Every finding on record at Polaris Hospice LLC

It is required that each patient’s individualized written plan of care: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients with wounds revealed that the agency did not ensure that frequency of services necessary to meet specific patients’ needs were documented. CLINICAL RECORD 4: The patient elected the hospice benefit on 12/16/2025. The registered nurse identified a wound to the lateral upper leg during the initial comprehensive assessment on 12/16/2025. The nurse documented wound care orders obtained on admission to hospice to cleans wound with wound cleanser, pat dry with gauze, apply calcium alginate, cover with abd pad and secure with tape, however, the frequency for the wound care was not included in the order. During a joint record review and interview on 05/05/2026, the RN/Alternate Administrator agreed there was no documented frequency for the wound care.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; Consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) Clinical records reviewed of patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide services were provided as ordered and included in the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 03/11/2026 with a diagnosis of CVA. The plan of care dated 03/11/2026 through 06/08/2026 ordered hospice aide services twice weekly(2xw), effective 03/15/2026. The week of 03/15/2026 through 03/20/2026, one (1) hospice aide visit was documented, dated 03/20/2026. There was no documented evidence of a second hospice aide visit or a reason for the missed visit. CLINICAL RECORD 2: The patient elected hospice care on 01/29/2026 with a diagnosis of Parkinson's Disease. The plan of care dated 01/29/2026 through 04/28/2026 ordered hospice aide services twice weekly(2xw), effective 01/29/2026. The week of 01/29/2026 through 01/31/2026, one hospice visit was documented, dated 01/30/2026. There was no documented evidence of a second hospice aide visit or a reason for the missed visit. CLINICAL RECORD 8: The patient elected hospice care on 02/14/2026 with a diagnosis of CHF. The plan of care dated 02/14/2026 through 05/14/2026 ordered hospice aide services twice weekly(2xw), effective 02/14/2026. The week of 03/01/2026 through 03/07/2026, one hospice aide visit documented, dated 03/03/2026. There was no documented evidence of a second hospice aide visit or a reason for the missed visit. During a joint record review and interview on 05/05/2026, the RN/Alternate Administrator (Personnel Record 4) agreed there was no documented evidence that the hospice aide provided services as ordered and included in the plan of care. The Alternate Administrator stated that she was not aware of the missed visits and concerns expressed about the hospice aide frequency. The Alternate Administrator stated that the aide should follow the plan of care and, if unable, notify the Registered Nurse (RN).

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 of patients that transferred to seek aggressive treatment, the agency did not ensure that a discharge summary was forwarded to the receiving hospital. CLINICAL RECORD 11: The patient elected hospice benefit on 01/12/2026 and transferred to a hospital on 01/29/2026 to seek aggressive treatment. There was a discharge summary completed by the RN dated 01/29/2026. There was no documented evidence that the discharge summary was forwarded to the receiving hospital for continuity of care. During a joint record review and interview on 05/05/2026, the RN/Alternate Administrator (Personnel Record 4) agreed that there was no documented evidence that a discharge summary was forwarded to the receiving hospital. No further information was provided.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 5 (20%) records reviewed revealed the hospice did not ensure the emergency preparedness plan was developed for each hospice patient as part of a patient/family comprehensive assessment. Record #3 was reviewed and revealed the patient elected hospice care on 5/13/22. A review of the record revealed the hospice's form "Patient Evacuation Plan" dated 5/13/22 was blank for the following sections: "remain in home, evacuate with assistance of hospice, or evacuate with assistance of emergency officials." The record was missing documented evidence that the patient/family emergency plans were developed as part of the comprehensive assessment. During an interview on 7/26/22, the Executive Director/Director Clinical Services confirmed the blank sections on the "Patient Evacuation Plan" form.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure that the patient or the patient's representative was given the opportunity to exercise the right to choose the patient's attending physician. Record #4 was reviewed and revealed the patient's choice of attending physician was not documented. The "Election of Medicare Hospice Benefit" form, signed and dated 5/16/22, by the patient's representative, did not include documentation of the patient/representative's choice of attending physician. The form included a section "Right to Choose Attending Physician" including the statement, "I understand that I have a right to choose my attending physician to oversee my care." There was no written response to document, "I do not wish to choose an attending physician... I acknowledge that my choice for an attending physician is.." During interview on 7/26/22, the Executive Director/Director Clinical Services reviewed the "Election of Hospice Benefit" form dated 5/16/22 and confirmed that the patient's choice for attending physician was not documented. The patient revoked hospice services on 6/4/22 and was unable to be interviewed.

