Every finding on record at Prime Healthcare Hospice and Palliative Care, LLC

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 clinical record review and interview. In 1 of 22 (5%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary comprehensive assessment was completed within 5 days after the election of hospice. CLINICAL RECORD 7: The patient was admitted to hospice on 01/22/2026. The chaplain assessment was completed on 01/26/2026. The psychosocial assessment was not completed by the social worker until 01/28/2026, 6 days after the election of hospice. On 03/18/2026, the Administrator confirmed finding and stated, "We knew we would have some opportunities to improve."

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed it was revealed that the agency did not ensure the plans of care included at least one of the required elements. CLINICAL RECORD 8: The patient was admitted on 02/06/2026 with a diagnosis of dissecting aorta. The SN assessment on 02/06/2026 revealed that the patient was using 4Liters of continuous oxygen and that the patient was anxious and medication was ordered for anxiety. The plan of care dated 02/06/2026 included one intervention to educate patient/caregivers on signs/symptoms of emergency cardiac/pulmonary symptoms and when /how to contact them. The plan of care did not contain orders to assess or manage the oxygen and did not contain orders to manage the patient anxiety. CLINICAL RECORD 22: The patient was admitted on 03/17/2026 to hospice and the inpatient unit. The patient was transferred from a hospital with a secondary diagnosis of urinary retention and a 16fr catheter in place as noted in the skilled nursing assessment on 03/17/2026. The plan of care dated 03/17/2026 did not provide orders for the care and management of the foley catheter. On 03/18/2026, the administrator(Personnel Record 3) reviewed clinical record 22 and reported that the information should have been included in the plan of care.

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, family, or patient’s legal representative(s). The Interdisciplinary Group ensures that the safe use and disposal of controlled drugs is understood and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed of patients who died at home it was revealed that the agency did not ensure that staff followed agency policy related to documentation of disposal of narcotic medications. Admissions Packet: The agency admission packet was provided to each patient upon election of hospice which contained education related to medication safety and disposal of controlled substances on page 40. The patient handbook read in part, "Caregivers will be instructed of safe disposal of controlled substances following federal prescription disposal guidelines in the event drugs are disposed of while a hospice nurse is not in the home. If a hospice nurse is in the home at the time of a narcotic pain medication change or at the time of a patient's death, the nurse will instruct the caregiver to count any remaining controlled substances that will no longer be used and dispose of them. The nurse will document the name of the medication(s), amount disposed and the method of disposal on a nursing progress note or drug disposal form. Both the caregiver and nurse witnessing the disposal will sign the document indicating their presence during disposal. CLINICAL RECORD 15: The patient died at home on 12/07/2025. The prescribed medications included Morphine concentrate and Lorazepam concentrate. The death note did not include information about disposal of narcotics consistent with policy and patient handbook information. The death note indicated that the nurse arrived at the patient home upon family reporting death. The electronic medical record read "Medications - was family instructed regarding the 800# for approved medication disposal site" and the nurse documented "YES." There was no further documentation related to medication disposal. There was no documented confirmation that medications were disposed of or specific medications or amounts. CLINICAL RECORD 17: Patient elected hospice on 02/15/2026 and died at home on 02/22/2026. The patient had orders for liquid morphine in the home. The death at home nursing note did not include medication disposal information consistent with patient handbook. The clinical record stated, Medications disposed per facility protocol. The patient was not residing in facility and there was no documentation related to a specific drug or amount disposed of or the specific manner of disposal. The records were reviewed with the administrator (Personnel Record 3) on 03/19/2026, who stated, "You are right, they should have documented the drug and the amount."

