Every finding on record at Stch NW Wi Opco 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, observation, and interview. In 3 of 19 (16%) 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 03/07/2025 with a primary diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Medical Social Worker (MSW) [Personnel Record 7] on 11/19/2025, copies of the SNF and hospice medication profiles were reviewed. The SNF medication profile documented Celexa (antidepressant) 10mg daily with an order date of 11/06/2025. The hospice did not document Celexa. The hospice medication profile documented buspirone 5 mg (take 2.5 mg) three times a day, with an order date of 04/25/2025, and vitamin C 500mg daily, with an order date of 03/07/2025. Buspirone and vitamin C were not documented on the SNF medication profile. These discrepancies would not allow a complete review of medications, as the SNF administers them, and the medications provided differ from the hospice medication profile. CLINICAL RECORD 4/HOME VISIT 4: The patient elected hospice care on10/16/2025 with a primary diagnosis of congestive heart failure (CHF). The patient resided at a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 9] on 11/20/2025, copies of the SNF and hospice medication profiles were reviewed. The hospice medication profile documented atorvastatin (cholesterol) 20 mg, PO daily, and omeprazole (stomach medication) 20 mg, delayed-release daily. Atorvastatin and omeprazole were not documented on the SNF medication profile. The SNF medication profile documented Lactobacillus one (1) capsule daily with a start date of 10/25/2025 (the SNF administered daily); metolazone 2.5mg daily on Monday, and Friday start date 09/12/2025 (given on this schedule by the SNF); and cetirizine hcl 10 mg, 0.5 tablet daily as needed for allergy (this had been given 3 times a week for the last 3 weeks by the SNF). The hospice medication profile did not include documentation of Lactobacillus, metolazone, or cetirizine hcl. These discrepancies would not allow a complete review of medications, as the SNF administers them, and the medications provided differ from the hospice medication profile. CLINICAL RECORD 12: The patient elected hospice care on 05/30/2025 with a primary diagnosis of malignant neoplasm of the overlapping site of the palate. The hospice medication profile reviewed on 11/19/2025 documented heparin 100 units, use 5 cc to flush the line as needed, and saline 0/9% use 10 cc to flush the line as needed. A clinical record review revealed that the patient had an infusion line in May 2025, but it was no longer present. The heparin and normal saline remained on the hospice medication profile and were reviewed, but the review was inaccurate. During the interview on 11/20/2025, the Administrator, Clinical Manager, and Regional Clinical Manager confirmed the findings, stating that the transition date for the organization was 09/01/2025 and that some medication profiles would need to be reviewed. DHS_131.20(3)(f) Drug profile. A review of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:

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 clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the comprehensive assessment. CLINICAL RECORD 5: The patient elected hospice care on 10/27/2025 with a primary diagnosis of disease of the esophagus. The Registered Nurse (RN) initial comprehensive assessment documented that the patient had problems with aspiration and was currently on clear liquids, which the patient easily aspirated. The plan of care interventions did not address the patient's documented aspiration problems. CLINICAL RECORD 11: The patient elected hospice care on 10/07/2024 with a primary diagnosis of congestive heart failure. The updated skilled nursing (SN) comprehensive assessment dated 08/12/2025 identified the patient's anxiety. Lorazepam was ordered at bedtime and prn (as needed). On 09/09/2025, the updated SN assessment documented the patient's increased difficulty with anxiety. On 10/16/2025, the lorazepam was changed to a tablet of 0.5mg at bedtime and was available every 2 hours for anxiety. On 11/07/2025, the lorazepam was changed to 0.5mg, scheduled 2 times a day and every 2 hours as needed. The recertification assessment dated 11/06/2025 documented lorazepam used 2 times a day and multiple times during the day to control anxiety. A clinical record review revealed no anxiety interventions documented in the plan of care updated 08/03/2025, or in any of the plans of care updated every two weeks as of review 11/19/2025. During an interview on 11/20/2025, the Clinical Team, who had reviewed the records, stated that the interventions were not documented. DHS_131.21(3)(b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following:

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, document review, and observation. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that updated plans of care documented all current medications and treatments. CLINICAL RECORD 2/HOME VISIT 2: The patient elected hospice care on 03/07/2025 with a primary diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Medical Social Worker (MSW) [Personnel Record 7] on 11/19/2025, the SNF medication profile documented Celexa (antidepressant) 10mg daily with an order date of 11/06/2025. The hospice plan of care was not updated to include Celexa as of 11/20/2025. CLINICAL RECORD 4/HOME VISIT 4: The patient elected hospice care on 10/16/2025 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing facility (SNF). During the home visit with the RN [Personnel Record 9] on 11/20/2025, the patient had ace wraps and kerlix gauze on bilateral lower extremities. The patient refused wound care during this visit. The initial Registered Nurse comprehensive assessment dated 10/16/2025, documented wounds #1 and #2 on the bilateral lower extremities, frontal leg. The wounds documented were related to diabetes. The initial plan of care dated 10/16/2025 documented skin integrity interventions to assess the skin, instruct on skin assessment, and prevent pressure ulcers; however, no interventions were documented for the wound care provided to the bilateral legs, including the frequency and care. The patient's dressing supplies at the SNF included normal saline, gauze, hydro blue dressing, and ace wraps. The hospice plan of care did not document these treatments, but did have the facility order. Additionally, during the home visit, the SNF medication profile documented Lactobacillus one (1) capsule daily with a start date of 10/25/2025, metolazone 2.5mg daily on Monday and Friday with a start date of 09/12/2025, and cetirizine hcl 10 mg, 0.5 tablet daily as needed for allergy (this had been given 3 times a week for the last 3 weeks by the facility. The hospice plan of care did not document Lactobacillus, metolazone, or cetirizine hcl. CLINICAL RECORD 7: The patient elected hospice care on 11/07/2025 with a diagnosis of hepatic biliary cancer. The Registered Nurse (RN) initial comprehensive assessment documented that the patient had an Aspira drain. The plan of care did not document interventions for the Aspira drain dressing change (which would have been weekly), nor for drainage interventions (which were done for comfort and were usually weekly). The plan of care ordered Fentanyl 24 mcg (micrograms) every 72 hours; hydromorphone 25mg/1 ml every 3 hours as needed for pain, and morphine concentrate 100 mg/5ml (milliliters), give 0.25ml every 2 hours for pain. The plan of care did not include a delineation of the identified pain level and the medication to be given sequentially. During an interview and joint record review on 11/20/2025, the clinical team agreed that the interventions were not documented and the medications were incorrect. DHS_131.21(3)(b)4 Drugs and treatment necessary to meet the needs of the patient.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including: ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG). This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed and home visits observed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that the Registered Nurse provided care coordination and continuous assessment of each patient’s needs. CLINICAL RECORD 4/HOME VISIT 4: The patient elected hospice care on 10/16/2025 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing facility (SNF). The initial Registered Nurse comprehensive assessment dated 10/16/2025, documented wounds #1 and #2 on the bilateral lower extremities, frontal leg. The wounds documented were related to diabetes. A clinical record review revealed no wound measurements or descriptions as of this review, 11/20/2025. The patient declined a wound assessment at the initial visit on 10/16/2025. The nursing assessment 10/29/2025 documented that the hospice nurse assisted the facility staff with wound care to assess the wound, but there was no documented assessment of the wound. On 11/03/2025, the nursing assessment documented that the wound was improving, but no objective documentation of what this was. During the home visit with the RN [Personnel Record 9] on 11/20/2025, the patient had ace wraps and kerlix gauze bilaterally. The patient refused wound care during this visit. The RN [Personnel Record 9] coordinated with the facility during the visit. RN [Personnel Record 9] is the new case manager for this case, and it was their first visit. CLINICAL RECORD 11: The patient elected hospice care on 10/07/2024 with a diagnosis of CHF. The patient resided in a SNF. The initial RN comprehensive assessment was on 10/07/2024. The updated assessments documented 09/01/2025 and every two weeks, documented a stage IV wound on the patient's coccyx with wound care ordered and updated with orders for a dressing change three (3) times a week with the hospice nurse to assess weekly. The facility changed the dressing the other times during the week. The updated comprehensive assessment dated 08/02/2025 documented the presence of the wound. The wound was measured on 09/15/2025, and then no further description was documented until 09/30/2025. The visits on 09/18/2025, 09/23/2025, 09/25/2025, and 09/29/2025 documented that wound care was neither provided nor ordered during these visits. A clinical record review revealed that no communication documented that updates were coordinated with the facility during these visits. Facility coordination was documented for behaviors and catheter issues, but not for the wound. During an interview on 11/20/2025, the Administrator and Regional Clinical Manager confirmed the findings and stated that improved wound documentation would be a goal.

Observed in Record Review. In 1 of 1 patient records reviewed, where the patient elected to revoke hospice care it was noted that the revocation form was incomplete and did not state the number of days in the certification that would be forfeited and also the number of certifications remaining if hospice was to be re-elected. This was confirmed by the staff assisting with clinical record review.

