Every finding on record at Lotus Hospice Inc

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, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 03/18/2026 with a diagnosis of malignant neoplasm of the prostate. The patient resided in a private home with paid caregivers. During the home visit observation on 04/16/2026 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the patient's current home medications with the patient's hospice medication profile dated 04/15/2026. The patient’s home medications included Valsartan 12.5 milligrams 1 tab daily, and Valsartan was present in the home. The caregiver confirmed that the patient does take Valsartan. The hospice medication profile did not include Valsartan and Valsartan was not included in the medication review process. During an interview on 04/16/2025, the Director of Nursing confirmed that Valsartan was not on the hospice medication profile. She stated, "I spoke with the RN and verified the patient is still taking Valsartan, and it should be on the profile. I have corrected the medication profile."

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the plan of care included treatments necessary to meet the needs of the patient. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/18/2026 with a diagnosis of malignant neoplasm of the upper lobe of the right bronchus. The Registered Nurse (RN) documented on 02/18/2026, in the initial nursing assessment, that a PleurX drain (small flexible catheter that a doctor places within the patient’s chest to drain fluid from the pleural space around the lungs) was in place, and "(The patient) has a right pleural effusion that requires daily to every other day drainage." The nurse documented on 02/20/2026, "Daughter drained the pleural drain yesterday, 150 milliliters. Dr Smith ordered to drain every other day instead of daily due to pain and minimal output." The plan of care dated 02/18/2026 did not include interventions for drainage of the pleural drain or site care for the insertion site of the drain. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/28/2026 with a diagnosis of senile degeneration of the brain. The initial nursing assessment dated 01/28/2026 included documentation that the patient was at high risk for aspiration (when substances that are meant to be swallowed enter the trachea/windpipe and lungs). The plan of care dated 01/28/2026 did not include interventions for dietary precautions or interventions to reduce the risk of aspiration. During an interview on 04/17/2026, the Director of Nursing (DON) reviewed the plan of care and then stated, "I will need to learn how to edit the plan of care to include patient needs that are not listed in the menu of choices."

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN), 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 and interview. In 2 of 12 (17%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific care instructions to the hospice aide. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/18/2026 with a diagnosis of malignant neoplasm of the upper lobe of the right bronchus. The Registered Nurse (RN) documented on 02/18/2026, in the initial nursing assessment, that a PleurX drain (small flexible catheter that a doctor places within the patient’s chest to drain fluid from the pleural space around the lungs) was in place. The hospice aide care plan dated 02/18/2026 did not include instructions to the aide on precautions for the PleurX drain and how to care for the PleurX insertion site while bathing the patient. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/28/2026 with a diagnosis of senile degeneration of the brain. The RN documented in the initial nursing assessment dated 01/28/2026 that the patient was at a high risk for aspiration (when substances that are meant to be swallowed enter the trachea/windpipe and lungs). The hospice aide care plan dated 01/28/2026 did not include instructions to the aide related to the patient’s risk of aspiration. During an interview on 04/17/26, the Director of Nursing stated, "The aide care plan should include precautions. I will have to determine where to enter it. I will contact the EMR (electronic medical record) administrator to find out if the aide care plan can be amended to include additional precautions."

It is required that each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the clinical record included physician orders. POLICY 1: Agency policy 1-025 Discharge from Hospice Program, required in part, "Procedure - 2. The case manager will ensure that necessary paperwork is completed at the time of discharge. This will include a signed revocation form, if necessary, and a written physician order to discharge if appropriate." CLINICAL RECORD 9: The patient elected the hospice benefit on 02/18/2026 with a diagnosis of malignant neoplasm of the upper lobe of the right bronchus. The Registered Nurse (RN) documented on 02/18/2026, in the initial nursing assessment, that a PleurX drain (small flexible catheter that a doctor places within the patient’s chest to drain fluid from the pleural space around the lungs) was in place, and "(The patient) has a right pleural effusion that requires daily to every other day drainage." The nurse documented on 02/20/2026, "Dr Smith ordered to drain every other day instead of daily due to pain and minimal output." The clinical record did not include a physician order for drainage and care of the PleurX drain. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/22/2025 with a diagnosis of senile degeneration of the brain. The patient was discharged on 10/31/2025 due to no longer meeting eligibility criteria for terminal illness. There was no evidence that a physician's order to discharge the patient was entered into the clinical record. During a review of findings and interview on 04/17/2026 with the Administrator and the Director of Nursing, the Administrator stated, "We were not aware that a discharge order was required for a live discharge for extended prognoses. We will be sure to review the requirements with the nursing staff." The Director of Nursing confirmed that there was no physician's order for the PleurX drain or site care. She stated, "I will enter the order and instruct the nurses to be sure a physician's order is obtained for all treatments."

