Every finding on record at Lily Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the drug profile included all of the patient's current prescription and over-the-counter medications. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the benefit on 01/10/2025. During the home visit on 09/24/2025, with the social worker (Personnel Record 8), a review of the patient’s medication profile revealed a discrepancy between the medications listed by the hospice and those documented by the assisted living facility (ALF). The medications polyethylene glycol 3350 1700 MG powder 17 gm daily and quetiapine 25 mg 0.5 tablet two times a day (ordered on 01/10/2025) were still included on the hospice med list but not active on the assisted living's medication profile. The Registered Nurse (RN) checked, and these were discontinued the end of August 2025. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the benefit on 09/05/2025. During the home visit on 09/24/2025, with an RN (Personnel Record 4), a review of the patient’s medication profile revealed a discrepancy between the medications listed by the hospice and those documented by the assisted living facility (ALF). The medication fluorouracil 5% topical cream 3 times weekly ordered on admission for the patient's facial lesions on her left cheek and left nose were not listed on the hospice medication list. During joint record review and interview on 09/24/2025 the Administrator agreed that there were discrepancies related to the drug profiles of the agency and the assisted living facilities.

It is required that each patient’s individualized written plan of care, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed it was revealed that the agency did not ensure that the written plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/21/2024. The initial comprehensive assessment conducted on the same date identified symptoms of anxiety and agitation, and a corresponding care plan problem with interventions was initiated. On 07/07/2025, the problem was marked as resolved and removed from the plan of care. However, a review of multiple skilled nursing assessment notes following the discontinuation of the anxiety/agitation care plan revealed ongoing behavioral symptoms, including combative behavior, verbal aggression (swearing), and physical aggression (swinging at the hospice aide during care). Despite these documented behaviors, the plan of care did not include the interventions based on the re-emergence of anxiety/agitation. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/10/2025. Documentation from the initial and subsequent comprehensive assessments indicated a history of multiple falls prior to hospice admission, a high-risk score for falls, as well as continued falls during the hospice episode. The plans of care, effective from 01/10/2025 to current dates of the site visit, did not include any interventions related to fall risk or safety precautions. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/05/2025 and the initial comprehensive assessment on that date documented that the patient had multiple skin lesions on her face. The lesions required the application of a topical cream three times per week. The plan of care effective on 09/05/2025 did not include interventions or goals associated with the skin issues or use of the topical medication. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/20/2025 with the primary diagnoses of Senile Degeneration of the Brain, Unspecified Dementia, Alcoholic Liver Disease, and Wernicke's Encephalopathy. The initial comprehensive assessment conducted on 02/20/2025 documented a history of cognitive impairment, anxiety, and depression. The plan of care dated 02/20/2025 did not include any goals, or interventions related to the patient’s cognitive deficits, anxiety, or depression. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/24/2025 and the comprehensive assessment completed on that date documented the patient had signs and symptoms of pain. The patient was started on MS Contin for pain management on 03/28/2025. Due to emerging symptoms of anxiety, the patient was subsequently prescribed Ativan 0.5 mg twice a day (on 04/17/2025), Zyprexa 10 mg daily (on 05/01/2025) and Haldol 2 mg three times per day (on 06/11/2025). Additionally, the patient experienced nausea, which was being effectively managed with Zofran. Despite the presence of these clinical issues and active pharmacologic interventions, the plans of care, dated from 03/24/2025 through the dates of the site visit which ended on 09/26/2025, did not include documented problems, goals, or interventions related to pain, anxiety, or nausea management. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/08/2025. Per the initial comprehensive assessment on that date and subsequent nursing notes the patient had documented episodes of restlessness, agitation, and sundowning behavior. The plan of care dated 08/08/2025 through the dates of the site visit which ended on 09/26/2025, lacked interventions addressing the patient’s agitation or behavioral symptoms. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/09/2023 and the initial comprehensive assessment, on that date, documented a history of seizures and that the patient was receiving anticonvulsant medication. Despite this known condition and active management, the individualized plan of care, effective on 06/09/2023, did not include a documented problem, goal, or intervention related to seizure activity or seizure risk. Following joint record review and interview on 09/26/2025, agreed that the plans of care lacked planned interventions based on the comprehensive assessments.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group, and written patient care instructions for a hospice aide are prepared by an 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 1 of 17 (6%) clinical records reviewed it was revealed that the agency did not ensure that the Registered Nurse created written instructions for the hospice aide to provide care. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/08/2025. At that time aide services were ordered 2 times weekly and aide visits were initiated on 08/11/2025. However, as of 09/25/2025, no written hospice aide plan of care had been documented or entered into the medical record by the assigned Registered Nurse (RN) Case Manager. The aide had been documenting care on a progress note that sponge baths or showers were provided and other ADL tasks per RN instructions, but no care plan was documented. The Administrator spoke with the RN who reported she makes joint visits with the aide, so she provided verbal instruction and didn’t realize she hadn’t entered a written aide plan of care. Following a joint record review and interview on 09/25/2025, the Administrator agreed that there was no written hospice aide plan of care.

