Every finding on record at Schha, 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; [and] 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; [and] 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 measures 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, document review, interview, and observation. Agency Policy #0-990 "Medication Management & Administration" (dated 05/06/2024) stated in part, "Medication reconciliation should be completed on every comprehensive assessment and reassessment. The comprehensive assessment includes: Drug profile (medication reconciliation), including prescriptions, over-the-counter medications, supplements, herbal remedies, and other alternative treatments that could affect drug therapy." In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. CLINICAL RECORD 2/HOME VISIT 2: The patient elected hospice care on 09/02/2025. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 2], the ALF medication list (dated 09/17/2025) was compared with the agency's medication profile (dated 09/17/2025). The ALF medication list documented the following medications not documented on the agency's medication profile: "allopurinol 100mg tablet, take two (2) tablets daily (ordered 09/01/2025); aspirin 81mg tablet, take one (1) tablet daily, (ordered 09/01/2025); atorvastatin 80mg tablet, take one (1) tablet daily at bedtime, (ordered 09/01/2025); carvedilol 25mg tablet, take one (1) tablet twice daily, (ordered 09/01/2025); Certavite Multivitamin tablet, take one (1) tablet daily, (ordered 09/01/2025); cranberry 250mg capsule, take one (1) tablet daily, (ordered 09/01/2025); ipratropium/albuterol 3ml nebulizer solution, take one (1) vial via nebulizer every 6 hours as needed, (ordered 09/01/2025); milk of magnesia 400mg/5ml suspension, take 30ml twice daily as needed for indigestion, (ordered 09/01/2025); and polyethylene glycol 17 gram powder, take 17 grams in 8 ounces of liquid daily as needed for constipation, (ordered 09/01/2025." During a joint record review and interview on 09/17/2025, the Hospice Director confirmed that the patient's medication profile did not match the medication record at the assisted living facility, stating, "This is a new facility that we recently started seeing patients at. There must have been a miscommunication between the facility staff and our nurse during the patient's admission."

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and observation. In 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that all the patient's plan of care included the necessary drugs and treatments to meet the patient's needs. CLINICAL RECORD 2/HOME VISIT 2: The patient elected hospice care on 09/02/2025. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 2], the ALF medication list (dated 09/17/2025) was compared with the agency's medication profile (dated 09/17/2025). The ALF medication list documented the following medications not documented on the agency's medication profile: "allopurinol 100mg tablet, take two (2) tablets daily (ordered 09/01/2025); aspirin 81mg tablet, take one (1) tablet daily, (ordered 09/01/2025); atorvastatin 80mg tablet, take one (1) tablet daily at bedtime, (ordered 09/01/2025); carvedilol 25mg tablet, take one (1) tablet twice daily, (ordered 09/01/2025); Certavite Multivitamin tablet, take one (1) tablet daily, (ordered 09/01/2025); cranberry 250mg capsule, take one (1) tablet daily, (ordered 09/01/2025); ipratropium/albuterol 3ml nebulizer solution, take one (1) vial via nebulizer every 6 hours as needed, (ordered 09/01/2025); milk of magnesia 400mg/5ml suspension, take 30ml twice daily as needed for indigestion, (ordered 09/01/2025); and polyethylene glycol 17 gram powder, take 17 grams in 8 ounces of liquid daily as needed for constipation, (ordered 09/01/2025." The clinical record did not include the physician's orders for allopurinol, aspirin, atorvastatin, carvedilol, Certavite Multivitamin, cranberry capsules, ipratropium/albuterol nebulizer solution, milk of magnesia, and Polyethylene Glycol. CLINICAL RECORD 5: The patient elected the hospice benefit on 09/05/2025. The initial nursing assessment dated 09/05/2025, documented "Patient has a Foley catheter in place." The plan of care did not include documentation for the care and maintenance of the Foley catheter. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/30/2025. The initial nursing assessment dated 01/30/2025, documented "Patient has a suprapubic catheter in place." The plan of care did not include documentation for the care and maintenance of the suprapubic catheter. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/15/2025. The initial nursing assessment, dated 02/15/2025, documented a "Suprapubic catheter 16 Fr. Last changed 02/10/2025 and will be changed every two weeks." The plan of care did not include documentation for the care and maintenance of the suprapubic catheter.

