Every finding on record at Superior Hospice V, LLC

Based on interview and record review, the hospice failed to maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for 1 of 1 (January 2024 – August 2025) time-period reviewed. This failure could result in the hospice not having all the information needed to implement the emergency preparedness plan effectively and could place patients at risk for harm. --- The findings included: During an interview conducted on 08/20/25 at 1:52 p.m., the Alternate Administrator said the hospice was not able to provide any documentation of the hospice’s emergency preparedness plan except for the policy as the documentation was located at the hospice’s former location which the hospice was unable to access. During an interview conducted on 08/20/25 at 4:12 p.m., the HR Manager said that the Administrator was out of the office on leave and unavailable for interview. During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said he was the hospice’s alternate disaster coordinator.  The Alternate Administrator said the hospice did not have documentation of the hospice’s hazard vulnerability risk assessment and said he was sure that it had been completed but he was not sure when it was last updated and said it was probably prior to 2024.  When asked if there could be a potential adverse outcome related to the hospice’s failure to develop and maintain an emergency preparedness plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, the Alternate Administrator said he thought that the hospice had completed a hazard vulnerability risk assessment as part of the emergency preparedness plan but the hospice did not currently have access to it as it was inside the hospice’s former location.  The Alternate Administrator said the failure to maintain the emergency plan based on the risk assessment could result in the hospice not having all the information needed to implement the plan and not being prepared could place patients at risk for harm.  Record review of a hospice policy titled, “Emergency Preparedness and Response Plan,” dated 09/01/24, indicated, “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The plan will … Be based on and include a documented facility-based and community-based risk assessment, utilizing an all-hazards approach … Establish a strategy/plan of action addressing emergency events identified by the risk assessment, in order to meet the health, safety, and security needs of the Hospice, the staff, the patient population, and the community prior to, during, and after an emergency or disaster …”

Based on interview and record review, the hospice failed to conduct exercises to test the emergency plan at least annually and to maintain documentation of all drills, tabletop exercises, and emergency events for 1 of 1 (2024) year reviewed.   This failure could result in the hospice failing to be prepared and able to respond appropriately in the event of an emergency or disaster and could result in harm to patients. --- The findings included: During an interview conducted on 08/20/25 at 1:52 p.m., the Alternate Administrator said the hospice was not able to provide any documentation of the hospice’s emergency preparedness plan except for the policy as the documentation was located at the hospice’s former location which the hospice was unable to access.  The Alternate Administrator said the hospice had not conducted a drill/evaluation of the plan or implementation of the plan for 2024 since he started with the hospice in November of 2024.  The Alternate Administrator said if the plan had been evaluated or implemented for the year of 2024 it occurred before he started with the hospice and the hospice was unable to provide documentation of a drill/evaluation/implementation of the plan for the year of 2024 and said if it had been completed the documentation would be located at the hospice’s former location.   During an interview conducted on 08/20/25 at 4:12 p.m., the HR Manager said that the Administrator was out of the office on leave and unavailable for interview.   During an interview conducted on 08/21/25 at 1:27 p.m., with the Alternate Supervising Nurse, when asked if she had participated in any implementations of the hospice’s emergency preparedness plan or any evaluations/drills/tests of the plan, the Alternate Supervising Nurse said, “No Ma’am.”   During an interview conducted on 08/21/25 at 10:53 a.m., the Supervising Nurse said she did not participate in the staff call downs or calling patients as part of the emergency preparedness plan for the hospice and said the Administrator would be responsible for handling that.  The Supervising Nurse said she believed the hospice implemented the emergency preparedness plan for an ice storm during the year of 2024, but she was not the supervising nurse for the hospice at that time.  The Supervising Nurse said she thought the hospice had only implemented the plan once for the year of 2024.  The Supervising Nurse said she did not know if the hospice had completed an evaluation of the emergency preparedness plan for the year of 2024 and said the Alternate Administrator would be the person who could answer that question and that she could not recall.    