Every finding on record at Phc Hospice, LLC

It is required that a hospice aide provide services that are 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 9 of 13 (69%) applicable clinical records reviewed, the agency did not ensure the aide provided care as ordered in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/24/2025, with a terminal diagnosis of severe protein-calorie malnutrition. The aide plan of care assignment created by the Registered Nurse dated 07/23/2025 assigned the task of nail care to be provided every visit. The aide documented on aide visit notes dated 07/31/2025, 08/04/2025, 08/05/2025, 08/07/2025, 08/11/2025, 08/12/2025 and 08/13/2025 that nail care was not completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025, with a terminal diagnosis of malignant neoplasm of the colon. The aide plan of care assignment created by the Registered Nurse dated 07/25/2025 assigned the task of nail care and oral care to be provided every visit. The aide documented on aide visit notes dated 08/01/2025 and 08/05/2025 that nail care was not completed at each visit. The aide documented on aide visit notes dated 08/07/2025, 08/12/2025, and 08/14/2025 that oral care were not marked completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/26/2025, with a terminal diagnosis of neurocognitive disorder with Lewy bodies. The aide plan of care assignment created by the Registered Nurse dated 05/27/2025 assigned the task of change linen, empty trash in patient room, nail care, oral care, change brief, and shampoo to be provided every visit. The aide documented on aide visit note dated 06/05/2025 that shampoo, empty trash, change brief, oral care, and nail care was not completed at this visit. The aide documented on aide visit notes dated 07/24/2025, 08/07/2025, and 08/14/2025 that nail care, oral care, and shampoo were not completed at these visits. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/11/2025, with a terminal diagnosis of Alzheimer's. The aide plan of care assignment created by the Registered Nurse dated 06/11/2025 assigned the task of change linen, empty trash in patient room, nail care, and shampoo to be provided every visit. The aide documented on aide visit notes dated 06/21/2025, 06/23/2025, 06/25/2025, 06/27/2025, 06/30/2025, and 07/01/2025 that change linen, empty trash, and shampoo were not completed at these visits. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/16/2025, with a terminal diagnosis of atherosclerotic heart disease. The aide plan of care assignment created by the Registered Nurse dated 06/16/2025 assigned the task of change linen and nail care to be provided every visit. The aide documented on aide visit notes dated 07/23/2025, 07/25/2025, 07/28/2025, 07/30/2025, 08/01/2025, and 08/13/2025 that change linen, and nail care were not completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/11/2025, with a terminal diagnosis of severe protein-calorie malnutrition. The aide plan of care assignment created by the Registered Nurse dated 07/11/2025 assigned the task of change linen and shampoo to be provided every visit. The aide documented on aide visit notes dated 08/07/2025 and 08/15/2025 that change linen and shampoo were not completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/08/2025, with a terminal diagnosis of late effects of CVA. The aide plan of care assignment created by the Registered Nurse dated 03/08/2025 assigned the task of change linen, nail care, and shave to be provided every visit. The aide documented on aide visit notes dated 05/06/2025 that nail care was not marked completed. The aide documented on aide visit note dated 05/09/2025 that change linen, nail care, and shave were not marked completed. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/18/2025, with a terminal diagnosis of heart failure. The aide plan of care assignment created by the Registered Nurse dated 04/18/2025 assigned the task of empty trash in patient room to be provided every visit. The aide documented on aide visit notes dated 06/06/2025, 06/10/2025, 06/12/2025, and 06/13/2025 that empty trash was not marked completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/27/2025, with a terminal diagnosis of senile degeneration of the brain. The aide plan of care assignment created by the Registered Nurse dated 06/27/2025 assigned the task of shave to be provided every visit. The aide documented on aide visit notes dated 07/28/2025, 07/30/2025, and 08/01/2025 that shave was not completed at each visit. The aide did not follow the aide plan of care assignment or give a reason as to why she did not complete the task. This was shared with leadership on 08/21/2025, and in an interview on the same day with the Director of Nursing (Personnel Record 3), who stated, " They need to do more education with the aides."