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 clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/18/2025. A physician's order dated 08/26/2025 ordered wound care and a dressing for a wound on the patient's coccyx. The plan of care dated 07/18/2025 through 10/15/2025 ordered "HA 2 times per week starting week of 07/20/2025." The first HA visit was dated 07/22/2025. The HA care plan dated 07/21/2025 assigned the HA the relevant task: "Bed bath every visit." The HA care plan did not include instructions regarding the patient's wound dressing on the coccyx if the dressing became wet or dislodged during the bed bath. CLINICAL RECORD 17: The patient elected the hospice benefit on 06/12/2025. A physician's order dated 06/16/2025 ordered wound care and dressings for the wounds on the patient's legs. The plan of care dated 06/12/2025 through 07/07/2025 ordered "HA 3 times per week starting week of 06/15/2025." The first Hospice Aide visit was dated 06/16/2025. The HA care plan dated 06/18/2025 assigned the HA the relevant task: "Bed bath every visit." The HA care plan did not include instructions regarding the patient's wound dressings on the legs if the dressings became wet or dislodged during the bed bath. CLINICAL RECORD 18: The patient elected the hospice benefit on 02/10/2025. A physician's order dated 02/10/2025 ordered wound care and a dressing for a wound on the patient's chest. The plan of care dated 02/10/2025 through 03/23/2025 ordered "HA 2 times per week starting week of 02/16/2025." The first Hospice Aide visit was dated 02/19/2025. The HA care plan dated 02/26/2025 assigned the HA the relevant task: "Shower every visit." The HA care plan did not include instructions regarding the patient's wound dressing on the chest if the dressing became wet or dislodged during the shower. During joint record reviews and interviews on 09/17/2025 and 09/18/2025, the Hospice Director confirmed that the Hospice Aide care plans did not include wound dressing instructions.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that Hospice Aide supervisory visits were completed by a Registered Nurse, no less frequently than every 14 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/30/2025. The plan of care, dated 01/30/2025 through 04/29/2025, ordered: "HA 2 times per week starting week of 02/02/2025." The first HA visit was dated 02/04/2025. Hospice Aide supervisory visits were completed on 03/11/2025 and 03/31/2025, with 20 days outstanding. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/18/2025. The plan of care, dated 07/18/2025 through 10/15/2025, ordered: "HA 2 times per week starting week of 07/20/2025." The first Hospice Aide visit was dated 07/22/2025. Hospice Aide supervisory visits were completed on 07/29/2025 and 08/19/2025, with 21 days outstanding. CLINICAL RECORD 16: The patient elected the hospice benefit on 03/27/2025. The plan of care, dated 03/27/2025 through 05/05/2025, ordered: "HA 3 times per week starting week of 03/30/2025." The first Hospice Aide visit was dated 03/31/2025. Hospice Aide supervisory visits were completed on 04/10/2025 and 04/25/2025, with 15 days outstanding. During joint record reviews and interviews on 09/16/2025, 09/17/2025, and 09/18/2025, the Hospice Director confirmed that the Hospice Aide supervisory visits were completed less frequently than every 14 days.

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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that all physician orders were included in the patient's clinical record. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/06/2025. A skilled nursing visit note dated 08/11/2025 documented, "A new 16 French (FR) Foley catheter was inserted using sterile technique." A clinical record review revealed no documentation of a physician's order for the Foley catheter size 16 FR or the care and maintenance of the Foley catheter. During joint record reviews and interviews on 09/16/2025 and 09/17/2025, the Hospice Director confirmed that the records lacked specific physicians' orders for the above-listed Foley catheter.

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 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, documents, and interviews. 1 of 2 (50%) applicable personnel records of contracted staff were reviewed and identified that initial emergency preparedness training was not provided. Personnel Record 1: Hospice Medical Director Contract Date: 1/27/2022. There was no documented evidence of initial emergency preparedness training in the personnel record. The Executive Director was interviewed on 11/2/2022 and agreed that there was no documentation of completed emergency training in the personnel record.

