Every finding on record at Hospice of Chattanooga Holdings, LLC

Upon patient record review, 1 of 31 (Patient #27) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #27: Right to Choose my Attending Physician and Do Not Wish to Choose My Attending Physician are both blank.

Upon patient record review, 1 of 31 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: During home visit and medication reconciliation, noted that patient/ALF medication profile listed Atenolol 25 mg (1/2) tab daily and hospice medication profile listed Atenolol 25 mg (1) tab daily. RN informed and will reconcile.

Upon patient record review, 1 of 31 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: Patient is IDDM. Initial assessment RN documented plan to decrease insulin, based on patient blood sugars. Patient had 2 prior hospitalizations for hypo-hyper glycemic episodes and has documented weight loss 8-9 lbs in past 4 months (per CTI). There was no documented evidence blood sugar is being monitored. Example visit notes November 22, Dec 1, 8, 19, 26 29 of 2025.

Upon patient record review, 2 of 31 (Patient #11, 17) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #11: 12/9/25 SN Visit, patient had symptoms URI and Levaquin ordered. No update to problems, goals, interventions. Patient #17: 12/19/25 SN Visit, a small toe wound was documented by nurse. No update to problems, goals, interventions.

Upon client record review, 4 of 31 (Patient #4, 6, 21, 26) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: 12/18/25 SN note: Patient has an unstageable wound on left heel, dressing peeling off. Area cleaned and redressed per MD order. Patient tolerated well. There are no documented orders for dressing change. Patient #6: Plan of Care includes order for wound measurements weekly. No documented evidence of measurements including, but not limited to 12/9, 12/16. 12/23, 12/30/25 SN visits. Patient #21: 7/2/25 written order for PT consult and up to 3 visits. Record only included documentation of Physical Therapist's evaluation visit, including plan for follow up visit; however, record did not include documentation of subsequent visits. Patient #26: Travel patient admitted into GIP in hospice care center. Volunteer visit documented 12/18/25. No ordered volunteer frequency. POC states provide volunteer as ordered.

Upon observation 1 of 6 visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #8 (Visit 6): Upon observation during home visit with RN, observed that clean and dirty was not clearly defined for barrier used. RN cleaned equipment and placed equipment back on dirty space where equipment had been placed after use on patient. Nurse also entered bag after contact with patient and without sanitizing first. Nurse retrieved used nasal cannula for patient from portable tank, and touched used cannula without sanitizing afterwards.

Upon patient record review, 1 of 31 (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #7: Patient has continuous oxygen prescribed with oxygen precautions not specified in Aide care plan.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency is unable to present evidence of 5 percent total patient care hours for volunteer services. Monthly tracking 2025 under 5% each month.

Upon patient client record review, 1 of 31 (Patient #27) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #27: Right to Choose my Attending Physician and Do Not Wish to Choose My Attending Physician are both blank.

Upon patient client record review, 4 of 31 (Patient #4, 5, 11, 12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: 12/18/25 SN note: Patient has an unstageable wound on left heel, dressing peeling off. Area cleaned and redressed per MD order. Patient tolerated well. SN did not document specifics of treatment provided. Patient #5: CTI signed 12/24/25 (for 12/23--2/20/25) includes documentation that patient she has a growth on her left neck with an eschar. She has a stage two pressure wound on her sacral area and bilateral buttock wounds as well. SN notes dated 12/10, 12/19, 12/31 say skin intact with no documented wounds. Interview with staff confirm patient has no wounds. Patient #11: Patient readmitted status post hospitalization for fall and hip fracture. 11/21/25 SN visit narrative references 3 surgical incisions. One of the three wound was described in wound care section as type: "Burn" with 4 staples intact. Interview with staff confirm all 3 wounds to be surgical incisions and "burn" is error. SC IDG note effective 11/26/25, says simply that patient revoked to seek aggressive treatment. At that point, should have included that patient had been readmitted 11/21/25, as most accurate status. Patient #12: SN initial eval and listing of multiple wounds failed to specify right or left for "lower calf" and "pinky toe" wounds.

Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 "exception number 1 and 2 and 19.3.6.3.6 number 2". If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During building tour the following was observed: 1. Self closing fire doors (11327) had greater than 1/8" gap at the meeting edges, which exceeds maximum allowable clearance (NFPA 101, 7.2.1.4.3). Corrected on site-Intumescent edge seal installed. 2. Missing corner in ceiling tile in smoke compartment corridor area. Corrected on site- Ceiling tile repaired.