During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said he was the hospice’s alternate disaster coordinator.  The Alternate Administrator said the hospice had not completed a full scale, community or hospice-based exercise, or tabletop exercise during the year of 2024 to evaluate and test the hospice’s emergency preparedness plan.  The Alternate Administrator said the hospice had a binder that had all documentation of the times the emergency preparedness plan was implemented during the year of 2024, but the hospice was not able to provide this because it was located at the hospice’s former location which the hospice could not currently access.  The Alternate Administrator said the hospice had last completed an evaluation of the emergency preparedness plan in December of 2024 during a quarterly QAPI meeting.  The Alternate Administrator said he did not have any documentation of an evaluation of the plan unless something was documented in the QAPI meeting note.  The Alternate Administrator said he would attempt to provide documentation of the evaluation.  When asked if there could be an adverse outcome to patients related to the hospice’s failure to evaluate the emergency plan at least annually, the Alternate Administrator said the failure could place patients at risk for not getting care they need and could place staff at risk of harm as well. During an interview conducted on 08/22/25 at 2:46 p.m., during the exit conference, the Alternate Administrator said he would provide any additional information/documentation regarding the emergency preparedness plan exercises/evaluation for the year of 2024 to the surveyor within two business days of the exit conference if the hospice was able to access the documentation.   As of 08/29/25 at 11:06 a.m., more than two business days after the exit conference, no additional information or documentation had been received from the hospice.  Record review of a hospice policy titled, “Emergency Preparedness and Response Plan,” dated 09/01/24, indicated, “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. … The Hospice will conduct exercises to test the emergency plan at least annually. The Hospice will (1) Participate in a full-scale exercise that is community-based every two years, or when a community-based exercise is not accessible, an individual facility-based functional exercise will be conducted every two years. The Hospice will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e., date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise). If the Hospice experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospice is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise for one year following the onset of the emergency event … Conduct an additional exercise every two years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: (a) A second full-scale exercise that is community-based or individual facility-based functional exercise, or (b) A mock disaster drill, or (c) A tabletop exercise or workshop that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) The Hospice will document the lessons learned following their tabletop and full-scale exercises and real-life emergencies and demonstrate that they have incorporated any necessary improvements in their emergency preparedness program. (a) The Hospice may complete an after-action review process to help develop an actionable after-action report (AAR). (i) The after-action review process will include: a A roundtable discussion that includes leadership, department leads and critical staff who can identify and document lessons learned and necessary improvements in an official AAR. (ii) The AAR, at a minimum, will include the following factors: a What was supposed to happen; b What occurred; c What went well; d What the Hospice can do differently or improve upon; and e A plan with timelines for incorporating necessary improvement. (b) The Hospice is responsible for documenting their compliance with and ensuring the after-action review and after-action report information is available for review at any time for a period of no less than three years.”

Based on interview and record review, the hospice failed to provide the patient with verbal and written notice of the patient’s rights and responsibilities in advance of furnishing care for 1 of 1 (Patient #1) patient who received services from the hospice in the last three years.  This failure could have resulted in the patient being unaware of her rights and therefore being unable to exercise her rights effectively and could result in harm to the patient and/or dissatisfaction with care. --- The findings included:  Record review of the clinical record for Patient #1, for the time-period of 12/03/21 – 06/11/25, indicated the patient had a start of care date of 12/03/21 and indicated the patient’s primary caregiver/emergency contact was Family Member #1.  Record review of the clinical record for Patient #1 did not include documentation of any other family members or patient contacts for Patient #1.  