Every finding on record at Myfamily 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, 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 measurements 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 observation and interview. In 2 of 3 (67%) home visit observations, 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. HOME VISIT 1: The patient elected the hospice benefit on 06/15/2024 and resided at an Assisted Living Facility (ALF). During the home visit observation on 07/09/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the hospice medication profile printed on 07/08/2025 to the patient’s medication list at the ALF. The hospice medication profile included Naprosyn oral tablet 250 mg, take 1 tablet by mouth every 4-6 hours as needed and Linzess oral capsule 145 mcg, take 1 tablet by mouth every day before breakfast. The ALF medication list included Vitamin E 180 mg (400 IU), take one capsule daily. The ALF Health and Wellness Director (HWD) stated that the patient had been receiving Vitamin E since May 2024. The HWD noted that the patient had not taken Linzess in two months and that Naprosyn was not included in the ALF medication list as an active or discontinued medication. HOME VISIT 2: During the home visit observation on 07/09/2025 with the Hospice Aide (HA) (Personnel Record 9), a medication review was completed by comparing the hospice medication profile dated 07/08/2025 to the patient’s current home medications. The hospice medication profile included Trazodone HCl oral tablet 50 mg take one tablet PO [by mouth] at bedtime, Tamsulosin HCl oral capsule 0.4 mg take one tablet PO after breakfast, Oxybutynin chloride oral tablet 5 mg take one tablet PO every 6 hours, Clopidogrel Bisulfate oral tablet 75 mg take one tablet PO daily, and Aspirin oral tablet delayed release 81 mg take one tablet PO daily. During the medication review the patient’s daughter stated that the patient had not been taking the Tamsulosin and Clopidogrel for "several months," and had been taking the Aspirin, Trazodone, and Oxybutynin as needed. During a joint record review and interview on 07/10/2025, the Director of Nursing (DON) (Personnel Record 2) confirmed there was no documentation that the medications were reconciled, and the medication profiles updated. The DON stated that the Linzess was discontinued 04/24/2025 per the physician's order and that the medication record was not updated in a timely manner.

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, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/09/2024. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/15/2024. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/12/2024. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed. During a joint clinical record review and interview on 07/10/2025, the Director of Nursing (DON) (Personnel Record 2) confirmed that the records did not include an initial bereavement assessment. The DON stated that these patients had declined the chaplain who completed the bereavement assessments.

It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview. The governing body did not ensure oversight and responsibility for the agency’s ongoing performance improvement program. Review of the governing body meeting minutes revealed no documented evidence that the governing body participated in, or reviewed agency outcomes related to the agency’s ongoing performance improvement program. During a joint document review and interview on 07/10/2025, the Director of Nursing (Personnel Record 2) reported that performance improvement meetings had been held following the interdisciplinary group meetings, but that no written documents had been created and provided to the Administrator for the governing body. During a joint document review and interview on 07/10/2025, the Administrator (Personnel Record 1) confirmed that the governing body meeting minutes lacked evidence that the governing body assumed legal authority and responsibility for the performance improvement program for the years 2023, 2024, and 2025 year to date. Upon reviewing the governing body meeting minutes, it was revealed that the agency ensured the hospice's governing body assumed the legal authority and responsibility for the ongoing performance improvement and patient safety programs. This was evidenced by the lack of performance improvement documentation in the hospice governing body meeting minutes for 2023, 2024, and 2025 to date.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation to demonstrate ongoing efforts to recruit and retain volunteers. During an interview on 07/10/2025, the Volunteer Coordinator (Personnel Record 10) confirmed that there was no documentation of recruitment or retention efforts for 2023, 2024, and 2025 year to date. The Volunteer Coordinator was unaware of the recruitment and retention requirements. During an interview on 07/10/2025, the Administrator (Personnel Record 1) confirmed that there were no recruitment or retention efforts for 2023, 2024, and 2025 year to date. The Administrator was unaware of recruitment and retention requirements. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to recruit and retain volunteers for 2023, 2024, and 2025 to date.

It is required that the hospice documents the cost savings achieved through volunteers. Documentation includes: 1. the identification of each position that is occupied by a volunteer, 2. the work time spent by volunteers occupying those positions. Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. The agency did not ensure documentation of the cost savings achieved through volunteers. Review of the agency’s volunteer program revealed that there was no documentation of the positions occupied by volunteers and the work time spent by the volunteers occupying those positions for 2024. During a joint review of the volunteer program and interview on 07/10/2025, the Volunteer Coordinator confirmed that there was no documentation of volunteer cost savings for 2024. The Volunteer Coordinator stated that the Administrator assisted with documenting the hours and adding them up at the end of the month. During a joint document review and interview on 07/10/2025, the Administrator (Personnel Record 1) confirmed that there was no documentation of volunteer cost savings for 2024. Upon reviewing the volunteer program, the documentation for the year 2024 lacked evidence, including the identification of each position that was occupied by a volunteer and the work time spent by volunteers occupying those positions.