Observed in Patient Home. In 2 of 5 home visits conducted, the organization failed to assess potential medication-related problems. The surveyor observed the hospice nurse conduct a medication assessment but failed to identify all medications, regime changes, and/or errors. For example, for HOS 1 the hospice nurse was observed setting up the patient's medication planner for the next week when she discovered that the patient had a bottle of Lorazapam 1 mg twice daily as needed that was started 01/13/2023 but was not on the hospice program's medication list. Additionally, the medication Hydroxyzine HCL by mouth 25 mg tablet 1 Tablespoon twice daily was on the medication list and started 2/06/2023 however the RN did not realize that it was regularly scheduled medication and had not filled the medication planner with the medication. For HOS 5, the patient's medication list was not accurate, for example several medications failed to include the frequency for administration and stated only as directed including; Docusate Sodium by mouth,100 mg capsule as directed. Gabapentin by mouth, 100 mg capsule as directed, Ondansetron by mouth 4 mg tablet as directed, Morphine Sulfate (concentrate) by mouth solution 100 mg/5ml as directed. Also, the medication list included Acarbose by mouth 10 mg tablet. 1 tablet twice a day P.O. however, the wife and patient reported that the medication had been discontinued before Christmas. Finally, the patient was taking Vitamin B12 and Vitamin C which were not included on the medication list. This was validated by the Assistant Program Director.

Observed in Record Review. In 14 of 20 patient records reviewed, the organization written care plans for patients were not based on the patient’s goals and the time frames, settings, and services required to meet those goals. For HOS 1 who was exhibiting signs/symptoms of pain during the home visit goals were broad and did not have time frames for achieving goals. The goal for pain management was patient/family verbalizes pain is controlled within their desired comfort level - desired level of pain is 2 or less on verbal report of 0-10 scale however failed to identify the timeframe for achieving the desired level of pain. Also, the care plan identified a problem for three wounds (sacral, right heel and left heel), however those wounds had healed and the problem had not been resolved and the care plan updated.. Additionally, for HOS 2 who had 7 documented wounds there was one goal which stated patient's wound improves within limits of disease process however there were no specific interventions/orders for each wound and no time frames were identified to achieve wound healing/goals. In review of the medical records for HOS 3, HOS 4, HOS 5, and in 9 of 15 additional records reviewed including; RR 1, RR 4, RR 5, RR 8, RR 9, RR 10, RR 12, RR 13 and RR 14 there was absence of measurable goals with time frames and interventions to achieve goals. This was validated with the Assistant Program Director.

Observed in Record Review. In 9 of 20 patient records reviewed, the organization did not follow their policy 2-044.1 Plan of Care which states, orders for the start of care will be verbally received by the Case Manager from the attending physician and documented on the plan of care. In review of the medical record for HOS 2 the intervention for skin/wound stated assess wound(s) at each dressing change and prn however there was no evidence of orders for the dressing change. In review of the medical record for HOS 3 the intervention for skin/wound stated coordinate wound with facility staff however there was no evidence of orders for wound care. This was also observed in review of medical records for HOS 5, RR 6, RR 7 RR 9, RR 11, RR 12, RR 15. This was validated by the Assistant Program Director.

Observed in Patient Home. In 1 of 5 home visits conducted, the organization failed to comply with their policy 9-014.1 Bag Technique which states, after hand washing supplies and/or equipment needed for the visit will be removed from the bag. For HOS 1 the nurse surveyor noted that although the RN did clean her hands prior to entering the clinical bag at the beginning of the home visit, the RN was observed entering the nursing bag several times throughout the visit without cleaning her hands as required by the organization's policy. This was validated with the Assistant Program Director. Observed in Patient Home. In 1 of 5 home visits conducted, staff failed to perform hand hygiene consistent with the organization's policy 9-009 Hand Hygiene which requires hand hygiene before donning gloves, after removing gloves and after contact with a patient's intact skin. For HOS 1 the nurse surveyor noted in observation of the RN perform the medication set up for the patient that a medication was dropped on the floor and the RN picked up the medication from the floor with her ungloved hands and disposed of it in the garbage and proceeded to complete the medication set up without cleaning her hands. Additionally, the RN was observed to move on from the medication set up to apply a Fentanyl Transdermal patch to the patient however failed to clean her hands prior to opening or applying the Fentanyl patch. This was validated with the Assistant Program Director.

Observed in Infection Control System Tracer. During the Infection Control System Tracer, the surveyor noted that there was no evidence presented that a formal risk analysis had been performed to identify the predominant risks for acquiring and spreading infections among hospice patients treated in the organization. Organization policy No. 9-001 which included the Infection Control Plan indicated that a risk analysis would be performed and evaluated at least annually. (section 4. A&B). This was discussed with the Administrators.

Observed in Patient Home. the hospice failed to provide the skilled nursing facility with the patient’s most recent hospice plan of care , the patient’s hospice election form and POLST, the physician certification of the patient’s terminal illness, and hospice orders. In review of the facility medical record for HOS 3 there was no evidence that the hospice had provided the facility with the required documentation. The Resident Care Coordinator stated that she scans all written documentation into the facility electronic medical record and she had not received any documentation from the hospice for HOS 3.