Record review of the clinical record indicated the patient died on 06/11/25. Record review of the clinical record for Patient #1, for the time-period of 12/03/21 – 06/11/25, did not include documentation to indicate the hospice provided Patient #1 with verbal and written notice of the patient’s rights and responsibilities in advance of furnishing care. The surveyor attempted to contact Patient #1’s Family Member #1 on 08/20/25 at 12:37 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a second attempt to contact Patient #1’s Family Member #1 on 08/20/25 at 3:04 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a third attempt to contact Patient #1’s Family Member #1 on 08/21/25 at 9:16 a.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor attempted to contact Patient #1’s Family Member #1 via text message on 08/21/25 at 9:38 a.m.  The surveyor’s contact information was provided and return contact was requested.  There was no response received from Patient #1’s Family Member #1 prior to the end of the survey.   During an interview conducted on 08/21/25 at 9:42 a.m., the Alternate Administrator said he had reviewed Patient #1’s record and he did not see the documentation of receipt of the required information, including the written notice regarding patient rights, for Patient #1 for the admission which began on 12/03/21.   During an interview conducted on 08/21/25 at 10:42 a.m., the Alternate Administrator said the patient was on services with another hospice under the same corporate leadership as the hospice being surveyed but with a different license number until 12/03/21 when she was discharged from the other hospice and admitted to the hospice being surveyed.   During an interview conducted on 08/21/25 at 10:53 a.m., the Supervising Nurse said at the start of care the hospice would provide the patient with information regarding patient rights.  The Supervising Nurse said the hospice had the patient/family sign the consent form which indicated all the required information had been provided and reviewed with the patient/family.  The Supervising Nurse said the only reason that she could see for the hospice failing to provide and review this information with Patient #1 at her start of care would be that she had changed from one hospice under the corporate leadership to another hospice under the same corporate leadership (the hospice being surveyed) with a different license number and the hospice did not realize they needed to provide the information again when the patient was admitted to a hospice with a different license number.  The surveyor attempted to contact Former RN U, a former employee who completed the admission visit with Patient #1 on 12/03/21, on 08/22/25 at 8:56 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.  The surveyor attempted to contact Former RN U via a text message on 08/22/25 at 8:59 a.m.  The surveyor’s contact information and reason for the contact were provided.   The surveyor made a second attempt to contact Former RN U via phone on 08/22/25 at 9:36 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.   Record review of the surveyor’s text messages on 08/22/25 at 9:37 a.m. did not indicate the previous message to Former RN U was delivered or read. The surveyor made a third attempt to contact Former RN U on 08/22/25 at 10:50 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.   Record review of the surveyor’s text messages on 08/22/25 at 10:51 a.m. did not indicate the previous message to Former RN U was delivered or read. There was no response received from Former RN U prior to the end of the survey. During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said the hospice provided written information regarding patient rights to patients at the start of care.  The Alternate Administrator said this information was not provided to Patient #1 at her start of care because the patient was first admitted to another hospice with a different license number under the same corporate structure and was then discharged from that hospice and admitted to the hospice being surveyed.  The Alternate Administrator said it did not look like the information was provided to the patient at the admission to the hospice being surveyed.  When asked if there was any adverse outcome to Patient #1 related to the hospice’s failure to provide the patient with the written notice of the patient’s rights and responsibilities, the Alternate Administrator said, no, because the patient had been on services with another hospice under the same corporate structure and had received the information at her start of care with the other hospice in March of 2021.  The Alternate Administrator said there could have been an adverse outcome to the patient if not for that as that as the patient would not know what her rights were.  The Alternate Administrator said the patient could be placed at risk for harm if they did not know what to do if something negative occurred.   Record review of a hospice policy titled, “Medical Record Content,” dated 09/01/24, indicated, “The patient or the representative(s) will acknowledge/sign receipt of the following … Notice of the Patient’s Rights and Responsibilities …”

