states that pain is all over his body, 7/10, family picking up comfort kit not in home at this time, called pharmacy and comfort kit was being prepped and would be given to patient's family member to take home." A clinical review revealed no documented evidence that the RN notified the physician of the 7/10 pain above the patient's self-identified threshold for pain (2/10) or that the RN provided any interventions for the pain during the visit. There was no documented evidence that the oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The pharmacy receipt provided by the hospice revealed that the family picked up the morphine and Magic Mouthwash on 10/21/2025 at 12:20 pm. The RN visit note dated 10/22/2025 documented "no BM (bowel movement) for approximately one month, 0/10 pain, received fentanyl patches and applied the first one approximately 30 minutes ago." There was no documented evidence that the RN notified the physician about the no BM for approximately one month or provided any interventions for the constipation during the visit. The SW visit documentation on 10/22/2025 documented family shows signs of grief and anger. The pharmacy receipt provided by the hospice revealed that the family picked up Fentanyl on 10/22/2025 at 11:28 am. The morning call report dated 10/23/2025 at 7:58 am documented a call from the patient's family stating, "He is in a great deal of pain, and no one has called back all night." The RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night for med refills at 2:30 am in which have not been completed until this morning, and hospice using family's personal items to bathe patient when hospice should be providing those items, Director of Clinical Services (DCS) notified. Patient (Pt) complaining of (c/o) pain in abdomen. Family reports Morphine, 0.50 ml to have been administered prior to this Registered Nurse Case Manager's (RNCM) arrival. (Face, Legs, Activity, Cry, Consolability- interprets pain in non-verbal individuals) FLACC score 2. Labored breathing and intermediate moaning. Fentanyl patch in place and scheduled to be changed tomorrow. Last bowel movement yesterday, reported to be 'a little bit.' SOB observed with conversation. Family informed pt oxygen (O2) levels can be increased to 4 liters per minute (LPM) or higher for comfort. Family reports new refills are being picked up now. Family denies further needs at this time, and RNCM informs to call hospice with additional concerns. The pharmacy receipt provided by the hospice revealed that the family picked up medications on 10/23/2025 at 12:49 pm. During an interview on 12/31/2025, the Administrator agreed there was no documented evidence that the RN notified the physician or provided interventions for the severe nausea and vomiting documented in clinical record 3. Additionally, the Administrator agreed there was no documented evidence that pain medications were available to the patient upon admission, prior to the family calling to report that the patient was in pain and had none. During an interview on 12/31/2025, the DCS (parent location & covering other locations) agreed there was no documented evidence that the RN notified the physician of the patient's severe nausea and vomiting, inability to keep medications down, and the patient's request to go to the emergency room (ER), or provided any interventions for the severe nausea/vomiting during the visit. Additionally, the DCS agreed there was no documented evidence that the patient had pain medications available prior to an urgent call from the family. During an interview on 12/30/2025, the DCS (Team D) stated, "I heard from on call about medications and that the family was upset about delays. The comfort kit was ordered by my on-call nurse in the morning, after receiving a call that the patient did not have medications. We ordered it for the family to pick up, and then we sent a nurse out that morning. I recall the staff told me that the family wasn't happy with delays in medications and supplies. I called the daughter; she asked about the medications and why they weren't ready. They were admitted after the pharmacy closed. The nurse was going to put it in the next morning, but the pharmacy was not available at night. We do not have a pharmacy available 24/7 in that area."