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. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 1 of 5 (20%) records reviewed revealed the hospice did not ensure that the documented comprehensive assessment includes a drug profile containing all of the patient's current medications. Record #0 was reviewed and identified the patient elected hospice care on 5/11/22. During the home visit conducted on 7/26/22, the patient provided an inhaler which documented the following on the label, "Albuterol Sulfate inhaler 90 mcg one puff by mouth every four hours as needed." The medication profile did not include the medication Albuterol. During interview 7/26/22, the Executive Director/Director Clinical Services confirmed the missing physician's order for the Albuterol inhaler.

It is required that the hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 1 of 5 (20%) records reviewed revealed the hospice did not ensure that the plan of care included drugs and treatments necessary to meet the patients needs. Record #0 was reviewed and identified the patient elected hospice care on 5/11/22. During the home visit conducted on 7/26/22, the patient provided an inhaler which documented the following on the label, "Albuterol Sulfate inhaler 90 mcg one puff by mouth every four hours as needed." The plan of care and the medication profile did not include the medication Albuterol. During interview 7/26/22, the Executive Director/Director Clinical Services confirmed the missing physician's order for the Albuterol inhaler.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by a review of personnel records, observations, and interviews. 2 of 2 (100%) applicable records of Hospice Aides reviewed revealed the agency did not ensure the required initial competency evaluations were completed. $taff #4: The personnel record was reviewed and identified the Hospice Aide's date of hire as 5/9/22. The "Competency Assessment Skills Checklist Hospice Aide" completed on 5/9/22 documented the required skills of bed bath, shampoo, nail care, skin care, oral care, transfer techniques, toileting/elimination, ambulation, range of motion, and positioning were evaluated using a verbal method of competency evaluation (V). In addition, a review of the form revealed the aide’s competency evaluation did not include observation of the aide’s performance with a patient or a pseudo patient. During a phone interview on 7/27/22, the Hospice Aide stated "yes, I have completed a bed bath, shampoo, nail care, skin care, oral care, transfer techniques, toileting/elimination, ambulation, range of motion and positioning on patients since I started working at this hospice." Staff #3: The personnel record was reviewed and identified the Hospice Aide's date of hire as 8/16/21. The "Competency Assessment Skills Checklist Hospice Aide" completed on 8/16/21 documented the required skills of bed bath, shampoo, nail care, skin care, oral care, transfer techniques, toileting/elimination, ambulation, range of motion, and positioning were evaluated using a verbal method of competency evaluation (V). In addition, a review of the form revealed the aide’s competency evaluation did not include observation of the Aide’s performance with a patient or a pseudo patient. During the home visit conducted on 7/26/22, the Hospice Aide was observed performing a bed bath, shampoo, nail care, range of motion and positioning. During a phone interview on 7/27/22, the Hospice Aide stated "yes, I have completed a bed bath, shampoo, nail care, skin care, oral care, transfer techniques, toileting/elimination, ambulation, range of motion and positioning on patients since I started working at this hospice." During interview on 7/27/22, the Executive Director/Director Clinical Services confirmed the finding stating, "yes, I completed the skills checklist and it was completed verbally with the aides and not with a patient or a pseudo patient."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 2 (50%) applicable clinical records of patients who revoked hospice services were reviewed and revealed the hospice did not ensure the revocation statement was signed by the patient, as required by hospice policy.. Record #4 was reviewed and revealed the patient elected hospice services on 5/16/22 and revoked hospice services on 6/4/22. The clinical record revealed the caregiver at the patient's group home called and stated the patient fell, had a laceration and was sent to the emergency room. In addition, the record revealed the "End of Care Summary" dated 6/4/22 included, "patient entered a facility to seek aggressive treatment and non-palliative care." The "Discharge Hospice Item Set" dated 6/4/22 documented, "patient revoked." The physician's order dated 6/4/22 documented, "discharged revoked." There was no signed revocation statement in the clinical record. "Revocation of Hospice Benefit" Policy No. 1-024, revised October 2019, included, "The patient will choose to revoke his/her election of hospice benefit when he/she elects active treatment inconsistent with the role of palliative care" and "A revocation of election of hospice care statement will be signed by the patient and will document the date, time and reason for the revocation". During interview 7/16/22, the Executive Director/Director Clinical Services stated the group home called her to report the patient was sent to the emergency room for stitches and that she spoke to the patient's representative who stated the patient was coming off services at the hospice and would be going to a new facility after discharge from the hospital. The Executive Director/Director Clinical Services stated a revocation form was not signed.