Based on interview and record review, the hospice failed to provide written information to a patient concerning the hospice’s written policies on advance directives (a legal document that details what medical treatment an individual consents to in the event the individual becomes incapacitated and unable to speak for themselves) for 1 of 1 (Patient #1) patient who received services from the hospice in the last three years. This failure could have resulted in the patient not being aware of her rights and options related to advance directives and could result in harm if the patient’s wishes were not honored. --- The findings included:   Record review of the clinical record for Patient #1, for the time-period of 12/03/21 – 06/11/25, indicated the patient had a start of care date of 12/03/21 and indicated the patient’s primary caregiver/emergency contact was Family Member #1.  Record review of the clinical record for Patient #1 did not include documentation of any other family members or patient contacts for Patient #1.  Record review of the clinical record indicated the patient died on 06/11/25. Record review of the clinical record for Patient #1, for the time-period of 12/03/21 – 06/11/25, did not include documentation to indicate the hospice provided Patient #1 with written notice of the hospice’s written policies regarding implementing advance directives. The surveyor attempted to contact Patient #1’s Family Member #1 on 08/20/25 at 12:37 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a second attempt to contact Patient #1’s Family Member #1 on 08/20/25 at 3:04 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a third attempt to contact Patient #1’s Family Member #1 on 08/21/25 at 9:16 a.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor attempted to contact Patient #1’s Family Member #1 via text message on 08/21/25 at 9:38 a.m.  The surveyor’s contact information was provided and return contact was requested.  There was no response received from Patient #1’s Family Member #1 prior to the end of the survey.   During an interview conducted on 08/21/25 at 9:42 a.m., the Alternate Administrator said he had reviewed Patient #1’s record and he did not see the documentation of receipt of the required information, including the written notice of the hospice’s written policy regarding implementing advance directives, for Patient #1 for the admission which began on 12/03/21.   During an interview conducted on 08/21/25 at 10:42 a.m., the Alternate Administrator said the patient was on services with another hospice under the same corporate leadership as the hospice being surveyed but with a different license number until 12/03/21 when she was discharged from the other hospice and admitted to the hospice being surveyed.   During an interview conducted on 08/21/25 at 10:53 a.m., the Supervising Nurse said at the start of care the hospice would provide the patient with information regarding advance directives.  The Supervising Nurse said the hospice had the patient/family sign the consent form which indicated all the required information had been provided and reviewed with the patient/family.  The Supervising Nurse said the only reason that she could see for the hospice failing to provide and review this information with Patient #1 at her start of care would be that she had changed from one hospice under the corporate leadership to another hospice under the same corporate leadership (the hospice being surveyed) with a different license number and the hospice did not realize they needed to provide the information again when the patient was admitted to a hospice with a different license number.   The surveyor attempted to contact Former RN U, a former employee who completed the admission visit with Patient #1 on 12/03/21, on 08/22/25 at 8:56 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.  The surveyor attempted to contact Former RN U via a text message on 08/22/25 at 8:59 a.m.  The surveyor’s contact information and reason for the contact were provided.   The surveyor made a second attempt to contact Former RN U via phone on 08/22/25 at 9:36 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.   Record review of the surveyor’s text messages on 08/22/25 at 9:37 a.m. did not indicate the previous message to Former RN U was delivered or read. The surveyor made a third attempt to contact Former RN U on 08/22/25 at 10:50 a.m.  A recorded message indicated the call could not be completed at the time of the attempt.  There was no answer and no way to leave a message.   Record review of the surveyor’s text messages on 08/22/25 at 10:51 a.m. did not indicate the previous message to Former RN U was delivered or read. There was no response received from Former RN U prior to the end of the survey. During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said the hospice provided written information of the hospice’s written policy regarding implementing advance directives to patients at the start of care.  The Alternate Administrator said this information was not provided to Patient #1 at her start of care because the patient was first admitted to another hospice with a different license number under the same corporate structure and was then discharged from that hospice and admitted to the hospice being surveyed.  The Alternate Administrator said it did not look like the information was provided to the patient at the admission to the hospice being surveyed.  When asked if there was any adverse outcome to Patient #1 related to the hospice’s failure to provide the patient with written notice of the hospice’s written policy regarding implementing advance directives, the Alternate Administrator said, no, because the patient had been on services with another hospice under the same corporate structure and had received the information at her start of care with the other hospice in March of 2021.  The Alternate Administrator said there could have been an adverse outcome to the patient if not for that as that as the patient would not know what her rights were.   Record review of a hospice policy titled, “Medical Record Content,” dated 09/01/24, indicated, “The patient or the representative(s) will acknowledge/sign receipt of the following … Advance care directive information …”