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that the hospice inpatient facility had documented, dated written reports of Life Safety Code (LSC) quarterly fire drills conducted at varying times on all shifts. Additionally, this references K712 "Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift...." The IPU facility operates two 12-hr shifts per day. A review of the IPU facility fire drill logs on 03/19/2026 revealed that the log dated 12/30/2025 documented that a fire drill for that quarter was conducted at 9:35 AM and included the day-shift staff. The review of documentation revealed no documented additional fire drills at the IPU during that time frame. During an interview on 03/19/2025, the Regional Physical Plant Operations Manager stated that they have been following another organization's standard of one fire drill per quarter. During an additional interview on 03/19/2025, the Facilities Manager agreed that they had only been conducting fire drills for one shift per quarter. The Hospice Director of Operations, who was present during this review, stated that they will begin conducting their own internal drill to capture all shifts each quarter. Review of the fire drill logs conducted on 3/19/2026 revealed that the agency did not ensure that fire drills were being conducted once per quarter per shift for IPU staff. Agency currently utilizes 2 12 hr shifts per day. Review of the fire drill log from December 30, 2025 indicated that the drill for that quarter was conducted at 9:35AM and only included day shift staff. During an interview with the regional physical plant Operations Manager, he stated that they have been following Joint Commission standards of one fire drill per quarter. During an additional interview with the Facilities Manager, she agreed that they had only been conduction fire drills for one shift per quarter. Hospice Director of Operations, who was present during this review, stated that they will begin to conduct their own internal drill to capture all shifts per quarter.

It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. The hospice inpatient facility (IPU) did not ensure that plumbing fixtures included control valves that automatically regulated the temperature of the hot water used by patients. During the tour of the IPU on 3/29/2026, the water temperature was measured at 120 degrees in patient room 14 and 115 degrees in patient room 15. The water temperatures were verified with an additional thermometer. During an interview on 3/19/2026, the IPU Facilities Manager and the Physical Plant Regional Manager, who were present for the IPU tour, agreed with the observed temperature and that the building’s hot water temperature needed to be adjusted. This was done immediately after the tour. During the tour of the IPU on 3/29/2026, it was revealed that the agency did not ensure regulation of hot water in the IPU. Water temperature was tested in room 14 at 120'. Water temperature was additionally tested in room 15 at 115'. Water temperatures were verified with an additional thermometer. During an interview with the IPU Facilities Manager and the physical plant Regional Manager on 3/19/2026, who were present for the tour, they agreed with the observed temperature and that the hot water temperature for the building needed to be adjusted. This was done immediately after the tour.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) record reviewed of a patient who requested to travel outside of the hospice’s service area, it was revealed there was no documented evidence that the social worker notified the interdisciplinary group of the patient's need for a travel contract. Document 3: Agency policy, "Interdisciplinary Group Coordination of Care,” stated in part, “Personnel will communicate changes in a timely manner. Documentation of all communications will be included in the clinical record. Clinical Record 3: The date of election of benefits was 6/28/2023. The initial visit by the Social Worker on 7/6/2023 documented discharge planning, patient and family/caregiver aware of and included in plan of care, expectations of care discussed with patient and family, anticipated discharge discussed with patient and family, notice of non-coverage not appropriate. During interview on 9/11/2023, the Social Worker stated she was originally made aware of the possible trip to (State) on her initial visit on 7/6/2023. The triage telephone call dated 7/29/2023 documented the patient's daughter called and stated the patient was dizzy. The patient was in another state and was requesting a visit, by the local hospice. There was no documented evidence that the Social Worker had informed the supervisor or interdisciplinary group of the patient's plan to travel and the need for a travel contract. During an interview on 9/11/2023, the Social Worker stated she was made aware on the 7/28/2023 telephone call that the daughters were taking the patient to Michigan the next day, on 7/29/2023, and would be returning in a week so a visit was planned for 8/8/2023. Additionally, The Social Worker stated the expectation is to notify the supervisor to get a contract. The Social Worker confirmed this was not completed and had no further information to provide. During a joint review of the record and an interview on 9/11/2023, the North Clinical Supervisor agreed there was no documented evidence the social worker notified the supervisor or interdisciplinary group of the patient's need for a travel contract.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. Sharing of information occurs and is ongoing with other non-hospice healthcare providers providing services unrelated to the terminal illness and related conditions. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) record reviewed of a patient that was traveling outside of the hospice’s service area, it was revealed that the hospice did not ensure that the patient's care needs were communicated and coordinated as defined by agency policy. Document 2: Agency policy, "Transfer information,” stated in part, "The physician will be notified of any transfers of patients from hospice to another organization, another level of care, service, or location (including traveling patient). In case of a patient who would like to travel outside of the hospice's service area, the following needs to be completed: The IDG must receive permission from the patient to contact a hospice near the travel destination in order to initiate a contractual agreement and to disclose the patient's PHI. The hospice will send a contractual agreement to the temporary receiving hospice." Clinical Record 3: The patient elected the hospice benefit effective 6/28/2023. During interview on 9/11/2023, the Social Worker stated she was originally made aware of the possible trip to (State) on her initial visit on 7/6/2023. The triage telephone call received on 7/29/2023 documented the patient's daughter called because the patient was complaining of dizziness. The patient was in (State) and requested a visit from the local hospice. There was no travel contract in place. The Administrator on Call was contacted for a travel contract, and returned the daughter's call and informed her of the option of going to the Emergency Room because a travel contract was not able to be completed after hours. During a joint review of the record and an interview on 9/11/2023, the Clinical Supervisor agreed there was no documented evidence that the hospice followed their transfer policy by setting up a travel contract. During the interview on 9/11/2023, the Social Worker stated the expectation is to notify the supervisor to get a contract. The Social Worker confirmed this was not completed and had no further information to provide.

