Every finding on record at Soreo Pathways LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over the counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The 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, observation, and interview. In 1 of 19 (5%) clinical records reviewed revealed the hospice did not ensure the drug profile was updated to include all current medications. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 08/05/2025 with a diagnosis of Alzheimer's disease. The hospice medication profile reviewed on 02/26/2026 included "haloperidol (2mg/ml) 0.25 ml oral every 6 hours as needed for agitation." During the home visit on 02/26/2026, the facility medication profile was reviewed. Haloperidol (2mg/ml) 0.25 ml oral every 6 hours as needed for agitation was not included on the facility medication profile. The registered nurse visit dated 02/23/2026 did not include evidence that an update to the facility medication profile was documented. During an interview with the clinical services director on 02/27/2026, the clinical services director contacted the facility medication tech by phone to verify that the medication profile did not include haloperidol. The facility medication tech verified that haloperidol was inadvertently omitted from the medication profile in January 2026. The clinical services director stated, "The nurse should have identified the discrepancy during her routine visits. I will advise the nurse to be sure to reconcile the medication profile during each visit."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visits in which hand hygiene was observed, the agency did not ensure that the hospice followed accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. DOCUMENT 2: The policy "HAND HYGIENE" stated in relevant parts; "Procedure/best practice. 3. Hand decontamination using an alcohol-based hand rub should be performed: F. When moving from a contaminated body site to a clean body site during patient care." HOME VISIT 4: The patient elected the hospice benefit on 08/05/2025 with a diagnosis of Alzheimer's disease. During the home visit with the hospice aide (PR8), the hospice aide provided a bed bath. The hospice aide was observed washing her hands with soap and water prior to donning gloves. She then began bathing the patient starting with her upper body and progressing downward toward her lower body. She then washed the patient's private areas (a contaminated body site). After washing and drying the patient's private areas, the hospice aide applied lotion to her soiled gloves and applied the lotion to the patient's upper body, arms, and back. She did not remove the soiled gloves and sanitize her hands before applying lotion to clean body parts. During an interview with the clinical services director on 02/27/2026, he stated, "The hospice aide should have changed her gloves and sanitized her hands after washing the patient's private areas and before applying lotion to the rest of her body. I will speak to her about that."

A clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient's attending physician and hospice staff. The patient's record must include physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of patients who were discharged live from hospice, the agency did not ensure a written physician's discharge order was documented. CLINICAL RECORD 16: The patient elected the hospice benefit on 09/26/2025 with a diagnosis of sequelae of unspecified infectious and parasitic disease and was discharged on 10/17/2025 to an out of service area/non-contracted facility (hospital). There was no documented evidence of a written physician's discharge order to discharge the patient from the hospice. During an interview with the chief of operations (COO) on 02/27/2026, she stated, "I was not aware that a discharge order was required when the patient chooses to go to the hospital."

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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of patients who were transferred to a Medicare/Medicaid certified facility, the agency did not ensure that hospice forwarded a copy of the discharge summary to the Medicare certified facility. CLINICAL RECORD 16: The patient elected the hospice benefit on 09/26/2025 with a diagnosis of sequelae of unspecified infectious and parasitic disease and was discharged on 10/17/2025 when transferred to a hospital, (Medicare certified facility), to seek aggressive treatment. There was no documented evidence in the clinical record that a discharge summary was sent to the Medicare certified facility/hospital. During an interview with the chief operations officer, she stated, "I was not aware of the need to send a discharge summary to the hospital."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical record reviewed revealed the agency did not ensure that the findings from the patient's updated comprehensive assessment and progress toward outcomes and goals were reflected in the revised plan of care (POC). Clinical Record 16: The patient elected the hospice benefit on 12/15/2022. In the Skilled Nurse Encounter Visit note on 4/7/2023, the RN identified the patient was experiencing increased pain and received an order from the hospice physician for a Fentanyl 12 microgram/hour (mcg/hr) patch. During a follow-up Skilled Nurse Encounter on 4/8/2023, the nurse received an order to increase the Fentanyl patch from 12mcg/hr to 25mcg/hr due to the patient's ineffective pain control. The patient's daughter called the agency on 4/20/2023 to report that her mother was experiencing uncontrolled pain. A new order for the Fentanyl patch to be increased to 50mcg/hr was received by the RN. During the Skilled Nurse Encounter visit on 4/24/2023, the patient reported that the pain was now being controlled at an acceptable level. On the POC with the effective dates 3/15/2023 to 6/12/2023, there was no update to the POC problems, interventions, or goals to reflect that the patient was experiencing issues with increased pain that required frequent changes to the pain medication regimen. During an interview with the Clinical Services Director on 4/25/2023, it was confirmed that there was no problem, interventions, or goals documented in the patient's clinical record to reflect the change in the patient's comprehensive assessment related to increased pain.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 11 (9%) applicable personnel records reviewed for staff members furnishing care, revealed the hospice did not ensure that an annual skills and competency assessment was completed for 2022. The agency policy "Annual Core Competency" with the revised date of 5/2022 stated, "Hospice will implement an objective, measurable system to evaluate competency. The performance criteria list will demonstrate the hospice employee is proficient in his/her skills." The title of the policy indicated that competency skills were performed annually. Personnel Record 10: The Hospice Medical Director was hired on 10/8/2020. Review of the Hospice Medical Director's personnel file did not include documented evidence of an annual clinical skills competency assessment for 2022. In interviews with the Compliance Officer on 4/26/2023 and 4/27/2023, it was confirmed that the Hospice Medical Director's Clinical Competency for 2022 was not in the personnel file.

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 and interview. I of 2 (50%) applicable clinical records reviewed in which there was a live discharge from hospice care, revealed the agency did not ensure that the discharge summary was sent to the patient's attending physician upon discharge. Clinical Record 1: The patient elected the hospice benefit on 7/7/2022. On 8/25/2022, the Interdisciplinary Team, including the Hospice Medical Director, discharged the patient for an extended prognosis. The discharge summary was completed, but there was no documented evidence that the discharge summary was sent to the patient's attending physician. In an interview with the Clinical Services Director and the Compliance Officer on 4/27/2022, it was confirmed that there was no documentation that the patient's discharge summary was sent to the patient's attending physician upon the patient's discharge from hospice care.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. A review of the contract for physical therapy, occupational therapy, and speech therapy (PT/OT/ST) services with the effective date of 3/2/2021 revealed the contract did not contain the requirement for criminal background checks to be performed for contracted staff who have direct patient contact or access to patient records. Contract 4: There was no language in the contract requiring criminal background checks for contracted staff who have direct patient contact or access to patient records. An interview on 4/27/2023, the Executive Director confirmed that the contract for PT/OT/ST services was missing the contract language requiring criminal background checks. A review of the contract for physical therapy, occupational therapy, and speech therapy (PT/OT/ST) with the effective date of 3/2/2021 revealed that the contract did not contain the requirement for background checks to be performed for those contracted staff with access to patients or the patient's medical record. An interview with the Executive Director on 4/27/2023 confirmed that the contract for PT/OT/ST services was missing the contract language requiring criminal background checks.