Every finding on record at Onesource HHC LLC

It is required that the written Patient Bill of Rights includes the right to: be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient was informed about the scope of services the hospice provided and any specific limitations on those services. Clinical Record 4: The patient elected the hospice benefit on 04/06/2025 and requested the non-covered items addendum. A clinical record review on 07/02/2025 revealed that the electronic medical record (EMR) did not contain documentation indicating that this had been completed or given to the patient. This should have been issued within five (5) days of the election of benefits, making it almost three (3) months outstanding. During a joint clinical record review and interview on 07/02/2025, the Quality Nurse stated, "It should have been uploaded in this area (of the EMR). All uploaded documents were checked to ensure they had not been mislabeled." During a joint clinical record review and interview conducted on 07/03/2025, the Administrator confirmed that the addendum could not be located.

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, observation, and interview. In 1 of 3 (33%) home visits observed, 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/Clinical Record 2: The patient elected the hospice benefit on 01/31/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide [Personnel Record 7] on 07/02/2025, the hospice medication profile (printed on 07/01/2025) was compared to the ALF medication profile (printed on 07/02/2025). The following medications were listed on the hospice medication profile and were not listed on the ALF medication profile: triple antibiotic 3.5 mg-400 units, apply to minor skin tears and wounds as needed (ordered 06/24/2025); Iodosorb gel 5.9%, apply weekly (ordered 02/03/2025); healthy eyes 4.296 mcg, twice daily (ordered 01/31/2025); docusate 100 mg, take daily (ordered 01/31/2025). The ALF medication profile contained the following medication not listed on the hospice medication profile: Albuterol inhaler, inhale two (2) puffs every 6 hours as needed (ordered 11/19/2021). A joint clinical record review and interview were conducted with the Administrator on 07/03/2025, in which the medication differences were confirmed.

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, document review, interview, and observation. In 1 of 13 (8%) clinical records reviewed and home visits observed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the patient's plan of care. Document 2: The state Administrative Code revealed the following: "Oxygen adjustment can be performed with clear direction from a licensed nurse." Home Visit 2/Clinical Record 2: The HA care plan dated 01/31/2025 and revised 05/01/2025 assigned the Hospice Aide the relevant tasks: "Shower; assist to bath chair; shampoo hair; comb hair; mouth care; assist with dressing; clean nails; file nails; wheelchair." All tasks were to be completed on every visit. The HA visit frequency was twice weekly. During the home visit with the HA [Personnel Record 7] on 07/02/2025, the HA assisted the patient with most of the tasks assigned in the HA care plan, as the patient "wanted to do it herself." The HA and the patient did not complete the cleaning or filing of the patient's nails. The HA was observed to blow-dry the patient's hair and change the patient's oxygen from the concentrator to a portable tank, which was not assigned in the care plan by the Registered Nurse (RN). During a joint clinical record review and interview on 07/02/2025, the Administrator stated that they 'thought the HA was allowed to do this."

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 of patients who required a discharge summary, the agency did not ensure that the patient's discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 12: The patient elected to revoke the hospice benefit on 07/21/2024. The discharge summary dated 07/21/2024 included the following note: "Patient revoked hospice to seek treatment." It did not include at least a summary of the patient's hospice stay, including treatments, symptoms, and pain management. During a joint clinical record review and interview on 07/02/2025, the Quality Nurse advised that the "IDG (interdisciplinary group) note contained the medications and notifications, but did not have the summary of the stay. There does not appear to be a summary added."