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review, document review, and interviews. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that drugs were available 24/7 to meet the patient's and family's needs. CONTRACT 1: Local Pharmacy Contract, November 10, 2016 (Parent, including entire service area of hospice) stated in part, "Provider agrees to be available for consultation and fill services and will make drugs and biologicals available to the Hospice and its patients on a twenty-four (24) hour per day, seven (7) days per week basis; provide delivery of prescriptions and biologicals to a patient's residence in the entire service area of Hospice, including emergency deliveries, on a twenty-four (24) hour per day, seven (7) days per week basis. The parties acknowledge and agree that the maximum response time to dispatch a prescription will be 2 hrs." CLINICAL RECORD 5: The patient elected the hospice benefit on 10/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, and co-morbidities: end-stage heart failure, fibromyalgia, and emphysema. The Registered Nurse (RN) start of care visit note dated 10/20/2025 at 6:11pm documented, "pain an active problem YES, mild pain to lower extremity, aching stabbing tender, intermittent, daily but not constantly, medications relieve pain, effect on quality of life YES-sleep/rest disturbance, patient self-identified threshold for pain 2, acuity level: level 2 moderate level of support needed, changes in symptoms or high-risk situations encountered (new onset of symptoms), symptom screening: symptom impact pain-slight, wound left lower extremity (LLE), keratotic skin flaky black in color wrapped with dry dressing, thrush noted in mouth/throat causing pain upon swallowing, will get orders to start nystatin, currently all medications stopped only on comfort medications and oxycodone for pain in his legs, left knee status post (s/p) arthroplasty developed a hematoma and infection, reviewed medications and all home medications (meds) were discontinued... patient agreed, comfort medications only and to be ordered at pharmacy for family to pick up, teaching discussed comfort medications, patient has adequate supply of medications on hand YES, patient has 7 days of medications on hand YES, no refills are needed." A clinical record review revealed no documented evidence that oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The morning call report on 10/21/2025 at 9:14 am documented that a call came in from the patient's family, "out of med YES, patient in pain YES, urgent RX refill YES." Additionally, the morning report documented that the patient's family stated, "I need a call back from a manager. A nurse came out last night and was supposed to send over the medications. The pharmacy has not received them. This is not acceptable." The Chaplain's visit note dated 10/21/2025 documented that the patient was "having pain all over." The RN visit note dated 10/21/2025 at 11:29 am documented that the "patient states that pain is all over his body, 7/10, family picking up comfort kit not in home at this time, called pharmacy and comfort kit was being prepped and would be given to patient's family member to take home." A clinical record review revealed no documented evidence that the RN notified the physician of the 7/10 pain above the patient's self-identified threshold for pain (2/10) or that the RN provided any interventions for the pain during the visit. There was no documented evidence that the oxycodone, comfort kit medications, or pain medications were available until the afternoon on 10/21/2025. The pharmacy receipt provided by the hospice revealed that the family picked up the morphine and Magic Mouthwash on 10/21/2025 at 12:20 pm. The RN visit note dated 10/22/2025 documented "no BM (bowel movement) for approximately one month, 0/10 pain, received fentanyl patches and applied the first one approximately 30 minutes ago." There was no documented evidence that the RN notified the physician of the absence of BM for approximately 1 month or that the RN provided any interventions for the constipation during the visit. The SW visit documentation on 10/22/2025 documented family shows signs of grief and anger. The pharmacy receipt provided by the hospice revealed that the family picked up Fentanyl on 10/22/2025 at 11:28 am. The morning call report dated 10/23/2025 at 7:58 am documented a call from the patient's family stating, "He is in a great deal of pain, and no one has called back all night." The RN visit note dated10/23/2025 at 12:21 pm documented "family appears upset and states she is unhappy with hospice services due to multiple calls made last night for med refills at 2:30 am in which have not been completed until this morning." Director of Clinical Services (DCS) notified. Patient (Pt) complaining of (c/o) pain in the abdomen. Family reports Morphine 0.50 ml to have been administered prior to this Registered Nurse Case Manager's (RNCM) arrival. (Face, Legs, Activity, Cry, Consolability- interprets pain in non-verbal individuals) FLACC score 2. Labored breathing and intermediate moaning. Fentanyl patch in place and scheduled to be changed tomorrow. Last bowel movement yesterday, reported to be 'a little bit.' SOB observed with conversation. Family informed pt oxygen (O2) levels can be increased to 4 liters per minute (LPM) or higher for comfort. Family reports new refills are being picked up now. Family denies further needs at this time, and RNCM informs to call hospice with additional concerns. The pharmacy receipt provided by the hospice revealed that the family picked up medications on 10/23/2025 at 12:49 pm. During an interview on 12/31/2025, the Administrator agreed that the hospice agency is contracted with a local pharmacy to deliver medications 24/7 to a patient's residence in the entire service area if needed. Additionally, the Administrator stated, "The DCS and Hospice Medical Director (HMD) were apparently unaware that 24/7 can be covered for all patients by the pharmacy near the parent branch in an emergent situation. Education has been provided, and we will be looking into this further." During an interview and joint review of clinical records 3 and 5 on 12/31/2025, the Hospice Medical Director (HMD) stated, "Those rural ones are followed by the other doctors, so I am not familiar with them." When the HMD was asked about patients having symptoms or a crisis where the patient is uncomfortable after hours, the HMD stated, "The nurses call if they aren't comfortable so that we can make changes. It's hard being that rural, so we try to provide comfort kits on admission. There are no 24/7 pharmacies. Patients have to tough it out till the morning or go to the hospital." During an interview on 12/30/2025, the DCS (Team D) stated, "I heard from on call about medications and that the family was upset about delays. The comfort kit was ordered by my on-call nurse in the morning, after receiving a call that the patient did not have medications. We ordered it for the family to pick up, and then we sent a nurse out that morning. I recall the staff told me that the family wasn't happy with delays in medications and supplies. I called the daughter; she asked about the medications and why they weren't ready. They were admitted after the pharmacy closed. The nurse was going to put it in the next morning, but the pharmacy was not available at night. We do not have a pharmacy available 24/7 in that area."

