Every finding on record at Peoples Hospice and Palliative Care of Florida 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, 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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 2: The patient's election date was 08/09/2024. The Medication Profile printed on 01/28/2026 revealed metoprolol tartrate 25 mg oral tablet, give 25 mg oral daily, started 08/09/2024; donepezil 10 mg oral tablet, give 10 mg oral daily, started 08/09/2024; DOXYCYCLINE hyclate 100 mg capsule, give one capsule oral twice a day, started 06/17/2025; Lorazepam 0.5 mg oral tablet, give 0.5 mg oral every 8 hours prn [as needed] anxiety disorder, started 08/09/2024; and Spiriva REspimat 1.25 mcg/inh inhalation aerosol, give 1.25 mcg/inh by inhalation daily, started 08/09/2024. During the Home Visit (Clinical Record ) on 01/28/2026 with the Registered Nurse (Personnel Record 7), the medications in the facility revealed ASA [aspirin] low chew 81 mg, give one tablet by mouth once daily, started 01/26/2024; Alprazolam 0.5 mg tablet, give one tablet every 8 hours prn agitation, started 08/07/2024; Acetaminophen 325 mg tablet, give 650 mg by mouth prn pain/fever, do not exceed 3 Gm from all sources in 24 hour period, started 01/26/2024; Docusate sodium capsule 100 mg, give one capsule by mouth daily as needed constipation, started 04/04/2025; Azelastine drop 0.05%, give one drop to both eyes twice daily, started 11/05/2025; Biotin 2500 mcg capsule, give one capsule by mouth daily, started 05/09/2024; Folic Acid 1 mg, give one tablet by mouth once daily, started 04/24/2024; and Tramadol 50 mg, give one tablet by mouth every morning as needed insomnia, started 01/02/2025. The above agency medications were not on the facility's medication record, and the above facility medications were not on the agency's medication record. The record lacked evidence of a medication reconciliation. During a joint record review and interview on 01/28/2026, the Clinical Director of Nursing/Alternate Administrator confirmed that there was no documented evidence that the medications had been reconciled and updated in the drug profile. It was verified with the facility staff that the medications on the hospice medication list were not found in the facility's medication record, active and discontinued.

It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above and at least one (1) year of social work experience in a health care setting or a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel records for social workers revealed that the agency did not ensure that the social worker was legally authorized in accordance with the agency's social worker job description DOCUMENT 1: Agency Job Description Social Worker, last revised 07/25/2022, stated in part, "Required Qualifications: 1. Master's degree in social work or LBSW. 2. Licensed to practice in the State of...." PERSONNEL RECORD 8: The date of hire was 09/09/2024. The agency job description was signed on 09/09/2024. The social worker obtained a master's in social work on 05/19/2007. The record contained a competency for the social worker upon hire and an annual skills evaluation. The record lacked evidence of a social worker's license within the state. PERSONNEL RECORD 13: The date of hire was 10/07/2024. The agency job description was signed on 09/09/2024. The social worker obtained a master's in social work on 12/15/2018. The record contained a competency for the social worker upon hire and an annual skills evaluation. The record lacked evidence of a social worker's state license. On 12/16/2025, the employee assumed the role of Bereavement Coordinator. During a joint clinical record review and interview on 01/28/2026, the Administrator confirmed that the Social Workers (Personnel Records 8 and 13) did not hold state licenses as required by the job description. The Administrator stated that the state did not require a social worker to be licensed. A discussion took place regarding the most stringent requirement in the job description. On 01/29/2026, the Administrator reported that the policies were from another agency in another state that required the social workers to be licensed. The Administrator reported that the social worker's job description was revised on 01/29/2026, removing the requirement for a state license. The social workers signed the new job description on 01/29/2026 DOCUMENT 2: Agency Job Description Social Worker, last revised 01/29/2026, stated in part, "Required Qualifications: 1. Master's degree in social work or LBSW."

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (12%) clinical records reviewed in which the patient received hospice aide services, revealed the hospice aide did not document communication with a registered nurse (RN) when services that were assigned on the aide plan of care were not provided. Clinical Record 2: The patient elected the hospice benefit on 3/7/23. The hospice aide plan of care initiated on 3/27/23 assigned the aide to perform the following services every visit: shower with chair, wash hair, apply lotion to all extremities, denture care, and change linens. On 3/28/23, the aide documented "No" under "Performed", indicating those tasks were not performed on that day and documented "Declined" under "Task Comment/Reason." The record did not include documented evidence that the hospice aide notified an RN of the services that were not provided. In an interview on 4/25/23, the Clinical Director confirmed the findings and stated, "The aide did not document communication with a nurse."

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). This standard was not met as evidenced by clinical record review, document review and interview. 8 of 10 (80%) clinical records reviewed in which a controlled substance was ordered revealed the agency did not provide the patient or the patient's legal representative a copy of its written policy and procedure for the management and disposal of controlled medications when the medications were first ordered. Agency Policy, Medication Disposal, Policy # PH104, approved 8/8/22, stated in relevant parts, "Upon admission to hospice, the patient/caregiver will be given a current copy of the federal guidelines for prescription drug disposal. (Proper Disposal of Prescription Drugs). Upon death of the patient, the hospice RN will destroy all Schedule II drugs and any medications related to the patient's diagnosis and provided by (agency name). Guidelines: Using a black permanent marker, conceal all personal information, including the Rx number from the drug container. Do not flush drugs down the toilet unless the label or accompanying drug information instructs you to do so". The agency's admission packet provided to all patients at the time of hospice election contained a handout titled, "Proper disposal of Prescription Drugs, Office of National Drug Control Policy October 2009, Federal Guidelines," however, the handout did not include specific information included in the agency's policy and procedure. Clinical Record 2: The patient elected the hospice benefit on 3/7/23 and Norco 5-325mg was ordered on 3/7/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 3/7/23. Clinical Record 3: The patient elected the hospice benefit on 3/22/23 and Morphine 5mg was ordered on 3/22/23.There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 3/22/23. Clinical Record 4: The patient elected the hospice benefit on 2/24/23 and Morphine 5mg was ordered on 2/24/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 2/24/23. Clinical Record 5: The patient elected the hospice benefit on 4/14/23 and Norco 5-325mg ordered on 4/14/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 4/14/23. Clinical Record 7: The patient elected the hospice benefit on 2/10/23 and Morphine 5mg was ordered on 2/10/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 2/10/23. Clinical Record 8: The patient elected the hospice benefit on 2/23/23 and Morphine 5mg was ordered on 2/23/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 2/23/23. Clinical Record 9: The patient elected the hospice benefit on 2/22/23 and Morphine 5mg was ordered on 2/23/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to patient when the controlled medication was first ordered on 2/23/23. Clinical Record 10: The patient elected the hospice benefit on 3/22/23 and Morphine 5mg was ordered on 3/22/23. There was no documented evidence in the clinical record that a copy of the agency's written policy and procedure for the management and disposal of controlled medications was provided to the patient when the controlled medication was first ordered on 3/22/23. In an interview on 4/25/23, the Clinical Director confirmed that they did not provide a copy of the agency's written policy and procedure related to the management and disposal of controlled substances to the patient or legal representative upon admission or at any time after admission when a controlled substance had been ordered.