Every finding on record at Transcend Hospice 19 LLC

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered in the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/06/2025 with a diagnosis of Alzheimer’s disease. The hospice aide plan of care dated 10/06/2025 included an order for aide frequency of visits five times per week. Clinical record review revealed the hospice aide documented four aide visits the week of 11/23/2025. Aide visits were documented on 11/24/2025, 11/25/2025, 11/26/2025, and 11/28/2025. The clinical record did not include documentation of the reason for the missed visit. During an interview on 12/23/2025, the Alternate Administrator stated the visit was not conducted on Thanksgiving at the patient's/family's request; however, it was not documented in the clinical record. The Alternate Administrator stated that they will provide education to clinical staff on the importance of documenting missed visits.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription drugs. The medication review process includes the identification of the following the effectiveness of drug therapy, drug side effects; actual or potential drug interactions. 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 observation, review of clinical records and interview. 1 of 3 (33%) home observation visits revealed the hospice did not ensure that medication profiles were updated and drug regime revies occurred when new medications were ordered for patients. Clinical Record #83810 was reviewed and documents the patient elected hospice services on 5/13/22 with a primary diagnosis of CVA. During a home observation visit with a skilled nurse the patient’s caregiver stated he placed a Lidocaine patch on the patient’s ankle for pain relief. The Lidocaine patch was evident on the patient’s ankle during this home visit. During medication review at the patient bedside, it was evident the patient was taking Tamsulosin 0.4mg orally per day. The caregiver confirmed this. Review of the clinical record revealed the drug profile did not contain the current prescription of Lidocaine and Tamsulosin. During the home visit the skilled nurse stated the medications should have been on the drug profile. There was no documented evidence that the a medication review was completed. During an interview with the administrator on 6/3/22, the administrator confirmed that the documented comprehensive assessment did not include a drug profile that contains the patient's current prescription drugs.

It is required that the hospice designates an Interdisciplinary Group or groups who, inonsultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. 3 of 6 (50%) clinical records reviewed revealed the hospice did not ensure a written plan of care for each patient that specified the hospice care and services necessary to meet the specific needs of the patient as identified in the comprehensive assessment. Clinical Record #83810 was reviewed and documents the patient elected hospice services on 5/13/22 with a primary diagnosis of CVA. The initial/comprehensive assessment documented on 5/13/22 states the patient had a boot on right foot for support, +1 pedal edema on both left and right lower extremities, dysphagia with risk for aspiration, a high risk for skin breakdown, and falls, and has insulin dependent diabetes. The plan of care dated 5/13/22 does not specify needs related to right foot support, edema, dysphagia, skin breakdown, falls and diabetes problems as identified in the patient’s initial/comprehensive assessment. Clinical Record #31631 was reviewed and documents the patient elected hospice services on 2/17/22 with a primary diagnosis of CVA. The initial/comprehensive assessment documented on 2/17/22 states the patient has insulin dependent diabetes. The plan of care dated 2/17/22 does not specify needs related to insulin dependent diabetes as identified in the patient’s initial/comprehensive assessment. Clinical Record #47234 was reviewed and documents the patient elected hospice services on 2/2/22 with a primary diagnosis of Alzheimer’s Disease. The initial/comprehensive assessment documented on 2/22/22 states the patient has a sensory problem with impaired vision, impaired speech and neurological problems of dizziness, mumbled speech, forgetfulness, and has weak/unequal handgrips. The plan of care dated 2/24/22 does not specify needs related to the sensory and neurological problems as identified in the patient’s initial/comprehensive assessment During an interview with the administrator on 6/3/22, the administrator confirmed the plan of care for each patient did not specify the hospice care and services necessary to meet the specific needs of the patient as identified in the comprehensive assessment.

It is required that each patient’s individualized written plan of care reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as by review of clinical records and interview. 2 of 6 (33%) clinical records reviewed revealed the hospice did not ensure the plan of care (POC) included social workand chaplain services necessary for the management of the terminal illness and related condition and interventions to assist with the end of life care. Clinical Record #31631 was reviewed and documents the patient elected hospice services on 2/17/22 with a primary diagnosis of CVA. The medical record included documented visits of the social worker and chaplain. The plan of care dated 2/17/22 did not include orders for social worker or chaplain visits. Clinical Record #83810 was reviewed and documents the patient elected hospice services on 5/13/22 with a primary diagnosis of CVA. The medical record included documented visits of the social worker and chaplain. The plan of care dated 5/13/22 did not identify any problems, interventions or goals related to social work and chaplain visits. During an interview with the administrator on 6/3/22, the administrator confirmed the plan of care did not include a detailed statement of the scope and frequency of services by the social worker and chaplain necessary to meet specific patient and family needs.