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 clinical record review, document review and interview. In 1 of 1 (100%) record reviewed of a patient who revoked the hospice benefit, it was revealed that the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician. Document 1: Agency policy, "Discharge from Hospice Program,” stated in part, “A copy of the discharge summary will be sent to the attending physician." Clinical Record 2: The date of the election of benefits was 3/9/2023. The patient revoked hospice services on 6/30/2023. The revocation documentation on 6/30/2023 stated, “Patient has decided to revoke hospice to seek aggressive treatment. Her oncologist will now take over her care.” There was no documented evidence that the discharge summary was forwarded to the oncologist or patient’s attending physician. During a joint review of the record and an interview on 9/11/2023, the Quality Manager agreed there was no documented evidence that the discharge summary was forwarded to the patient's attending physician.

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 review of clinical record, document review and interview that in 4 of 20 (20%) records, the requirement for spiritual care, to complete the initial comprehensive assessment failed to be documented in the required 5 days, or a documented reason for not providing this service. Agency Policy: 11148284 Comprehensive Assessment [revised 02/04/2022] stated in part, "An assessment of the patient and family/caregiver spiritual orientation, including, as appropriate...... A comprehensive patient assessment will be performed by the hospice interdisciplinary group no later than 5 calendar days after the election of hospice care...." Record #41814: with signed hospice benefit of election 12/23/021. The spiritual assessment documented for chaplain was 01/03/2022 (day 11 and 6 days late). Record #48800: with signed hospice benefit of election on 04/04/2022. The spiritual assessment documented for chaplain was not documented as of review 05/16/2022. Interview with the chaplain clarified that the family refused chaplain service and a late entry was made in the record 05/18/2022 to clarify this. Record #45481 with signed hospice benefit of election 01/04/2022. The spiritual assessment for chaplain was not documented as of review 05/16/2022. Interview with the chaplain clarified that the family refused chaplain service and a late entry was made in the record 05/18/2022 to clarify this. The patient was transferred to a different hospice on 01/17/2022. Record #20925 with signed hospice benefit of election on 03/01/2022. The spiritual assessment for chaplain was not documented as of review 05/17/2022. Interview with the chaplain clarified that the family refused chaplain service and a late entry was made in the record 05/18/2022 to clarify this. Interview with the quality manager stated that the late entry notes have been added and attention to documentation is needed.

