Every finding on record at The Community Hospice, Inc.

Based on clinical record review, the hospice failed to ensure in one of three clinical records reviewed (Patient # 1) an individualized and comprehensive Plan of Care (POC) was developed to meet the specific needs of the patient.  Failure to develop an individualized and comprehensive POC has the potential to result in unmet patient needs and negative patient outcomes. --- Finding: Patient #1 (admitted on 03/23/2026 and deceased on 03/26/2026) with diagnoses of Glioblastoma and Crohn’s Disease of the Colon without complication. The clinical record contains the following orders:-"Acetaminophen (TYLENOL) 650mg suppository; insert 650mg in to the rectum every six hours..."-"Bisacodyl (DULCOLAX) 10mg suppository; insert 10mg into the rectum one time each day..."The clinical record also contains a physicians note (dated 03/23/2026) which states the following:"...status post total colectomy for Crohn's disease and high output ostomy..." The clinical record requires clarification regarding the route by which the Acetaminophen and Bisacodyl should be administered.  The finding was confirmed on 05/28/2026 at 8:45 AM with the Director of Patient Services, Executive Director and Patient Care Supervisor; no additional evidence was provided.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 30 (7%) records reviewed it was revealed that the agency did not ensure that the clinical records contained documentation that the spiritual assessments were either completed within the 5-day period or documentation to indicate why this did not occur. Clinical Record 8: The Election of Benefits was dated 6/6/23. The initial assessment was completed by the nurse on 6/6/2023. The clinical record did not contain any documentation related to the chaplain attempting to reach the patient until 7/6/23 when the chaplain documented, "Family declined SC (spiritual care) services." Clinical Record 13: The Election of Benefits was dated 6/6/23. The initial assessment was completed by the nurse on 6/6/23. A communication note, dated 6/15/23, stated, "Family declined chaplain services." The clinical record did not contain any supportive documentation to indicate the chaplain services were offered/declined prior to that date. Interview: During an interview, on 9/21/23, the Director of Clinical Services (DCS) confirmed that these records did not contain any additional documentation that the chaplain had contacted the patient/family within the 5-day requirement nor was there any documentation indicating the chaplain services were initially declined.

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 2 of 9 (22%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that the RN provided specific instructions to the hospice aides, thus leaving the aide to make decisions which were outside the aide scope of practice. Clinical Record 14: The aide care plan, with an effective date of 9/6/23, listed the following relevant tasks: hair care every visit PRN (as needed), mouth care every visit PRN, nail care every visit PRN, shaving every visit PRN. The aide care plan did not provide further directions for the aides to determine when these tasks would be needed in addition to the visit. Clinical Record 29: The aide care plan, with an effective date of 9/17/23, listed the following relevant tasks: bathing- complete bed bath every day and PRN (as needed), hair care- comb/brush, shampoo PRN, oral care every shift and PRN. The aide care plan did not provide further directions for the aides to determine when these tasks would be needed. Interview: In an interview with the Director of Clinical Services, on 9/21/23, it was confirmed that the aide care plans should not have PRN items.