Every finding on record at Hospice Visions, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 2: The patient elected the hospice benefit on 06/29/2022 with a diagnosis of chronic respiratory failure. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (Personnel Record 7) on 06/03/2025, the hospice medication profile (printed 06/03/2025) was compared to the ALF medication profile (printed on 06/03/2025). The hospice medication profile listed the following medications not on the ALF profile: Simethicone 80 mg tablet. One tablet four times daily as needed for gas/belching relief (ordered 10/30/2024); Children's Zyrtec allergy 1 mg/ml. Give 10 mg twice daily (ordered 05/29/2024); Calmoseptine topical ointment. Apply four times daily and as needed for skin breakdown (ordered 05/30/2025). The following discrepancies were noted: Hospice profile had Budesonide ER 3 mg capsule. Take 2 capsules as needed (ordered 03/28/2024) and Budesonide 8 mg tablet. Take 1 tablet daily in the AM (ordered 07/26/2023). Facility had Budesonide ER 3 mg capsules. Take 2 capsules daily. An interview and joint clinical record review was conducted with the Compliance Officer on 06/06/2025. She confirmed the discrepancies and advised the "process was to review the medications at each nursing visit."

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure the agency included detailed treatments necessary to meet the needs of the patient. CLINICAL RECORD 7: A physician's order dated 08/20/2024 noted "Dressing to left hip. Clean with NS (normal saline). Abx (antibiotic) dressing cut to size, covered with foam dressing." The order did not include the frequency of wound care. CLINICAL RECORD 9: A physician's order dated 09/19/2023 noted "Cleanse with normal saline, air dry, apply dressing of choice." A physician's order dated 09/20/2023 noted "Apply PRN (as needed) dressing of choice to potential/actual skin breakdown PRN hospice standing orders." A physician's order dated 10/11/2023 noted "Apply Cerave cream to area as needed." The orders did not contain the frequency of wound care, or when the PRN orders should be implemented and what for. CLINICAL RECORD 15: A physician's order dated 11/21/2024 noted "Apply PRN dressing of choice to potential/actual skin breakdown PRN hospice standing orders." The order did not contain the location of the wound or area being treated, the frequency of wound care, or the reason the PRN order would be implemented. An interview and joint clinical record review was conducted with the Compliance Officer on 06/05/2025. She advised the wound care orders had been discussed with the physician and were part of "standing orders" but the "nurses should be modifying them to make them complete."

It is required that 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 and interview. In 4 of 16 (25%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 2: Home Visit 2 was performed with the Hospice Aide (Personnel Record 7) on 06/03/2025. The patient was noted to be on continuous oxygen at 2 liters per minute. The oxygen was not noted on the aide care plan dated 06/29/2022, nor was the aide given specific instructions for the oxygen during tasks. CLINICAL RECORD 4: A physician's order dated 03/27/2025 noted "Apply hydrocolloid dressing to right buttock." The hospice aide care plan dated 03/13/2025 included the following tasks: "change linen, oral care, tidy bathroom." The hospice aide care plan dated 03/28/2025 included the following tasks: "shower needs help with back and legs; skin care-calmoseptine to buttocks." The hospice aide care plan did not provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 7: The hospice aide care plan(s) dated 08/14/2024, 09/16/2024, 11/14/2024, 1/10/2025, and 03/12/2025 included the following tasks: "bed bath, peri care, barrier cream after bath, skin care-lotion back and legs, back rub." The initial nursing assessment dated 06/21/2023 noted "Wound Stage IV to right hip covered with dressing." This wound was still present on the date of the Clinical Record review (06/04/2025). The hospice aide care plan(s) did not provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged or wet. CLINICAL RECORD 15: The hospice aide care plan(s) dated 10/15/2024, 10/18/2024, 10/24/2024, and 01/10/2025 included the following tasks: " shower needs help with back and legs; skin care-apply lotion" The initial nursing assessment dated 10/14/2024 noted a "Pressure ulcer on right heel." A nursing assessment dated 10/21/2024 noted "Pressure blister to right heel covered with bordered foam." The nursing assessment dated 11/21/2025 noted to add "heel protectors." The hospice aide care plan did not provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged or wet. The aide care plan did not give the aide specific instructions for the heel protectors. An interview and joint clinical record review was conducted with the Compliance Officer on 06/05/2025 in which she confirmed the aide(s) had not been provided with specific instructions or notifications of the wounds, heel protectors or oxygen.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 4 of 16 (25%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Home Visit 2: Clinical Record 2 was performed with the Hospice Aide (Personnel Record 7) on 06/03/2025. The aide was observed to remove the patient's oxygen cannula and set it on the bed while she changed the patient's shirt, rolled her over to check her brief, and applied lotion to her coccyx. The aide then replaced the oxygen cannula after tasks. The oxygen was not noted on the aide care plan dated 06/29/2022 nor was the aide given instructions for the oxygen during tasks. CLINICAL RECORD 3: The hospice aide care plans dated 04/03/2025, 04/11/2025, 05/01/2025, and 05/19/2025 contained the following relevant task: "oral care-sponge mouth." The hospice aide visit dated 04/17/2025 did not address the task of oral care sponge mouth. The hospice aide visit dated 05/05/2025 and 05/22/2025 noted that oral care was not provided CLINICAL RECORD 15: The hospice aide plan of care dated 10/15/2024 noted "shower on morning visit Tuesday and Friday." The hospice aide visit dated 11/11/2024 (Monday) noted "shower completed." The aide visit on 11/12/2025 (Tuesday) noted the shower was not completed. CLINICAL RECORD 17: The hospice aide plan of care dated 10/31/2024 included the task of "shower every visit." The hospice aide visits on 11/26/2024 and 11/29/2024 noted that a bed bath was given. An interview and joint clinical record review was conducted with the Compliance Officer on 06/05/2025, in which she agreed "the aide(s) did not follow the plan of care."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review were conducted with the Volunteer Coordinator on 06/05/2025. The volunteer percentage for the past year (April 2024 to March 2025) in either an administrative or patient care role was calculated at 1.5%. A document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review was conducted with the Volunteer Coordinator on 06/05/2025 and the volunteer percentage for the past year (April 2024 to March 2025) in either an administrative or patient care role was calculated at 1.5%. April 2024 1.14%, May 2024 1.21%, June 2024 0.95%, July 2024 2%, August 2024 1.8%, September 2024 1.62%, October 2024 2.62%, November 2024 1.19%, December 2024 0.86%, January 2025 0.96%, February 1.47%, March 2025 2.42%

