Every finding on record at Karemore Hospice Inc

Observed in Emergency Management Session. The surveyor observed that the organization had not critiqued or reviewed the disaster drills in the past 2 years this issue was discussed and confirmed with leadership. The organization stated that they had discussed and reviewed , but had not documented.

Observed in Tracer Activities. The surveyor observed that the organization had not provided volunteer hours equal to 5 percent in 2023 or 2024. In 2023 and 2024 the organization had less than 2 percent volunteer hours. The issue was discussed and confirmed with hospice leadership, who stated and provided documentation that it was an issue they had made a PIP for 2025.

Observed in Individual Tracer. In 2 of 2 HR files reviewed, of certified nursing assistants (CHHA) ,the surveyor observed that the organization had not obtained proof of CHHA required 12 hour education in-service training in 2024 and to date in 2025 . This issue was discussed and confirmed with hospice leadership.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not provide notice to the patient of non covered items. RR#1 was a Medicare patient and based on medication record had at least three medications that were not covered by the hospice. Per the administrator, a consent form should be completed on each patient that identifies whether the patient was to receive information on noncovered items. This consent form was not completed for this patient based on review of the home chart and electronic medical record.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not provide the patient with information upon admission regarding the organization's advance directive policies. Based on a review of the admission packet and the home chart of RR#1 there was no information provided to the patient/caregivers regarding advance directive policies. This observation was discussed with the administrator.

Observed in Individual Tracer. In 3 of 11 patient records reviewed, the hospice care plan goals were not individualized related to time frames to achieve. RR#2, RR#4, RR#9 all had target dates for most of the goals by xx/xx/xxxx or by the end of the certification date. RR#2 and RR#4 both had 17 out the 18 goals with the same target dates. Some of these goals related to bowels, skin, nutrition, and oxygenation. Similarly, all of the goals for RR#5 had the same target date. Some of these goals related to bowels and nephrostomy care. These observations were discussed with the administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the hospice care plan did not reflect the medications that were available in the home. A medication review of RR#1 revealed that a suppository and a laxative were not in the home although listed on the medication sheet. This observation was discussed with the administrator.

Observed in Leadership Session. Based on a review of the available data for 2021, the QAPI did not reflect the complexity of the hospice. The hospice had nursing home services, durable medical equipment, and pharmacy services arranged under contract. These services were not included in the QAPI reports for 2021. This observation was discussed with the administrator.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice did not educate/reeducate the patient/caregivers regarding the management of durable medical equipment. RR#1 was oxygen dependent and the oxygen concentrator casing and the external filter were occluded with dust. There was no documentation in the record that this risk was identified and or that education was provided. This observation was discussed with the administrator.