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; [and] 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; [and] 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 measures 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, document review, interview, and observation. Agency procedure: "Medication Profile" (revised 01/20/2019) read in part, "For patients residing in the nursing facility setting, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit after admission... Review the current MAR at the medication cart for the hospice patient...Note whether there are any new medications or medication order changes documented on the MAR... Update the patient's medication profile." In 1 of 3 (33%) home visits observed of patients residing in a skilled nursing facility, the agency did not ensure that the comprehensive assessment included a review of the patient's current medications. Home Visit 1/Clinical Record 1: The patient elected hospice care on 01/09/2025 with a diagnosis of malignant neoplasm of the bladder and resided in a skilled nursing facility (SNF). The SNF medication profile was reviewed with the Registered Nurse [Personnel Record 1] and the facility nurse during the home visit on 01/15/2025. The SNF medication profile did not match the hospice medication profile or hospice IDG comprehensive assessment. The hospice medication profile did not include brimonidine tartrate ophthalmic solution 0.2%, instill one (1) drop in both eyes two times a day for dry eyes (order date 01/09/2025); dorzolamide HCL ophthalmic solution, instill one drop in both eyes two times a day for glaucoma (order date 01/09/2025); erythromycin ophthalmic ointment 5mg/gm, instill one ribbon in right eye three times a day for conjunctivitis (order date 01/12/2025); fluticasone propionate nasal suspension 50 mcg/act, one puff in both nostrils two times a day for allergy ( order date 01/09/2025; hydroxyzine HCL oral tablet 25 mg, give one (1) tablet by mouth every 8 hours as needed for itching/nausea (order date 01/09/2025); latanoprost preservative-free (PF) ophthalmic solution 0.005%, instill one (1) drop in both eyes in the evening for glaucoma (order date 01/09/2025) which were listed on the SNF medication profile. Skilled nursing visits were provided on 01/12/2025 and 01/13/2025. A clinical record review revealed no evidence that the drug profile was updated, and the medications were reviewed with the patient's medication regimen at the time of each comprehensive assessment. During an interview and the joint clinical record review on 01/16/2025, the Area Executive of Clinical Operations confirmed that the hospice medication profile did not accurately reflect the medications the facility administered to the patient.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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, document review, and interview. Agency policy #C9, "Written Interdisciplinary Plan of Care" (revised 09/27/2019), stated in part, "The content of the plan of care includes at minimum... An assessment of the patient's and family's needs and goals...Measurable goals and outcomes for planned interventions." In 6 of 23 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 6: The patient elected hospice on 10/22/2024 with a diagnosis of chronic systolic heart failure. On 11/08/2024, the physician ordered: "Nystatin 100,000 units/gram three times a day and as needed for fungal infection." The skilled nursing (SN) visit note dated 11/08/2024 documented, "Pt has excoriation to buttocks, low back & peri area. RNCM to ask MD for nystatin powder for fungal infection." A review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 11/20/2024 revealed the plan of care did not reflect patient and family goals addressing the fungal infection. Clinical Record 8: The patient elected hospice care on 07/17/2024 with a diagnosis of chronic obstructive pulmonary disease(COPD). On 10/15/2024, the physician ordered: "Macrobid 100 mg PO bid x 5 days. Reason: UTI." The SN visit note dated 10/15/2024 documented, "Describe medication utilized in treatment of urinary tract infection (UTI): Macrobid. Pt has odorous urine and is having incontinence with every urinary episode." A review of the Hospice IDG Comprehensive Assessments and Plan