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the patient's discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 16: The patient elected to revoke their hospice benefit on 05/18/2025. The discharge summary dated 05/18/2025 included the following note: "Patient requested to transfer to home health with ******** home health after talking with grandson and daughter." It did not include a summary of the patient's hospice stay including treatments, symptoms and pain management. An interview and joint clinical record review was conducted with the Compliance Officer on 06/03/2025. She advised she had "been educating about the proper requirements needed in the discharge summary and they were not included in this one."

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed, the hospice did not ensure the plan of care (POC) reflected patient and family goals with outcomes that were defined and measurable. Record #1 was reviewed and identified the patient elected hospice on 9/29/2021. The POC dated 9/14/2022, documented, "Problem: Pain...Goal: Pt will maintain pain controlled at an acceptable level for pt./cg." The goal controlled pain did not include a measurable outcome anticipated from implementing and coordinating the plan of care. Record #4 was reviewed and identified the patient elected hospice care on 7/8/2020. The POC dated 3/16/2022, documented, "Problem: Pain. Goal: CG will verbalize understanding of nonverbal signs of pain." The goal "verbalize understanding of nonverbal signs of pain" did not include a measurable outcome anticipated from implementing and coordinating the plan of care. The RN/ Compliance Officer was interviewed on 9/21/2022 and confirmed the patient’s acceptable pain level was not identified in Record 1. The RN/Compliance Officer was interviewed on 9/21/2022 and agreed, the goal for pain did not reflect a patient and family goal in Record 4. Record 1: This patient was admitted to hospice on 9/29/2021. Diagnosis Chronic diastolic (congestive) heart failure. The plan of care on 9/14/2022 was reviewed. Problem: Pain. Goal: Pt will maintain pain controlled at an acceptable level for pt/cg. Record 4: This patient was admitted to hospice on 7/8/2020. Diagnosis Frontotemporal dementia. The plan of care on 3/16/2022 was reviewed. Problem: Pain. Goal: CG will verbalize understanding of nonverbal signs of pain. The Registered Nurse Compliance Officer was interviewed on 9/21/2022 and agreed, the patient’s acceptable pain level was not identified in Record 1. The Registered Nurse Compliance Officer was interviewed on 9/21/2022 and agreed, the goal for pain did not reflect a patient and family goal in Record 4.