It is required that the hospice aides must report changes in the patient’s nursing, needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 9 of 13 (69%) applicable clinical records reviewed, the agency did not ensure the aide reported change in the patient’s needs to the registered nurse. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/24/2025, with a terminal diagnosis of severe protein-calorie malnutrition. The aide plan of care assignment created by the Registered Nurse dated 07/23/2025 assigned the task of nail care to be provided every visit. The aide documented on aide visit notes dated 07/31/2025, 08/04/2025, 08/05/2025, 08/07/2025, 08/11/2025, 08/12/2025 and 08/13/2025 that nail care was not completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025, with a terminal diagnosis of malignant neoplasm of the colon. The aide plan of care assignment created by the Registered Nurse dated 07/25/2025 assigned the task of nail care and oral care to be provided every visit. The aide documented on aide visit notes dated 08/01/2025 and 08/05/2025 that nail care was not completed at each visit. The aide documented on aide visit notes dated 08/07/2025, 08/12/2025, and 08/14/2025 that oral care were not marked completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/26/2025, with a terminal diagnosis of neurocognitive disorder with Lewy bodies. The aide plan of care assignment created by the Registered Nurse dated 05/27/2025 assigned the task of change linen, empty trash in patient room, nail care, oral care, change brief, and shampoo to be provided every visit. The aide documented on aide visit note dated 06/05/2025 that shampoo, empty trash, change brief, oral care, and nail care was not completed at this visit. The aide documented on aide visit notes dated 07/24/2025, 08/07/2025, and 08/14/2025 that nail care, oral care, and shampoo were not completed at these visits. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/11/2025, with a terminal diagnosis of Alzheimer's. The aide plan of care assignment created by the Registered Nurse dated 06/11/2025 assigned the task of change linen, empty trash in patient room, nail care, and shampoo to be provided every visit. The aide documented on aide visit notes dated 06/21/2025, 06/23/2025, 06/25/2025, 06/27/2025, 06/30/2025, and 07/01/2025 that change linen, empty trash, and shampoo were not completed at these visits. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/16/2025, with a terminal diagnosis of atherosclerotic heart disease. The aide plan of care assignment created by the Registered Nurse dated 06/16/2025 assigned the task of change linen and nail care to be provided every visit. The aide documented on aide visit notes dated 07/23/2025, 07/25/2025, 07/28/2025, 07/30/2025, 08/01/2025, and 08/13/2025 that change linen, and nail care were not completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/11/2025, with a terminal diagnosis of severe protein-calorie malnutrition. The aide plan of care assignment created by the Registered Nurse dated 07/11/2025 assigned the task of change linen and shampoo to be provided every visit. The aide documented on aide visit notes dated 08/07/2025 and 08/15/2025 that change linen and shampoo were not completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/08/2025, with a terminal diagnosis of late effects of CVA. The aide plan of care assignment created by the Registered Nurse dated 03/08/2025 assigned the task of change linen, nail care, and shave to be provided every visit. The aide documented on aide visit notes dated 05/06/2025 that nail care was not marked completed. The aide documented on aide visit note dated 05/09/2025 that change linen, nail care, and shave were not marked completed. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/18/2025, with a terminal diagnosis of heart failure. The aide plan of care assignment created by the Registered Nurse dated 04/18/2025 assigned the task of empty trash in patient room to be provided every visit. The aide documented on aide visit notes dated 06/06/2025, 06/10/2025, 06/12/2025, and 06/13/2025 that empty trash was not marked completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/27/2025, with a terminal diagnosis of senile degeneration of the brain. The aide plan of care assignment created by the Registered Nurse dated 06/27/2025 assigned the task of shave to be provided every visit. The aide documented on aide visit notes dated 07/28/2025, 07/30/2025, and 08/01/2025 that shave was not completed at each visit. There was no documented evidence that the aide reported to the nurse changes in the patient’s needs. In an interview with the Director of Nursing (Personnel Record 3) on 08/21/2025, it was stated, " They need to do more education with the aides."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Document 1: The review of the 2024 Hospice Volunteer Requirement Report revealed the volunteer percentage of hours worked for January 2024 through December 2024 was 2.4%. The Administrator stated in an interview on 08/21/2025, that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. She stated, "They are getting more volunteer hours, and the percentage is up to 4.2% in 2025." The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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. 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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the medication profile included the patient's current prescription drugs. Clinical Record 4: The patient elected the hospice benefit dated 07/14/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The Registered Nurse documented in the initial comprehensive assessment dated 07/14/2023, that the patient was utilizing oxygen at 3.5 LPM [liters per minute] via nasal cannula. Oxygen was not included on the medication profile at the time of clinical record review dated 8/21/2023. Clinical Record 5: The patient elected the hospice benefit dated 07/05/2023, with a terminal diagnosis of breast cancer. The Registered Nurse documented in the initial comprehensive assessment dated 07/05/2023, that the patient was utilizing oxygen at 2.5 LPM via nasal cannula. Oxygen was not included on the medication profile at the time of clinical record review dated 8/21/2023. During an interview dated 08/21/2023, the Director of Patient Care Services reviewed the associated records and stated oxygen had been inadvertently omitted and the medication profiles had since been corrected.