of Care Update Reports dated 11/05/2024 and 11/19/2024 revealed the plan of care did not reflect patient and family goals addressing genitourinary problems or the urinary tract infection (UTI). Clinical Record 10: The patient elected hospice on 07/12/2024 with a diagnosis of cerebral infarction. On 01/03/2025, the physician ordered: "Bactrim DS 800mg-160mg tablet, one PO BID x 5 days for UTI." The SN visit note dated 01/03/2025 documented, "Pt has been urinating frank blood since 04:30 am with pain with urination. RNCM asked MD ... for instructions & RX. MD ...has given RX for Bactrim DS one PO BID x5 days." A review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 01/15/2025 revealed the plan of care dated 01/08/2025 did not reflect patient and family goals addressing the urinary tract infection. Clinical Record 14: The patient elected hospice on 08/05/2024 with a diagnosis of Alzheimer's Disease. On 10/08/2024, the physician ordered: "Amoxicillin 500mg, one (1) capsule by mouth every 8 hours x10 days for pneumonia." The SN visit note dated 10/08/2024 documented, "Caregiver took patient to Emergency dept for assessment, pt had testing for Covid-19, strep and was finally diagnosed with pneumonia." A review of the Hospice IDG Comprehensive Assessments and Plan of Care Update Reports dated 10/22/2024 and 11/05/2024 revealed the plan of care did not reflect patient and family goals addressing pulmonary problems or the infection (pneumonia). Clinical Record 20: The patient elected hospice on 11/17/2024 with a diagnosis of heart failure. On 12/02/2024, the physician ordered: "Cipro 500 mg BID x7 days Reason: UTI." A coordination note dated 12/02/204 documented, "Pt's wife called with concern for UTI. Pt "out of his mind," confused, and keeps trying to get up...Cipro ordered for UTI." A review of the Hospice IDG Comprehensive Assessments and Plan of Care Update Reports dated 11/20/2024 and 12/04/2024 revealed the plan of care did not reflect patient and family goals addressing genitourinary problems or the urinary tract infection. Clinical Record 21: The patient elected hospice care on 10/25/2024 with a diagnosis of malignant neoplasm of the lower lobe, right bronchus, or lung. On 11/01/2024, the physician ordered: "Oxygen 1-4 liters via nasal cannula as needed (prn) for shortness of breath." A review of the Hospice IDG Comprehensive Assessments and Plan of Care Update Reports dated 11/05/2024 and 11/19/2024 revealed the plan of care did not reflect patient and family goals addressing pulmonary problems or the use of oxygen. During a joint record review and interview on 01/16/2025, the Area Executive of Clinical Operations confirmed the plans of care did not include the patient and family goals for problems identified during the comprehensive assessments.

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 to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency procedure "Supervision of Hospice Aides and LP/VN Colleagues" (revised 08/18/2022) read in part, "At every scheduled visit, the RN is responsible to evaluate the care provided by the hospice aide (if one is assigned); it is required that this supervision be completed not less than every 14 days." In 2 of 17 (12%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made 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 HA. Clinical Record 8: The patient elected hospice care on 07/17/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The plan of care dated 10/15/2024 ordered HA services twice (2) weekly beginning 10/15/2024. The HA visits were provided beginning 10/15/2024 as ordered. The HA supervisory visits were provided on 10/30/2024 and 11/27/2024, with 28 days outstanding. Clinical Record 18: The patient elected hospice care on 04/04/2024 with a diagnosis of Alzheimer's Disease. The recertification plan of care dated 11/20/2024 ordered HA services twice (2) weekly beginning 12/02/2024. The HA visits were provided beginning 12/02/2024 as ordered. The HA supervisory visits were provided on 12/14/2024 and 01/07/2025, with 24 days outstanding. In a joint record review and interview on 01/16/2024, the Area Executive of Clinical Operations (personnel record 7) confirmed that HA supervisory visits were not completed every 14 days per agency policy.