Based on interview and record review, the hospice failed to develop, implement, and evaluate a performance improvement project for 1 of 1 (2024) year reviewed. This failure could result in the hospice failing to identify and address areas of concern with care and services to ensure improved quality of care and patient safety and could result in harm to patients and a failure to provide optimal patient care. --- The findings included:  During an interview conducted on 08/20/25 at 1:52 p.m., the Alternate Administrator said the hospice previously used a consultant company to complete record reviews for the QAPI program (during the year of 2024) and the hospice’s QAPI committee would meet with the consultant company to discuss the findings quarterly.  The Alternate Administrator said the last QAPI meeting was held in March of 2025. The Alternate Administrator said the hospice had no PIPs in place or implemented for the year of 2024 and said the consulting company would always provide information about opportunities to improve usually regarding documentation or new regulations they needed to implement but the hospice did not implement any PIPs to address those areas.  The Alternate Administrator said the hospice could not provide any documentation of QAPI activities for the year of 2024 as it was located at the hospice’s former location which the hospice was unable to access at the time of the survey. During an interview conducted on 08/21/25 at 1:27 p.m., the Alternate Supervising Nurse said she was not aware of any hospice PIPs which had been implemented for the year of 2024.   During an interview conducted on 08/22/25 at 9:05 a.m., the QAPI coordinator said that she had been in the position of QAPI Coordinator for the hospice for two years, as of March.  The QAPI Coordinator said she would review the hospice’s information and if she noted any concerns or issues, she would report those to her supervisor, the Supervising Nurse.  The QAPI Coordinator said she would not implement any PIPs or action plans to address the issues herself and said the Supervising Nurse would be responsible for that.  The QAPI Coordinator said she would make recommendations, but it was the Supervising Nurse’s responsibility to implement any PIPs to address any issues.  The QAPI Coordinator said she did not recall any specific PIPs that were implemented for the hospice for the year of 2024. During an interview conducted on 08/21/25 at 10:53 a.m., the Supervising Nurse said she assisted with the hospice’s QAPI program and said she would assist with audits and run QAPI reports.  The Supervising Nurse said if the hospice identified any issues from the audits or reports or noted any processes that needed to be corrected, she would help to implement the changes.  When asked if the hospice had implemented any PIPs for the year of 2024, the Supervising Nurse said she thought they updated the QAPI manual with PIPs when the consultant company came in.  The Supervising Nurse said the hospice was unable to provide the QAPI manual during the survey because it was located at the hospice's former location which the hospice was unable to access.  When asked what PIPs had been implemented for the hospice, the Supervising Nurse said she did not recall what PIPs might be in place.  During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said the hospice did not have any PIPs for the year of 2024.  The Alternate Administrator said the QAPI Coordinator reviewed the hospice’s records and reports and made recommendations.  The Alternate Administrator said the Supervising Nurse would then be responsible for implementing PIPs and completing training with staff.  The Alternate Administrator said there could be an adverse outcome to a patient if the hospice was not focusing on required elements and said there was a potential for a patient or patients to not be served in the appropriate way.  When asked if there had been any adverse outcomes to patients related to the hospice’s failure to develop, implement and evaluate performance improvement projects for the year of 2024, the Alternate Administrator said, no, but there could be a potential adverse outcome of the hospice failing to provide optimal care for patients.   Record review of a hospice policy titled, “Quality Assessment/Performance Improvement,” dated 10/02/18, indicated, “Hospice will … Complete a QAPI Performance Improvement Project … Hospice will document what the PIPs are, the reasons for conducting these projects, and the measurable progress achieved.”