It is required that the hospice designates a registered nurse member of the IDG to: Ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by review of clinical record and interview that in 2 of 20 (10%) records the clinical staff did not follow the interdisciplinary plan of care for providing visits ordered. Record #92876: Chaplain frequency ordered on 02/22/2022, 4 times a month for 3 months. No visits were documented in March or April of 2022 and no visits documented as of review 05/17/2022. Interview with the chaplain stated that collaboration with the nurse and family that the patient had a spiritual provider in place and refused further chaplain visits after the initial visit. Late entry clarification note documented 05/18/2022 . Record #25972: Nursing frequency ordered on 08/12/2021, 1 time a week for 13 weeks. The week beginning 11/07/2021, no nursing visit documented and no reason for the visit not provided. Interview with the case manager and review of that week of schedules stated that the case manager was off and the facility seemed to have had active COVID cases that week but agreed that the documentation of this and potential refusal by the facility for visits was not documented. Interview with the quality manager stated that the late entry was accomplished and oversight of visit frequency will be monitored for future documentation.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical record, document review and interview that in 3 of 20 (15%) of records failed to include all interventions for problems identified on the initial or updated comprehensive assessment. Agency Policy: 11031317 The Plan of Care, [revised 1/15/2022] stated in part, "The written plan of care will contain, but will not be limited to, the following: Individualized interventions to assist with end of life care." Record #47587 documented on nursing admission 04/25/2022 a stage 1 pressure ulcer on right heel. Nursing assessment on 05/06/2022 documented an Optifoam [ highly absorbent dressing] Dressing on the right calf with a healed right heel. The plan of care reviewed 05/17/2022 failed to document an intervention for the Optifoam dressing and the wound identified on 05/06/2022 on the right calf. Interview with the case manager who identified the new wound and the care plan documented intervention was updated on 05/18/2022. Record #92876 documented on the initial comprehensive assessment on 02/18/2022 that the patient had a supra pubic catheter to large bag drainage. The plan of care dated 02/08/2022 - 05/18/2022 failed to document intervention for the supra pubic catheter. Updated plans of care failed to document the supra pubic catheter as of review 05/16/2022. Review of the plan of care on 05/18/2022 documented the correction for the supra pubic catheter care and the interventions. Record #81316 documented on the initial comprehensive assessment on 02/04/2022 that the patient had a stage 2 sacral decubitus. Interventions were documented on the plan of care to clean with normal saline and apply a medihoney [dressing to aide in healing] dressing to be changed every 72 hours and as needed. Nursing assessment 02/28/2022 documented that the wound was healed and the daughter wanted to continue treatment. Review of the plan of care on 05/16/2022 documented the intervention to clean sacral wound with normal saline and apply medihoney dressing change every 72 hours and as needed. This intervention was not updated until 05/17/2022 that the dressing was not still being used. Interview with the quality manager that the plans of care did not document all interventions stated that plans now updated on 05/18/2022.

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 review of clinical record, document review and interview that 1 of 20 (05%) records failed to document all required physician orders. Agency Policy: 11053078 Verification of Physician Orders [revised 01/20/2022] stated in part, "Verbal orders will be documented in the Electronic Documentation Record. ....a process will exist to review and update orders as needed to support clarity, accuracy, and safety." Record #47587 documented on nursing clinical visit note on 05/06/2022 that an Optifoam [ a highly absorbent dressing] dressing was place on right calf of the patient. Review of record on 05/17/2022 failed to document a physician order for this dressing. Review of the record on 05/18/2022 with a documented late entry of the order for the dressing. Interview with the quality manager that the record had been updated with the physician order.

It is required that the hospice inpatient facility provides meals to each patient that are: Obtained, stored, prepared, distributed, and served under sanitary conditions. Food is available 24/7 to respond to patient’s needs or requests. This standard was not met as evidenced by observation during Life Safety tour on 05/17/2022, that in 1 of 1 (100%) of patient use refrigerators, an opened large bottle of berry juice was in the patient use refrigerator door with no date or label. The manager of the in patient unit was not able to identify which patient the juice may have belonged to or how long the juice had been in the refrigerator. This storage of juice is unsafe and the manager stated that it would be disposed of that day. Interview with the quality manager on 05/18/2022 stated that the juice was the chaplains and that it was used for communion. The chaplain agreed that juice was not to be placed in the patient refrigerator but that the staff area had been too full and that it had been incorrectly placed in the patient area.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview that 1 of 7 (14%) records of patients cared for at a skilled facility failed to document which provider was responsible for the care included in the plan of care. Record #92876 admitted 02/18/2022 in a skilled facility and had a supra pubic catheter in place to large bag drainage. The plan of care dated 02/08/2022 - 05/18/2022 (reviewed 05/16/2022) failed to document interventions for the catheter and failed to document who was responsible for the care of the supra pubic catheter. Review of the records 05/18/2022 with a late entry that included interventions for the supra pubic catheter and that the facility would provide the catheter care. Interview with the quality manager confirmed that the plan was updated with a late entry for the facility participation.