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), ensures hospice multiple locations are approved by Medicare and licensed in accordance with state licensure laws; and ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by interview. THIS IS A CONTINUING REQUIRED ACTION. During an interview dated 8/21/23, the Hospice Director and the Administrator revealed the agency could not provide the documents needed to prove the ADS was approved by CMS (Centers for Medicare and Medicare Services). They stated that the agency has served hospice patients at this site in the past but at the time of this focus visit there were no hospice patients assigned to the site. The agency continues to be unable to ensure that the alternative delivery site (ADS) is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. In an interview with the Hospice Director and the Administrator it was revealed that the agency could not provide the paperwork needed to prove the ADS was approved by CMS. They have served hospice patients at this site in the past but at the time of the focus visit there were no hospice patients assigned to this site.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. 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 the volunteer received initial training in emergency preparedness. Staff #7: The record of the volunteer with the hire date of 11/16/2021, was reviewed and revealed there was no documented evidence of emergency preparedness training upon hire. The Human Resources Director was interviewed on 8/18/2022 and agreed, there was no evidence of emergency preparedness training upon hire. The Administrator was interviewed on 8/18/2022 and stated, “this was missed, we need to add access to the volunteers for online education.” Staff 7: (Volunteer): hire date 11/16/2021. Review of the personnel file revealed there was no documented evidence of emergency preparedness training upon hire. The Human Resources Director was interviewed on 8/18/2022 and agreed, there was no evidence of emergency preparedness training upon hire. The Administrator was interviewed on 8/18/2022 and stated, “this was missed, we need to add access to the volunteers for online education.”