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 clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the aide provided care as ordered in the plan of care. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 1: The patient elected the hospice benefit dated 05/09/2023, with a terminal diagnosis of Alzheimer’s disease. The aide plan of care assignment created by the Registered Nurse dated 05/09/2023 assigned the task frequency of nail care and shampoo to be provided one time per week. The aide documented on aide visit notes dated 07/31/2023, 08/02/2023, 08/04/2023, 08/07/2023, 08/09/2023, 08/11/2023, 08/14/2023, and 08/16/2023 that shampoo and nail care were completed at each visit. The aide did not follow the plan of care assignment when the aide provided shampoo and nail care at each visit. Clinical Record 4: The patient elected the hospice benefit dated 07/14/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The Registered Nurse entered a physician interim order clarification dated 07/04/2023 that ordered aide visit frequency of once a week for one week, then three times a week for remainder of episode. There was no evidence of an aide visit or missed visit documentation for the week of 07/04/2023. During an interview dated 08/21/2023, the Director of Patient Care Services reviewed the associated records and stated the aide had not provided care as ordered on the plan of care.

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. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that physicians orders were obtained for all medications provided to the patient. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 4: The patient elected the hospice benefit dated 07/14/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The Registered Nurse documented in the initial comprehensive assessment dated 07/14/2023 that the patient was utilizing oxygen at 3.5 LPM [liters per minute] via nasal cannula. The clinical record contained no documented evidence of a physician's order for oxygen at the time of the clinical record review on 08/21/2023. During an interview dated 08/21/2023, the Director of Patient Care Services reviewed the associated record and stated that the order had been obtained but had inadvertently been omitted and had since been entered into the medical record.

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 hospice EP training program includes the following training 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 and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document reviews, interviews and personnel records review. 12 of 12 (100%) personnel records reviewed reveal that the agency did not ensure emergency preparedness training and education upon hire. Staff #12: For the Registered Nurse hired on 9/24/22, the personnel file contained no evidence of emergency preparedness training. Staff #11: For the Aide Pharm hired on 7/11/22, the personnel file contained no evidence of emergency preparedness training. Staff #10: For the Volunteer Coordinator hired on 6/21/22, the personnel file contained no evidence of emergency preparedness training. Staff #9: For the Advanced Practice Registered Nurse hired on 7/8/22, the personnel file contained no evidence of emergency preparedness training. Staff #8: For the Administrator hired on 8/18/21, the personnel file contained no evidence of emergency preparedness training. Staff #7: For the Chaplain hired on 1/11/22, the personnel file contained no evidence of emergency preparedness training. Staff #6: For the Hospice Aide hired on 8/18/22, the personnel file contained no evidence of emergency preparedness training. Staff #5: For the Medical Social Worker hired on 2/14/22, the personnel file contained no evidence of emergency preparedness training. Staff #4: For the Hospice Clinical Director hired on 8/19/21, the personnel file contained no evidence of emergency preparedness training. Staff #3: For the Bereavement Coordinator/Chaplain hired on 8/18/22, the personnel file contained no evidence of emergency preparedness training. Staff #2: For the Medical Director (MD) contracted on 4/1/22, the personnel file contained no evidence of emergency preparedness training. Staff #1: For the Registered Nurse (RN) hired on 2/28/22, the personnel file contained no evidence of emergency preparedness training. During an interview on 11/1/22, the Administrator confirmed the finding and stated they inform new employees that there will be an Emergency Preparedness drill at some point, but they do not provide Emergency Preparedness education and training upon hire. 12 of 12 (100%) of personnel records reviewed reveal that the agency did not ensure emergency preparedness training and education upon hire.