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 and interview. In 3 of 18 (17%) patient records reviewed in which hospice aide services were provided, it was revealed that the aide did not provide services according to the hospice aide plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/24/2025 and hospice aide services were ordered 2 times a week. The hospice aide plan of care ordered the bathing task as bed bath every visit, there were no other bathing methods/options included. On 5/23/2025 per aide documentation stated, "(patient) sitting on bed, socialized, showered and hair washed." The ordered bathing method was not provided by the aide. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/08/2025. At that time aide services were ordered 2 times weekly and aide visits were initiated on 08/11/2025. However, as of 09/25/2025, no written hospice aide plan of care had been documented or entered into the medical record by the assigned Registered Nurse (RN) Case Manager. The aide had been documenting care on a progress note that sponge baths or showers were provided and other ADL (activities of daily living) tasks per RN instructions, but no care plan was documented. The Administrator spoke with the RN who reported she makes joint visits with the aide, so she provided verbal instruction and didn’t realize she hadn’t entered a written aide plan of care. There was no aide plan of care, or services ordered by the Interdisciplinary Group, for the hospice aide to follow; the services provided by the aide were verbally given to them by the RN. CLINICAL RECORD 19: The patient elected the hospice benefit on 07/24/2024, with hospice aide services ordered at 2 times a week. The aide plan of care, dated 07/24/2024, specified a tub bath during the first visit of each week. The aide’s documented that they provided showers on multiple visits, including 07/23/2025, 07/29/2025, and 09/03/2025. The documentation from nursing identified a patient decline on 09/10/2025 and the patient passed on 09/19/2025. After 09/10/2025 the aides were documenting that bed baths were provided. The aide was not providing the bathing services as ordered on the aide plan of care. Following joint record review and interview on 09/25/2025 with the Administrator she agreed that the hospice aide plans of care were not being following accordingly.

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 clinical record review and interview. In 1 of 17 (6%) clinical records reviewed of patients with hospice aide services provided, it was revealed that the agency did not ensure that the hospice aide reported changes to the registered nurse as they related to the plan of care. CLINICAL RECORD 19: The patient elected the hospice benefit on 07/24/2024 and was ordered to receive hospice aide services twice weekly. The initial plan of care specified a tub bath during the first visit of each week. The aide’s documented that they provided showers on 07/23/2025, 07/29/2025, and 09/03/2025. There was no documentation that the registered nurse (RN) was notified that a shower was being provided instead of the ordered tub bath. During an interview, on 09/26/2025, with the Administrator she reported that she was surprised the RN was not notified because they work side by side frequently.

It is required that a written agreement with another organization or individual to furnish hospice care or services includes the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice and care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice and care delivered in accordance with patient’s plan of care. This standard was not met as evidenced by document review and interview. In 1 of 5 (20%) contracts reviewed it was revealed that the agency did not ensure that the written agreement included all required elements. CONTRACT 5: The therapy services (physical therapy, occupational therapy, and speech-language pathology) contract was signed and executed on 10/12/2022. The documented included payment for services provided but lacked how the Interdisciplinary Group (IDG) management oversight and coordination would be provided, how communication with the IDG and hospice administration would occur, that care would be provided only upon authorization of the hospice and care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice and care delivered in accordance with patient’s plan of care. Following review of the contract and interview with the Administrator agreed that, when reviewing the standards, the contract did not have all the required elements.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients who were discharged from services, it was revealed that the agency did not ensure that a discharge summary was completed and included all required components. CLINICAL RECORD 15: The patient elected the hospice benefit on 03/31/2025. On 09/08/2025, the patient revoked the Medicare Hospice Benefit and signed the revocation form to seek aggressive treatment. As of this entry on 09/26/2025, a discharge summary had not been completed or entered into the medical record. Following joint record review and interview on 09/26/2025 the Administrator agreed that there was not a discharge summary for this patient following the revocation.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: 1. Discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand; 2. Ensures that the safe use and disposal of controlled drugs is understood; 3. Documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by a review of clinical records and interviews. In 7 of 7 (100%) records reviewed where controlled medications had been ordered and placed in the home, there was no documented evidence that managing and disposing of controlled medications was provided and discussed with the patient and family or patient’s legal representative. Clinical Record 3 Patient had morphine and hydrocodone ordered per plan of care dated 10/28/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 4 Patient had morphine ordered per plan of care dated 9/26/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 5 Patient had morphine ordered per plan of care dated 11/22/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 7 Patient had morphine ordered per plan of care dated 10/19/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 8 Patient had morphine ordered per plan of care dated 11/14/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 9 Patient had morphine IR Tablets ordered per plan of care dated 10/14/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, Clinical Record 10 Patient had morphine ordered per plan of care dated 9/29/22. The patient chart revealed no evidence that a written policy and procedure for the management and disposal of controlled medications had been provided to the patient/family, President In a joint record review with the President and Administrator on 12/5/22, this finding was confirmed.