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, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) records reviewed of patients who revoked hospice services revealed the hospice did not ensure the discharge summary included the patient’s current plan of care and physician orders. Record #2 was reviewed and revealed the completed discharge summary form, "End of Care Summary" dated 7/1/22, did not document the patient’s current plan of care and latest physician orders. The record did not include evidence that the patient’s current plan of care and physician orders were sent to the attending physician. During an interview on 7/26/22, the Executive Director/Director Clinical Services confirmed that the "End of Care Summary" dated 7/1/22 was sent to the physician without the current plan of care and physician orders. Record #4 was reviewed and revealed the completed discharge summary form, "End of Care Summary" dated 6/4/22, did not document the patient’s current plan of care and latest physician orders. The record was reviewed and did not include evidence that the patient’s current plan of care and physician orders were sent to the attending physician. During an interview on 7/26/22, the Executive Director/Director Clinical Services confirmed only the discharge summary titled "End of Care Summary" dated 6/4/22 was sent to the physician without the current plan of care and physician orders.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care and provided to a patient while under the care of the hospice. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 2 of 3 (67%) applicable clinical records of patient home visits reviewed revealed the hospice did not ensure that medications related to the palliation and management of the terminal illness and related conditions were provided by the hospice while the patient is under hospice care. . Record #1 was reviewed and revealed the date of hospice election was 5/11/22, with the terminal diagnosis of hepatic failure and related condition of portal vein thrombosis. The initial nursing assessment dated 5/11/22 documented "portal vein thrombosis." A home visit was conducted with the Hospice RN on 7/26/22. During a review of the home record, the patient was informed and given a printed list of medications which documented medications that were not provided or covered by the hospice, "Aspirin … Bumetanide...Cefdinir...Potassium ." The labels on the medication containers were from the patient's pharmacy. During the interview 7/26/22, the Registered Nurse (RN) present during the home visit confirmed the Aspirin, Bumetanide, Cefdinir, and Potassium were related to the terminal diagnosis and related conditions and should be covered by the hospice and not the patient and that the printed medication list from the clinical record and given to the patient had "typos" and did not list all the medications that the hospice would provide and cover. Record #0 was reviewed and revealed the date of hospice election was 5/11/22, with the terminal diagnosis of chronic obstructive pulmonary disease. The home visit conducted with the Social Worker on 7/26/22, revealed the patient was given a printed list of medications which listed "ProAir" inhaler would not be provided by the hospice and read in part that the "patient" covered the medication. The label on the medication inhaler was from the patient's pharmacy. During the interview 7/26/22, the Executive Director/Director Clinical Service confirmed the printed medication list given to the patient had "typos" and did not list all the medications that the hospice would provide and cover.