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 a review of clinical records and interviews. 1 of 13 (8%) records reviewed with a hospice aide ordered revealed, the hospice did not ensure the registered nurse (RN) assigned specific instructions in the hospice aide plan of care. Record #8: This patient was admitted to hospice on 12/6/2021. The RN visit note dated 8/2/2022, documented the patient's: hallucinations; memory changes; forgetful; and confused. The hospice aide plan of care completed by the RN on 12/9/2021 assigned the aide the tasks: shower if asked; shampoo if asked; peri care if asked; and shave face if needed. The aide did not receive specific instructions for the patient's personal care from the RN. The RN/ Compliance Officer was interviewed on 9/21/2022 and agreed, the RN did not assign specific instructions for the aide to follow in the records identified. Record 6: This patient was admitted to hospice on 4/15/2022. The hospice aide plan of care completed by the RN on 5/2/2022 assigned: light meal preparation per pt request and revealed functional limitations “pt is forgetful and poor historian.” The nursing assessment on 4/15/2022 revealed a diagnosis of dementia. Record 8: This patient was admitted to hospice on 12/6/2021. The hospice aide plan of care completed by the RN on 12/9/2021 assigned: shower if asked, shampoo if asked, peri care if asked, shave face if needed. The registered nurse documentation on 8/2/2022 revealed mental conditions: hallucinations, memory changes, forgetful, confused. The Registered Nurse Compliance Officer was interviewed on 9/21/2022 and agreed, the RN did not assign specific instructions for the aide to follow in the records identified.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed of patients accepting hospice aide services revealed, the hospice did not ensure the hospice aide reported a change in condition to the registered nurse (RN). Record 8 was reviewed and identified the patient elected hospice care on 12/6/2021. The hospice aide visit note dated 2/4/2022 read in part, “Pt refused shower stated she didn’t feel good today.” The record was missing evidence that the hospice aide reported the patient's change in condition to the RN. The RN/ Compliance Officer was interviewed on 9/21/2022 and confirmed there was no documented evidence the hospice aide notified the RN with the change in condition. Record 8: This patient was admitted to hospice on 12/6/2021. The hospice aide documentation on 2/4/2022 stated, “Pt refused shower stated she didn’t feel good today.” There was no documented evidence that the hospice aide notified the registered nurse. The Registered Nurse Compliance Officer was interviewed on 9/21/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the change in condition.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 10 (10%) records reviewed revealed the hospice did not ensure that a competency assessment was completed on hire Staff #10: The personnel record of the volunteer with the hire of date 3/4/2021, was reviewed and revealed no documented evidence that a competency was completed upon hire. During an interview on 9/21/2022, the Volunteer Coordinator and the Human Resources Manager confirmed the required competency was not completed prior to the volunteer making visits on 4/13/2021. The Volunteer Coordinator stated, “we did not complete a competency before September 19, 2022.” Record 10: (Volunteer): hire date 3/4/2021. There was no documented evidence that a competency was completed upon hire. The Volunteer Coordinator was interviewed on 9/21/2022 and agreed, the required competency was not completed prior to the volunteer making visits starting 4/13/2021. The Volunteer Coordinator stated, “we did not complete a competency before September 19, 2022.” The Human Resources Manager was interviewed on 9/21/2022 and confirmed this finding.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 13 (23%) records reviewed revealed, the hospice did not ensure the clinical record included a physician’s order for wound and or catheter care. Record #9 was reviewed and identified the patient elected hospice on 8/4/2021. The Registered Nurse (RN) visit note dated 5/10/2022 documented, "Portacath was flushed." The clinical record was missing evidence of a physician's order for the Portacath flush. Record #10 was reviewed and identified the patient elected hospice on 4/9/2022. The RN visit note dated 5/10/2022 read in part, “RN performed care to skin tear on right knee...Cleaned with NS, patted dry, and covered with small island drsg...care provided to left upper arm...Cleaned with NS, patted dry, covered with tegaderm.” The clinical record was missing evidence of a physician's order for the wound care provided. Record #11 was reviewed and identified the patient elected hospice on 1/26/2022. The Licensed Practical Nurse (LPN) visit note dated 1/27/2022 documented, "18FR Foley catheter was inserted." A second LPN visit note dated 1/27/2022 documented, "Foley catheter was not draining, Foley catheter replaced with 18FR 10cc balloon." The LPN visit note dated 1/28/2022 documented, "dressings to buttocks and posterior thighs were changed, areas were cleaned with gel wound cleanser, wound to coccyx area was cleaned and foam was applied inside wound, skin prep was applied on skin, foam dressing applied on wounds." The clinical record was missing evidence of a physician's orders for the wound care provided and the Foley catheter insertion. The RN/ Compliance Officer was interviewed on 9/21/2022, and confirmed there were no physician’s orders for the care provided in the records identified. Record 9: This patient was admitted to hospice on 8/4/2021. The Registered Nurse documentation on 5/10/2022 revealed, the portacath was flushed. There was no documented evidence of a physican’s order for the portacath flush. Record 10: This patient was admitted to hospice on 4/9/2022. The Registered Nurse documentation on 5/10/2022 revealed, “RN performed care to skin tear on right knee. Cleaned with NS, patted dry, and covered with small island drsg” and care provided to left upper arm “Cleaned with NS, patted dry, covered with tegaderm.” There was no documented evidence of a physican’s order for the wound care provided. Record 11: This patient was admitted to hospice on 1/26/2022. The Licensed Practical Nurse (LPN) documentation on 1/27/2022 identified two visits by the LPN on the same day. The first LPN visit documentation on 1/27/2022 revealed, 18FR foley catheter was inserted. The second LPN visit documentation on 1/27/2022 revealed, foley catheter was not draining, foley catheter replaced with 18FR 10cc balloon. The LPN visit note on 1/28/2022 revealed, dressings to buttocks and posterior thighs were changed, areas were cleaned with gel wound cleanser, wound to coccyx area was cleaned and foam was applied inside wound, skin prep was applied on skin, foam dressing applied on wounds. There was no documented evidence of a physican’s order for the catheter insertion or wound care provided. The Registered Nurse Compliance Officer was interviewed on 9/21/2022 and agreed, there were no physician’s orders for the care provided in the records identified.