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, physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the clinical record included physician orders for services provided. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/04/2023. Clinical record review revealed physical therapy visits were documented as provided to the patient on 01/06/2023, 01/12/2023, 01/19/2023, 01/26/2023, 02/03/2023, 02/10/2023, 02/15/2023, 02/23/2023, and 03/02/2023. There was no documented evidence in the clinical record of a physician's order for physical therapy. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/14/2025. The Registered Nurse documented in the initial nursing assessment dated 06/14/2025 that the patient had a left and right nephrostomy tube [tube inserted through the skin into the kidney to drain urine] that "need flush with 10ml prefilled normal saline." The interdisciplinary group meeting dated 06/27/2025 included the documentation "Intervention Type - Other: Dressing change once a week, if get wet, change dressing as needed. Activities: 06/25/2025 - Dressing was changed." There was no documented evidence in the clinical record of a physician's order for flushing the nephrostomy tubes and specific instructions for the type of dressing needed for the left and right nephrostomy tubes. CLINICAL RECORD 13: The patient elected the hospice benefit on 10/01/2024. On 10/04/2024 the physician ordered oxygen nasal canula concentrator/tank 7-10L/MIN [liters per minute]; continuously; give oxygen 7-10L /MIN via nasal cannula." The Registered Nurse documented on the skilled nursing visit dated 10/14/2024, "Family uses dual o2 [oxygen] concentrator and setup O2 at 18L on SN [skilled nurse] visit." The Registered Nurse documented on the skilled nursing visit dated 10/14/2024, "[patient] on 12L of oxygen supplement via NC [nasal cannula] continuously..." There was no documented evidence in the clinical record of a physician's order to increase oxygen to 12 and 18 liters per minute. During a joint record review and interview on 07/10/2025, the Director of Nursing (Personnel Record 2) confirmed that the records lacked evidence of physician's orders for physical therapy, nephrostomy care, and increased oxygen rates.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient transfer, the agency did not ensure the discharge summary was sent to the receiving facility. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/29/2024 and was transferred to another hospice provider on 07/29/2024. There was no documented evidence in the clinical record that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 07/10/2025, the Director of Nursing (Personnel Record 2) confirmed that the record did not include documentation that the discharge summary was sent to the receiving hospice.

It is required that hospice inpatient care for pain control and symptom management is provided in one of the following: A Medicare-certified hospital or a skilled-nursing facility that also meets the standards specified in §418.110(b) (requiring 24-hour nursing care) and §418.110(f) (regarding home-like patient areas); or A Medicare-certified hospice that meets the conditions of participation (CoP) for providing inpatient care directly as specified in §418.110 for a hospice-operated inpatient facility. This standard was not met as evidenced by document review and interview. The agency did not ensure a written agreement/contract for short term inpatient care was obtained with a facility that could provide short-term inpatient care for pain control and symptom management. During an interview on 07/10/2025, the Alternate Administrator confirmed that the agency did not have a contract or written agreement for short-term inpatient care with a facility that met the requirements for 24-hour nursing care and home like patient areas. The Alternate Administrator stated that the facilities they have relationships with do not have the requirements for inpatient care and that no other facilities were willing to give a "blanket" contract, but only individual one-time agreements. During a document review, the agency lacked evidence of a contract or written agreement for short-term inpatient care under the arrangement with a facility.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by interview and personnel record review. In 1 of 9 (11%) personnel records reviewed, the agency did not ensure criminal background checks were obtained within three months of the date of employment. PERSONNEL RECORD 11: Volunteer date of hire 09/15/2023. Personnel record review revealed a criminal background check was dated 07/10/2025. There was no documented evidence in the personnel record of a criminal background check within three months of the date of employment. During a joint personnel record review and interview on 07/10/20254, the Alternate Administrator confirmed that the record lacked a criminal background check within three (3) months of the date of employment.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) of records reviewed revealed the agency did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Record #1 was reviewed and identified the patient elected hospice care on 7/14/21. Review of the clinical record revealed the Social Worker assessment was not completed. There was no evidence of communication with the patient or the physician explaining the reason the assessment was not completed. Record #2 was reviewed and identified the patient elected hospice care on 12/9/21. The Chaplain's initial assessment was completed on 12/24/21, 15 days outstanding. The record did not include documentation of the reason the assessment was not completed within 5 calendar days after the election of hospice care. During an interview, the Director of Nursing reported that she was aware that a comprehensive assessment must be completed within 5 days from the election of hospice care .

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 a review of clinical records and interviews. 1 of 11 (9%) records reviewed revealed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Record #10 was reviewed and identified the patient elected hospice care on 5/19/22. Review of the clinical record revealed the Registered Nurse (RN) completed the initial assessment on 5/19/22, the Chaplain completed an assessment on 5/23/22, and the Social Worker (SW) completed an assessment on 5/20/22. There was no evidence the bereavement assessment was completed by the RN, SW, or Chaplain. During an interview, the Director of Nursing reported that she was aware of the need for bereavement assessment to be completed and did not know why there was no bereavement assessment completed.

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 8 (12%) records reviewed of patients receiving hospice aide services, revealed the agency did not ensure that the hospice aide received specific written instructions. Record #4 was reviewed and identified the patient elected hospice care on 10/6/19. The aide care plan dated 7/22/22, included tasks assignments for: nail care as needed; shave as needed; change linen as needed. The aide care plan did not provide the frequency to perform the tasks assigned, thus allowing the aide to make decisions that are out of the aide's scope of practice. During an interview, the Director of Nursing confirmed the finding and stated she was aware of Hospice Aide scope of practice and was not aware the Hospice Aide care plan had as needed tasks.