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 11 (18%) records reviewed revealed the hospice did not ensure the plan of care included planned interventions and measurable outcomes based on problems identified in the initial and updated comprehensive assessments. Record #3 was reviewed and identified the patient elected hospice care on 6/29/2022. The plan of care dated 6/29/2022, documented the patient's diagnosis as "Malignant neoplasm of unspecified part of right bronchus or lung." The completed Registered Nurse assessment dated 7/23/2022, documented the patient’s current respiratory status as, "deteriorating... does dyspnea significantly affect the patient...yes... dyspnea score 7." The plan of care did not include interventions or goals to manage the patient's dyspnea. Record #7 was reviewed and identified the patient elected hospice care on 8/16/2021. The plan of care dated 8/16/2021, documented the patient's diagnosis as, "Severe protein calorie malnutrition." The completed skilled nursing assessment dated 3/21/2022, documented, “patient has Foley catheter in place.” The plan of care did not include interventions or goals to manage the patient's altered genitourinary status. During an interview and a joint review of the records on 8/18/2022, the Director of Nursing agreed the plans of care did not include interventions or goals based on the problems identified in the assessments. Record 3: This patient was admitted to hospice on 6/29/2022. Diagnosis Malignant neoplasm of unspecified part of right bronchus or lung. The plan of care dated 6/29/2022 was reviewed. The Registered Nurse assessment on 7/23/2022 revealed the patient’s current respiratory status: deteriorating, does dyspnea significantly affect the patient: yes, dyspnea score 7. The plan of care did not include interventions or goals to manage the dyspnea. Record 7: This patient was admitted to hospice on 8/16/2021. Diagnosis Severe protein calorie malnutrition. The plan of care dated 8/16/2021 was reviewed. The skilled nursing assessment on 3/21/2022 revealed “patient has foley catheter in place.” The plan of care did not include interventions or goals to manage the altered genitourinary status. The Director of Nursing was interviewed on 8/18/2022 and agreed, in the records identified, the plan of care did not include interventions or goals based on the problems identified in the assessments.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 9 (22%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the hospice aide followed the plan of care as ordered.. Record #3 was reviewed and identified the patient elected hospice care on 6/29/2022. The hospice aide plan of care dated 6/29/2022, documented the hospice aide services to be provided, "shower and shampoo each visit." The hospice aide visit note dated 7/26/2022, revealed the hospice aide did not complete the assigned services of shower and shampoo. The hospice aide documented, “patient preference.” The Registered Nurse (RN) assessment completed on 6/29/2022 documented the patient was cognitively impaired. The RN assessment completed on 8/10/2022 documented the patient was confused. There was no evidence that the hospice aide notified the RN of the changes to the aide care plan. Record #7 was reviewed and identified the patient elected hospice care on 8/16/2021. The hospice aide plan of care dated 8/16/2021, documented the hospice aide services to be provided, "shower twice weekly on Monday’s and Friday’s, shampoo once weekly on Monday’s, and skin care and oral care every visit." The hospice aide visit note dated 9/6/2021, revealed the shower, shampoo, skin care and oral care were not completed, the aide documented, “patient refused.” The RN assessment completed on 8/16/2021 documented the patient was cognitively impaired. There was no evidence that the hospice aide notified the RN of the change to the aide care plan. The Director of Nursing was interviewed on 8/18/2022 and agreed, the hospice aide did not follow the plan of care as ordered. Record 3: This patient was admitted to hospice on 6/29/2022. The hospice aide plan of care dated 6/29/2022 ordered shower and shampoo each visit. The hospice aide documentation on 7/26/2022 revealed the shower and shampoo were not completed with a note, “patient preference.” The Registered Nurse assessment on 6/29/2022 revealed the patient was cognitively impaired. The Registered Nurse assessment on 8/10/2022 revealed the patient was confused. There was no documented evidence that the hospice aide notified the registered nurse. Record 7: This patient was admitted to hospice on 8/16/2021. The hospice aide plan of care dated 8/16/2021 ordered shower twice weekly on Monday’s and Friday’s, shampoo once weekly on Monday’s, and skin care and oral care every visit. The hospice aide documentation on 9/6/2021 revealed the shower, shampoo, skin care and oral care were not completed with a note, “patient refused.” The Registered Nurse assessment on 8/16/2021 revealed the patient was cognitively impaired. There was no documented evidence that the hospice aide notified the registered nurse. The Director of Nursing was interviewed on 8/18/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS) complies with federal regulation regarding disclosure of ownership and control information, ensures hospice multiple locations are approved by Medicare and licensed in accordance with state licensure laws, ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients, clearly delineates lines of authority and professional and administrative control in the hospice’s organizational structure and in practice that can be traced to the location issued the certification number (CCN), shares administration, supervision, and services with the hospice issued the certification number. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) records reviewed of patients receiving care from an alternative delivery site (ADS) revealed the agency did not ensure the ADS is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. Record #3 was reviewed and identified the patient elected hospice care on 6/29/2022. A review of the clinical record revealed this patient was assigned to the ADS, Branch PO2. Record #4 was reviewed and identified the patient elected hospice care on7/7/2022. Review of the clinical record revealed this patient was assigned to the ADS, Branch PO2. During a visit to the ADS on 8/17/2022, the Director of Nursing was interviewed and confirmed that the location provides services for hospice patients assigned to Branch PO2. The Administrator was interviewed on 8/16/2022 and confirmed, Branch PO2 is the alternate delivery site (ADS) and confirmed 4 patients currently on census assigned to the ADS and 4 discharged patients assigned to the ADS. The Administrator was interviewed on 8/17/2022 and stated, “the approval is here somewhere.” The Administrator was interviewed on 8/18/2022 and stated, “we are looking for it.” The Administrator did not provide documented evidence of CMS approval of the alternate delivery site. Record 3: This patient was admitted to hospice on 6/29/2022. Review of the clinical record revealed this patient was assigned to the alternate delivery site, Branch PO2. Record 4: This patient was admitted to hospice on 7/7/2022. Review of the clinical record revealed this patient was assigned to the alternate delivery site, Branch PO2. During a visit to the alternate delivery site on 8/17/2022, the Director of Nursing was interviewed and confirmed that the location provides services for hospice patients assigned to Branch PO2. The Administrator was interviewed on 8/16/2022 and confirmed, Branch PO2 is the alternate delivery site (ADS) and confirmed 4 patients currently on census assigned to the ADS and 4 discharged patients assigned to the ADS. The Administrator was interviewed on 8/17/2022 and stated, “the approval is here somewhere.” The Administrator was interviewed on 8/18/2022 and stated, “we are looking for it.” The Administrator did not provide documented evidence of CMS approval of the alternate delivery site.

