Every finding on record at Transitions Lifecare, LLC

Based on record review and interview, the hospice failed to ensure the community-based risk assessment (All Hazards Risk Assessment) was reviewed and updated every two years for 52 patients and all employees. --- Findings:A review of administrative records showed no community-based risk assessment updated within the past two years of 2023, 2024 and January 01, 2025, to June 11, 2025, which addressed the agency and its patient population.On 06/11/25 at 1:49 pm, Staff A stated the community-based risk assessment had not been updated within the past two years.

Based on record review and interview, the hospice failed to provide documentation of the analyzation of quality indicators and performance improvement projects potentially affecting 52 current patients. --- Findings:A review of administrative records showed no documented analysis of quality indicators or performance improvement projects for 2024 and from 01/01/25 to 06/06/25.On 06/11/25 at 2:45 pm, Staff A stated the QAPI for 2024, from 01/01/25 to 06/11/25 had no documented analysis of quality indicators or performance improvement projects.

Based on record review and interview, the hospice failed to ensure a timely review of medications for two (Patients #5 and 10) of 11 patients. Findings: Patient #5 A review of clinical records showed a skilled nurse assessment dated 03/04/22 which documented the use of oxygen. Documentation showed no addition of oxygen to the medication profile. Patient #10 A review of clinical records showed a skilled nurse assessment dated 06/04/22 which documented the use of oxygen. Documentation showed no addition of oxygen to the medication profile. On 07/26/22 at 1:50 pm, Staff C stated oxygen was not added to the medication profile for Patient's #5 and 10.

Based on record review and interview, the hospice failed to ensure the comprehensive assessment included data elements (with the exception of pain) that allowed for measurement of outcomes for two (Patients #2 and 10) of 11 patients. Findings: Patient #2 A review of the Initial Assessment dated 04/22/22 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #10 A review of the Initial Assessment dated 06/04/22 showed no data elements (with the exception of pain) included in the comprehensive assessment. On 07/26/22 at 1:55 pm, Staff C stated pain was the only data element which was documented on the initial comprehensive assessments for Patients #2 and 10.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for five (Patients #1, 2, 3, 4 and 6) of 11 patients reviewed. Findings: Patient #1 A review of the plan of care dated 04/29/22 to 06/27/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 04/22/22 to 07/20/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 04/24/22 to 06/22/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 05/09/22 to 07/07/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A review of the plan of care dated 05/13/22 to 08/10/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 07/26/22 at 2:00 am, Staff C stated the plans of care for Patients #1, 2, 3, 4 and 6 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to; 1. ensure skilled nursing services met the needs of the patient for the management of pain for one (Patient #8) of 11 patients and 2. ensure skilled nursing services met the needs of the patient for the management of constipation for one (Patient #4) of 11 patients. Findings: Patient #8 1. A plan of care dated 05/07/22 to 08/03/22 documented a skilled nurse frequency of two visits per week and showed the patient's acceptable pain level of 4 on the classic 1-10 pain scale. A review of the electronic medical record showed the following: A skilled nurse assessment dated 05/14/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 05/17/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 05/20/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 05/24/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 05/28/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 05/29/22 documented a patient pain level of 5 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/03/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/10/22 documented a patient pain level of 5 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/15/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/16/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/21/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 06/24/22 documented a patient pain level of 5 with no physician notification of pain level outside acceptable pain level. A skilled nurse assessment dated 07/01/22 documented a patient pain level of 6 with no physician notification of pain level outside acceptable pain level. 2. A skilled nurse assessment dated 06/21/22 documented the patient reported no bowel movement in one week. The nurse documented interventions of instructing the patient to increase laxative medications. A review of the electronic medical record showed no follow up regarding the reported no bowel movement in one week until 06/24/22 (three days later). A skilled nurse assessment dated 06/24/22 documented the patient had no bowel movement after the increase in the laxative medications. On 07/26/22 at 2:30 pm, Staff C stated: 1. the physician should have been notified of the pain levels outside the Patient #8 acceptable pain levels and 2. the skilled nurse should have followed up with Patient #8 in regards to no bowel movement reported in over one week on 06/21/22.