Based on interview and record review, the hospice RN failed to make an on-site visit to a patient's home to supervise the hospice aide services at least every 14 days to assess the quality of care and services provided by the hospice aide for 1 of 1 (Patient #1) patient who received services from the hospice in the last three years. This failure could result in the hospice failing to identify and address issues with the care provided by the hospice aides in a timely manner which could result in harm to patients. --- The findings included: Record review of the clinical record for Patient #1, for the certification period of 12/03/21 – 06/11/25, indicated the patient had a start of care date of 12/03/21 and indicated the patient’s primary caregiver/emergency contact was Family Member #1.  Record review of the clinical record for Patient #1 did not include documentation of any other family members or patient contacts for Patient #1.  Record review of the clinical record indicated the patient died on 06/11/25. Record review of the clinical record for Patient #1 included a Hospice Recertification Plan of Care Update physician’s order, for the certification period of 03/17/25 – 05/15/25, which indicated the patient was to receive skilled nurse and hospice aide services once a week. Record review of the clinical record for Patient #1 included a Hospice Recertification Plan of Care Update physician’s order, for the certification period of 05/16/25 – 07/14/25, which indicated the patient was to receive skilled nurse and hospice aide services once a week. Record review of the clinical record for Patient #1 indicated the patient received hospice aide visits on 04/29/25, 05/06/25, 05/13/25, 05/20/25, and 06/06/25. Record review of the clinical record for Patient #1 indicated RN M conducted skilled nurse visits with Patient #1 on 05/06/25, 05/15/25, 05/20/25, 05/27/25, and 06/02/25.  Record review of the clinical record for Patient #1 did not include RN visits from any RN other than RN M during the time-period of 04/23/25 – 06/11/25. Record review of the clinical record for Patient #1 did not include documentation of hospice aide supervisory visits completed during the time-period of 04/23/25 – 06/11/25 (a time-period of 49 days).   The surveyor attempted to contact Patient #1’s Family Member #1 on 08/20/25 at 12:37 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a second attempt to contact Patient #1’s Family Member #1 on 08/20/25 at 3:04 p.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor made a third attempt to contact Patient #1’s Family Member #1 on 08/21/25 at 9:16 a.m.  There was no answer.  A voicemail message was left requesting a return phone call.   The surveyor attempted to contact Patient #1’s Family Member #1 via text message on 08/21/25 at 9:38 a.m.  The surveyor’s contact information was provided and return contact was requested.  There was no response received from Patient #1’s Family Member #1 prior to the end of the survey. During an interview conducted on 08/20/25 at 1:05 p.m., RN M said she did provide RN visits to Patient #1 during the time-period of 04/23/25 to 06/11/25.  When asked if she had completed hospice aide supervisory visits every 14 days during that time-period, RN M said, “I don’t exactly remember but I want to say yes.”  RN M said if she had completed the hospice aide supervisory visit she would document it on the skilled nurse’s note.  RN M said if the hospice aide supervisory visit was not documented on the skilled nurse’s note there was no other place that she would have documented it.   During an interview conducted on 08/20/25 at 4:12 p.m., the HR Manager said that the Administrator was out of the office on leave and unavailable for interview.   During an interview conducted on 08/21/25 at 1:27 p.m., the Alternate Supervising Nurse said the Supervising Nurse and the scheduler were responsible for scheduling the hospice aide supervisory visits and the RN seeing the patient was responsible for completing the hospice aide supervisory visit.  The Alternate Supervising Nurse said the hospice aide supervisory visits should be completed every 14-15 days. The Alternate Supervising Nurse said the hospice aide supervisory visit was documented in the skilled nurse’s note and said they use the “RN 10” note which is a skilled nurse visit and supervisory visit note to document the hospice aide supervisory visits.  The Alternate Supervisory Nurse said she did not know why the hospice aide supervisory visits were not completed for Patient #1.  The Alternate Supervising Nurse said it was not reported to her that there was an issue with Patient #1’s hospice aide supervisory visits.   During an interview conducted on 08/21/25 at 10:53 a.m., the Supervising Nurse said the Administrator worked with the scheduler to ensure the hospice aide supervisory visits were completed and the field RNs conducted the hospice aide supervisory visits.  The Supervising Nurse said the hospice aide supervisory visits should be completed every 14 days.  The Supervising Nurse said the hospice aide supervisory visits were documented on the skilled nurse’s notes, and said they use the “RN 10” note for a nurse visit and a supervisory visit for the visits where a supervisory visit was conducted as part of the nurse visit.  When asked why the hospice aide supervisory visits were not completed for Patient #1, the Supervising Nurse said the only thing she could think of was that sometimes the electronic medical records system would not allow the hospice to schedule certain visits until the plan of care was accepted in the system.  The Supervising Nurse said in those cases the hospice aide supervisory visits had to be documented on a paper note.   The Supervising Nurse said if the hospice aide supervisory visits were documented on paper notes they would be uploaded into the attachments section in electronic medical records system and the notes should be uploaded to the patient’s record within 48-72 hours of completion of the visit.  The Supervising Nurse said she would not know if the hospice aide supervisory visits for Patient #1 were conducted every 14 days.   During an interview conducted on 08/22/25 at 11:17 a.m., the Alternate Administrator said the RN was responsible for completing the hospice aide supervisory visits and said the hospice aide supervisory visits should be completed every two weeks.  The Alternate Administrator said the hospice aide supervisory visits were documented in the skilled nurse’s note which had an add on for the supervisory visit.  The Alternate Administrator said he did not find the hospice aide supervisory visits for Patient #1 (either on paper or in the electronic medical records system) and said he did not know why the hospice aide supervisory visits were not present.  The Alternate Administrator said there could be a potential adverse outcome related to the hospice’s failure to ensure the RN conducted an on-site visit to the patient's home at least every 14 days, in that the hospice aides might be under-caring for the patient or doing more than they should.  The Alternate Administrator said the hospice could fail to identify issues with the care provided by the hospice aides in a timely manner.   Record review of a hospice policy titled, “Employee Supervision,” dated 12/06/24, indicated, “A registered nurse (RN) must make 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 to ensure that services … meet the patient’s needs.”