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, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the notification of hospice non-covered items was signed by the agency and the patient or patient’s representative. Record #4 was reviewed and identified the patient elected hospice care on 7/7/2022. A review of the hospice election statement revealed the patient/caregiver requested the addendum on 7/7/2022. The notification of hospice non-covered items was completed and emailed on 7/10/2022. There was no documented evidence the notification of hospice non-covered items was signed by the hospice agency or the patient or patient’s representative. Record #5 was reviewed and identified the patient elected hospice care on 2/3/2022. A review of the hospice election statement revealed the patient/caregiver requested the addendum on 2/3/2022. The notification of hospice non-covered items was completed and delivered to the patient on 2/7/2022. There was no documented evidence the notification of hospice non-covered items was signed by the hospice agency or the patient or patient’s representative. The Director of Nursing was interviewed on 8/18/2022, and agreed there was no documented evidence the notification of hospice non-covered items was signed by the hospice agency or patient or patient’s representative in the records identified. Record 4: This patient was admitted to hospice on 7/7/2022. The hospice election statement was reviewed and identified the patient/caregiver requested the addendum on 7/7/2022. The notification of hospice non-covered items was completed and emailed on 7/10/2022. There was no documented evidence the notification of hospice non-covered items was signed by the hospice agency. There was no documented evidence the notification of hospice non-covered items was signed by the patient or patient’s representative. Record 5: This patient was admitted to hospice on 2/3/2022. The hospice election statement was reviewed and identified the patient/caregiver requested the addendum on 2/3/2022. The notification of hospice non-covered items was completed and delivered to the patient on 2/7/2022. There was no documented evidence the notification of hospice non-covered items was signed by the hospice agency. There was no documented evidence the notification of hospice non-covered items was signed by the patient or patient’s representative. The Director of Nursing was interviewed on 8/18/2022 and agreed, there was no documented evidence the notification of hospice non-covered items was signed by the hospice agency or patient or patient’s representative in the records identified.

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. 1 of 5 (20%) records reviewed of patients with wounds revealed the hospice did not ensure the record included a physician’s order for the wound care. Record #3 was reviewed and identified the patient elected hospice care on 6/29/2022. The Registered Nurse (RN) visit note dated 8/10/2022 stated, “wound to left ring finger was cleaned with wound cleanser and gauze, silver mesh applied and then covered with gauze and medipore tape." The RN visit note dated 8/14/2022 stated, “SN then performed wound care to patient’s fingers: wound cleansed with non-cytotoxic wound cleaner, covered with silver dressing, gauze and medipore tape.” The record did not include evidence of a physician's order for the wound care provided. The Director of Nursing was interviewed on 8/18/2022 and agreed, there were no physician orders for the wound care. Record 3: This patient was admitted to hospice on 6/29/2022. The Registered Nurse visit note on 8/10/2022 stated, “wound to left ring finger was cleaned with wound cleanser and gauze, silver mesh applied and then covered with gauze and medipore tape. The Registered Nurse visit note on 8/14/2022 stated, “SN then performed wound care to patient’s fingers: wound cleansed with non-cyctoxic wound cleaner, covered with silver dressing, gauze and medipore tape.” There was no documented evidence of a physican’s order for the wound care. The Director of Nursing was interviewed on 8/18/2022 and agreed, there were no physician orders for the wound care.

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. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of documents and interviews. 1 of 7 (14%) contracts reviewed revealed the contract failed to include the clause, in writing, between the contracted entity and the agency, for the provision that requires that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. A review of the hospice's pharmacy contract executed 3/4/2021, revealed no clause between the pharmacy and the hospice documenting that the pharmacy was required to obtain criminal background checks on pharmacy employees who have direct hospice patient contact or access to hospice patient records. The Administrator was interviewed on 8/18/2022 and stated, “this was a shorter contract than we normally use.” The Administrator agreed, the pharmacy contract did not include the requirement to obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. Contract 1: (Pharmacy): signed date 3/4/2021. Review of the contract revealed there was no evidence that the contracted entity was required to obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. The Administrator was interviewed on 8/18/2022 and stated, “this was a shorter contract than we normally use.” The Administrator agreed, the pharmacy contract did not include the requirement to obtain criminal background checks on contracted employees who have direct patient contact or access to patient records.