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. 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 a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that all prescription drugs were included on the medication profile. Clinical Record 9: was reviewed and identified the patient elected hospice care on 6/16/2022. The skilled nursing visit note dated 6/28/2022 documented, "RN advised c/g to continue to clean abdominal folds and apply nystatin powder at least twice daily to the area to prevent fungal growth." The medication Nystatin was not included on the medication profile. During an interview on 11/1/2022, the Director of Clinical confirmed the finding and stated, "You are right, I don't see orders for Nystatin either." 1 of 11 (9%) of clinical records reviewed revealed that the agency did not ensure that all prescription drugs were included on the medication profile.

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 10 (10%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that the aide plan of care provided specific patient care instructions related to individual patient needs. Clinical Record 9: was reviewed and identified the patient elected hospice care on 6/16/2022. The initial assessment completed by the Registered Nurse and the plan of care dated 6/16/2022 documented the patient had a "stage 2 pressure ulcer on the coccyx with Optifoam applied." The aide care plans dated 6/16/2022 and updated on 6/17/2022 did not include instruction to the aide related to the dressing and wound area. During an interview on 11/1/2022, the Director of Clinical stated in part, "That makes sense, but I never knew we needed to put that kind of stuff on the aide care plan." 1 of 10 (10%)clinical records with a hospice aide reveal that agency did not ensure that the aide plan of care provided specific patient care instructions related to individual patient needs.

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 a review of clinical records and interviews. 2 of 10 (20%) clinical records reviewed of patients receiving aide services revealed that the agency did not ensure that the aide provided services as written in the plan of care. Clinical Record 5: was reviewed and identified the patient elected hospice care on 5/24/2022. The plan of care ordered aide services "3 x week." The week of 5/24/2022 the aide completed one visit on 5/26/2022. There were no other aide visits completed that week and no evidence of missed visits. The aide care plan dated 5/24/2022, assigned the aide the tasks " Assist to dress, Comb hair, Shampoo hair, Complete Shower, Change linen." The aide visit note dated 5/26/2022 documented, "Not performed" for the assigned tasks: complete shower and change linen. The aide visit note dated 5/31/2022 documented, "Not Performed" for the assigned tasks: assist to dress; comb hair; shampoo hair; complete shower; change linen. There was no evidence of communication with the Registered Nurse regarding a change in the aide care plan. Clinical Record 6: was reviewed and identified the patient elected hospice care on 5/5/2022. The plan of care ordered aide services effective Friday 5/6/2022 .. 3 x week." The week of 5/6/2022 the aide completed one visit on 5/6/2022. There were no other aide visits completed that week and no evidence of missed visits. The aide care plan effective on 5/6/2022, assigned the aide the tasks assigned the tasks "Complete Shower and Assist with transfer." The aide visit notes dated 5/9/2022 and 5/10/2022 documented, "Not Performed" for the assigned tasks: complete shower and assist with transfer. During an interview on 11/1/2022, the Director of Clinical confirmed the finding and stated, "Oh I see what you mean..." 2 of 10 (20%) clinical records with an aide ordered on the plan reveal that the agency did not ensure that the aide provided services as written in the plan of care.

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 physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed that agency did not ensure that physicians orders were obtained for all medications provided. Clinical Record 9: was reviewed and identified the patient elected hospice care on 6/16/2022. The skilled nursing visit note dated 6/28/2022 documented, "RN advised c/g to continue to clean abdominal folds and apply nystatin powder at least twice daily to the area to prevent fungal growth." The medication Nystatin was not included on the medication profile and there were no physician orders for Nystatin. During an interview on 11/1/2022, the Director of Clinical confirmed the finding and stated, "You are right, I don't see orders for Nystatin either." 1 of 11 (9%) of clinical records reviewed reveal that agency did not ensure that physicians orders were obtained for all medications provided.