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 effectiveness of drug therapy. 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 clinical record review and interview. 6 of 12 (50%) clinical records reviewed revealed the agency did not ensure the plan of care included a complete medication profile or an update on the comprehensive assessment and/or when a new medication is added or changes are made to existing medication. Record # 90269 was reviewed and identified the patient elected hospice care on 11/27/2021. The admission narrative note dated 11/27/2021 included "oxygen concentrator ordered prior to admission for respiratory distress". Medication profile effective 6/29/2022 did not include the oxygen as a current medication.There was no documented evidence that a medication review was completed. Record # 30668 was reviewed and identified the patient elected hospce care on 12/2/2021. The admission narrative note dated 12/2/2021, included "oxygen @ 2 liters via nasal cannula for shortness of breath is noted". Medication profile effective 6/29/2022 did not include the oxygen as a current medication. There was no documented evidence that a medication review was completed. Record # 42166 was reviewed and identified the patient elected hospce care on 5/5/2022. The admission narrative note dated 5/5/2022, included" an oxygen concentrator was ordered for respiratory distress". Medication profile effective 6/29/2022 did not include the oxygen as a current medication. There was no documented evidence that a medication review was completed. Record # 88989 was reviewed and identified the patient elected hospce care on 3/11/2022. The narrative note by nurse on 4/24/2022, documented the patient being on "oxygen 3 liters via nasal cannula for decreased oxygen saturations". Medication profile effective 6/29/2022 did not include the oxygen as a current medication. There was no documented evidence that a medication review was completed. Record # 42418 was reviewed and identified the patient elected hospce care on 4/21/2022. The admission narrative note dated 4/21/2022, included "oxygen at four (4) liters per nasal cannula was ordered for respiratory distress". The medication profile effective 6/29/2022 did not include the oxygen as a current medication. There was no documented evidence that a medication review was completed. Record #61345 was reviewed and identified the patient elected hospce care on 12/31/2021. The admission narrative note dated 12/31/2021,included "oxygen concentrator was ordered for decreased oxygen saturations". On 12/31/2021, nursing noted Ambien was refilled by Medical Director for insomnia. On 2/28/2022, nursing note, antibiotic Levaquin was ordered by the Medical Director for respiratory infection. Medication profile effective 6/29/2022 did not include the oxygen, Ambien or Levaquin as current or discontinued medications. There was no documented evidence that a medication review was completed. In an interview (6/30/2022) with the Alternate Administrator (11340) confirmed that the documented comprehensive assessments did not include a drug profile that contained the patient's current prescription drugs.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualizedcare 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 record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met by clinical record review and interview. 1 of 12 (10%) records reveiwed revealed that the hospice did not document all problems identified in the initial comprehensive assessment. Record #61345 was reviewed and identified the Plan of Care dated 12/3/2021 documented primary diagnosis of CVA, with multiple falls in the home. The initial care plan (dated 12/3/2021) for High Risk for Falls/Safety was noted. Review of all updated plans of care on 6/30/2022 did not include the problem, intervention, or goals for a patient at a high risk for falls or safety in the home setting. in an interview with the Alternate Administrator on 06/30/2022 stated "that a high risk for falls/safety should have been care planned in IDG".