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, document review, and interview. Agency policy #C04 "Discharge/Transfer/Revocation" (revised 02/06/2023) read in part "(Agency name) will provide a discharge summary to the attending physician or receiving facility containing...Treatments, symptoms, and pain management information... Current plan of care... Latest physician's orders...Other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility." In 1 of 2 (50%) clinical records reviewed of patients discharged, the agency did not ensure the patient's attending physician was forwarded a copy of the hospice discharge summary. Clinical Record 20: The patient elected hospice care on 11/17/2024 with a diagnosis of heart failure. The patient revoked the hospice benefit on 12/08/2024 to seek aggressive treatment. A "Hospice Discharge-Transfer Summary" report was completed on 12/08/2024. A clinical record review revealed no evidence that the discharge summary was forwarded to the patient's attending physician. The Area Executive of Clinical Operations confirmed the findings in a joint record review and interview on 01/16/2025, stating, "We do send the discharge summaries to the physician, but I don't see it in this patient's record."

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 clinical record review, document review, and interview. One of 16 (6%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Record #37085: election of hospice benefit dated 04/26/2021. There is no evidence of documentation that the medical social worker (MSW) performed a MSW assessment no later than 5 calendar days after the election of hospice care. Interview and record review with the Area Executive Director of Clinical Operations (RN) and Director of Patient Clinical Services on 3/2/2022 confirmed this finding.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review, document review, and interview. Four of 16 (25%) clinical records revealed that an initial bereavement assessment was not performed. Record #67258: election of hospice benefit dated 1/28/21 Record #36500: election of hospice benefit dated 2/8/21 Record #42816: election of hospice benefit dated 12/1/21 Record #37085: election of hospice benefit dated 4/26/21 [All records failed to provide documentation that an initial bereavement assessment was performed by the Medical Social Worker, Spiritual counselor, or RN case manager.] Agency procedure: C_19A titled Bereavement Risk Assessment and Acuity Scale revision dated 11/2018 reads in relevant parts, “The social worker completes the initial bereavement risk assessment during the social worker’s comprehensive assessment within 5 days of the hospice election.” and “A spiritual counselor or RN case manager may be asked to complete the assessment if the social worker is not able to complete the assessment timely.” Interview and record review with the Area Executive Director of Clinical Operations (RN) and Director of Patient Clinical Services on 3/2/2022 confirmed this finding.

It is required that the hospice provides nursing care under the supervision of a Registered Nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Two of 2 (100%) clinical records reviewed in which a Licensed Vocational/Practical Nurse (LPN/LVN) provided services, revealed that a Registered Nurse (RN) did not perform LPN/LVN supervisory visits. Record #58423: election of hospice benefit dated 9/26/21. The LPN/LVN visited the patient on 12/30/21, 1/4/22, 2/8/22, and 2/15/22. The clinical record failed to provide documentation that a RN supervised the LPN/LVN. Record #37085: election of hospice benefit dated 4/26/21. The LPN/LVN visited the patient on 12/31/21, 1/3/22, 1/11/22, 1/25/22, 2/7/22, and 2/24/22. The clinical record failed to provide documentation that a RN supervised the LPN/LVN. Agency procedure: C_12A Supervision of Hospice Aide and LP/VN Colleagues reads in relevant parts that the “The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days.” and “Documentation of this supervisory evaluation is completed as part of the RN visit note.” Interview and record review with the Area Executive Director of Clinical Operations (RN) and Director of Patient Clinical Services on 3/3/2022 confirmed this finding.

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 clinical record review, document review, and interview. One of 15 (7%) clinical records reviewed in which a Hospice Aide (HA) provided care, revealed that the care provided by the Hospice Aide was not consistent with the tasks assigned on the Hospice Aide plan of care (HA POC). Record #12484: election of hospice benefit dated 1/20/22. The HA POC states “skincare.” The HA documented the patient had an open sore on “her bottom” and that she applied cream to it. There were no orders in the clinical record or listed on the HA POC that provided instructions for the HA to apply lotion to the open wound. Agency policy #C21 titled Hospice Aide and Homemaker Services revision dated 9/10/21 reads in relevant parts, “The specific activities of the hospice aide are written by the RN for each patient…” and “The hospice aide follows the assigned activities in the delivery of care and services to the patient.” Interview and record review with the Area Executive Director of Clinical Operations (RN) and Director of Patient Clinical Services on 3/1/2022 confirmed this finding.