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 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, and 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 a review of clinical records and interview. 2 of 13 (15%) clinical records reviewed revealed that the drug profile was not updated at the time of comprehensive assessments. Clinical Record 8: The patient elected the hospice benefit on 10/30/2022 with a primary diagnosis of CVA. The admission assessment identified that the patient required oxygen as needed. There was no liter flow provided in the documentation. Oxygen was not included in the drug profile. Clinical Record 12: The patient elected the hospice benefit on 8/5/2022 with a primary diagnosis of COPD. The admission assessment identified that the patient required oxygen as needed. Oxygen was not included in the drug profile. The Executive Director was interviewed on 11/2/2022 and stated that this issue had been identified by the quality team and that there was a plan in place to correct this problem.

It is required that each patient’s individualized written plan of care: reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 12 (17%) applicable clinical records of patients who accepted the Hospice Social Worker (SW), the individualized plan of care (POC) did not include all of the required elements. Clinical Record 2: The patient elected the hospice benefit on 9/9/2022 with a primary diagnosis of Neuromyelitis Optica. The SW completed the initial assessment on 9/13/2022 with a planned visit frequency of one time each month. The patient's individualized POC did not include all appropriate problems or interventions to be provided by the SW. Clinical Record 4: The patient elected the hospice benefit on 9/21/2022 with a primary diagnosis of Heart Disease. The SW completed the initial assessment on 9/22/2022 with a planned visit frequency of one time each month. The patient's individualized POC did not include all appropriate problems or interventions to be provided by the SW. The SW was interviewed on 11/3/2022 during a home visit. She stated that she provided companionship and support for the patient but agreed that she had not created an individual problem to define her interventions with the patient. The Executive Director was interviewed on 11/2/2022 and agreed that the POC should include individualized problems with interventions from all disciplines providing care to the patient.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records and interview. 11 of 13 (85%) clinical records reviewed the written certification did not include the required elements. Clinical Record 12: The patient elected the hospice benefit on 8/5/2022 with a primary hospice diagnosis of COPD. The narrative on the Certification of Terminal Illness (CTI) for the initial benefit period which began on 8/5/2022 documented the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 13: The patient elected the hospice benefit on 8/11/2022 with a primary hospice diagnosis of Breast Cancer. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 8/11/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 10: The patient elected the hospice benefit on 7/27/2022 with a primary hospice diagnosis of Brain Cancer. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 7/27/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 9: The patient elected the hospice benefit on 8/26/2022 with a primary hospice diagnosis of CVA. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 8/26/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 7: The patient elected the hospice benefit on 9/17/2022 with a primary hospice diagnosis of Heart Disease. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 9/17/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 6: The patient elected the hospice benefit on 10/10/2022 with a primary hospice diagnosis of Heart Disease. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 10/10/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 5: The patient elected the hospice benefit on 9/13/2022 with a primary hospice diagnosis of Cerebral Edema. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 9/13/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 4: The patient elected the hospice benefit on 9/21/2022 with a primary hospice diagnosis of Heart Disease. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 9/21/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 3: The patient elected the hospice benefit on 10/18/2022 with a primary hospice diagnosis of Protein Calorie Malnutrition. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 10/18/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 2: The patient elected the hospice benefit on 9/9/2022 with a primary hospice diagnosis of Neuromyelitis Optica. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 9/9/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. Clinical Record 1: The patient elected the hospice benefit on 9/20/2022 with a primary hospice diagnosis of Protein Calorie Malnutrition. The narrative on the Certification of Terminal Illness (CTI) completed for the initial benefit period which began on 9/20/2022 contained the nursing narrative completed on admission. There was no evidence that the physician utilized the nurse's information to synthesize a new narrative statement. The Executive Director was interviewed on 11/1/2022 and stated that this problem had been identified during QA chart reviews and that ongoing education was being provided to the physician regarding the proper completion of the narrative for the CTI.