Observed in Record Review. In 6 of 13 patient records reviewed, it was noted that in hospice record reviews the goals were not all measurable or timed. For example, in review of record for home visit #1 the goals for nursing were all dated to be achieved at the end of the certification period. In addition, there was no short term goal for an identified problem related to eye irritation for which eye drops were ordered. The was no problem identified or goal stated for the patient who had ongoing pedal edema. Lastly the ST goals for oral care and feeding practices were not timed. In another example, for record review of home visit #2 the Chaplain goal was stated as Opportunity to address spiritual issue will be provided. In review of record #7 it was noted that the goal for pain issues for this patient with pancreatic cancer was stated as will have satisfaction with pain control. In record review #5 for a patient with 4 + edema, it was noted that the goal for edema was stated as caregiver will verbalize management of edema. In record review #4 a stated goal for respiratory issues was stated as demonstrate understanding of an ability to manage respiratory symptoms. In record review #2 the stated goal for pain issues was will have satisfaction with pain control and did not contain the patient stated goal for pain management with use of pain scale. In review of record #1 the following goals were stated, pt will verbalize satisfaction with level of chest pain, fatigue and edema mgmt. through 2/28/23, caregiver will expresscoping, caregiving and psychosocial need by ... and pt will demonstrate understanding of ability to manage respiratory symptoms by 2/28/23, which was the end of the certification period. This was reviewed with the hospice staff assisting with record review.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the plan of care was not updated. For example, in record review #2 a pain care plan was initiated on 10/24/22, however the start of care was 8/17/22 and the patient had pain at the start of care. The patient also had a wound at the start of care and dyspnea at the start of care and neither of these problems were address on the initial plan of care. This was discussed with the hospice staff assisting with record review.

Observed in Record Review. it was noted in record review #5 that the hospice medication sheet stated Toujeo give 35 units BID, the next sentence stated, give 25 units at HS. Discussion with leadership indicated that this should have been written as two separate orders, one for morning dose of 35 units and one for HS does of 25 units. Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that all hospice records reviewed contained a standardized set of standing orders and therefore were not individualized to meet the needs of each patient. For example, there were orders for foley catheter insertion with 16/5 foley, oxygen at 2L/nc PRN, wound care orders that did not specify the cleansing of the wound and stated as clean with water, normal saline or wound cleanser. DME orders that were not personalized and medications such as artificial saliva with no specific medication name, frequency of use. This was discussed with hospice leadership.

Observed in Record Review. In 3 of 13 patient records reviewed, it was noted that the revised plan of care did not include information from the updated comprehensive assessment. For example, in review of record for home visit #3 it was noted that the documentation in the IDT meeting every 14 days remained unchanged from August 2022 although documentation in the record indicated that there were changes to the patient's condition. For example, the patient was receiving aide services, but the IDT note indicated that the patient was refusing, also the IDT note indicated that the patient was receiving ST however the patient had not had a ST visit in 6 months and also the IDT note indicated that the patient had fallen in the past two weeks but there was no other documentation in nursing notes or falls report to indicate that the patient had recently fallen. In record review #2 on 11/17/22 a new issue of edema was documented in the nursing notes however there was no update to the plan of care for this new problem. In record review #10 it was noted that the documentation in the IDT meeting every 14 days remained unchanged for the last four IDT notes. This was confirmed by the hospice nurse assisting with record review.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.104, 418.100,

Observed in Record Review. In 2 of 13 patient records reviewed, t was noted that the records did not contain updated assessments. For example, in review of record for home visit #3 it was noted that the documentation in the IDT meeting every 14 days remained unchanged from August 2022. The update patient summary documentation stated that in the past two weeks the patient has had 4 falls in the past two weeks, is refusing aide visits, receiving ST visits and change in diet to mechanical soft. This was documented in the IDT meetings every two weeks since August 2022. Visit note documentation revealed that ST had not seen the patient since June 2022, there was no other documentation of falls in the recent past and the patient was accepting of aide visits at this time. In another example in record review #10 it was noted that the IDG meeting documentation every 14 days remained unchanged for the last two months and continued to address resolution of hand edema and medication changes that were not new. This was confirmed by the hospice nurse assisting with record review.

Observed in Tracer Visit. In 1 of 1 home visits conducted, with a skilled nurse, it was noted that there were discrepancies between the hospice medication profile and the Assisted Living Facility medication record. For example, Haldol was ordered as a regularly scheduled BID and also as PRN every 4 hours however the PRN dosage was not on the facility medication sheet. This was confirmed by the nurse completing the visit as well as the hospice supervisor.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that for record reviews #8 and #9 which were discharged records, the discharge summary did not contain a summary of the patient's care and no list of medications as stated in organization policy. This was discussed with hospice leadership.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that for a hospice aide the certification had expired on 7/31/21 however the primary source verification was not run until 9/3/21. This was confirmed by HR and hospice leadership.