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: Is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. Review of the agency's Emergency Preparedness Plan revealed that the agency did not ensure a risk assessment using an "all hazards" approach had been completed. The Emergency Preparedness Response Plan and documented reviews of the Emergency Preparedness plan conducted by the incident commander on 2/3/21, 2/2/22 and 2/1/23 revealed that the agency did not complete a risk assessment to identify the potential hazards for the geographic region and population served by the hospice. During an interview on 7/20/23, the Administrator stated that the risk assessment had not been completed. This standard is not met as evidenced by a review of the agency's Emergency Preparedness Plan which revealed that the agency did not ensure the completion of a risk assessment using an "all hazards" approach.

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that a bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 7/23/22 with a diagnosis of Alzheimer's Disease. The comprehensive assessment completed by the IDG team did not contain evidence of an initial bereavement assessment component. Clinical Record 4: The patient elected the hospice benefit on 11/16/22 with a diagnosis of Unspecified Protein-calorie Malnutrition. The comprehensive assessment completed by the IDG team did not contain evidence of an initial bereavement assessment component. Clinical Record 9: The patient elected the hospice benefit on 9/6/22 with a diagnosis of Aortic Valve Disorder. The comprehensive assessment completed by the IDG team did not contain evidence of an initial bereavement assessment component. During an interview on 7/19/23, the Director of Nursing stated that the bereavement assessment had been missed during the comprehensive assessment of these patients but should have been completed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed it was revealed that the agency did not ensure that the agency's Hospice Election Statement contained documentation of all the required elements as described in CFR 418.24. Clinical Record 1: The patient's date of hospice election was 4/27/23 with a diagnosis of Atherosclerotic Heart Disease. The Hospice Election Statement signed by the patient/representative on 4/27/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 2: The patient's date of hospice election was 10/25/22 with a diagnosis of Malignant Neoplasm of the Lung. The Hospice Election Statement signed by the patient/representative on 10/25/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 3: The patient's date of hospice election was 7/23/22 with a diagnosis of Alzheimer's Disease. The Hospice Election Statement signed by the patient/representative on 7/23/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 4: The patient's date of hospice election was 11/16/22 with a diagnosis of Unspecified Protein calorie Malnutrition. The Hospice Election Statement signed by the patient/representative on 11/16/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 5: The patient's date of hospice election was 1/3/23 with a diagnosis of Heart Failure. The Hospice Election Statement signed by the patient/representative on 1/3/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 6: The patient's date of hospice election was 7/18/22 with a diagnosis of Chronic Respiratory Failure. The Hospice Election Statement signed by the patient/representative on 7/18/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 7: The patient's date of hospice election was 6/16/23 with a diagnosis of Parkinson's Disease. The Hospice Election Statement signed by the patient/representative on 6/16/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 8: The patient's date of hospice election was 5/2/23 with a diagnosis of Parkinson's Disease. The Hospice Election Statement signed by the patient/representative on 5/2/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 9: The patient's date of hospice election was 9/6/22 with a diagnosis of Aortic Valve Disorder. The Hospice Election Statement signed by the patient/representative on 9/6/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 10: The patient's date of hospice election was 4/12/23 with a diagnosis of Senile Degeneration of the Brain. The Hospice Election Statement signed by the patient/representative on 4/12/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 11: The patient's date of hospice election was 4/10/23 with a diagnosis of Malignant Neoplasm of the Colon. The Hospice Election Statement signed by the patient/representative on 4/10/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 12: The patient's date of hospice election was 3/21/22 with a diagnosis of Right Breast Mass. The Hospice Election Statement signed by the patient/representative on 3/21/22 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 13: The patient's date of hospice election was 5/23/23 with a diagnosis of Senile Degeneration of the Brain. The Hospice Election Statement signed by the patient/representative on 5/23/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. Clinical Record 14: The patient's date of hospice election was 1/22/23 with a diagnosis of Alzheimer's Disease. The Hospice Election Statement signed by the patient/representative on 1/22/23 did not contain documentation that the beneficiary was offered the opportunity to request an election statement addendum titled, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. During an interview on 7/18/23, the Administrator stated they were not familiar with the regulation, that went into effect on 10/1/2020, regarding the hospice election addendum statement. They reported that they did not have a “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum statement, and had not been providing them to patients.