Every finding on record at Western Health Resources

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 and interview. In 2 of 19 (11%) 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 1/Home Visit 1: The patient elected the hospice benefit on 05/28/2025 with a diagnosis of malignant neoplasm, unspecified. The patient resided in a skilled nursing facility (SNF). The patient received daily skilled nursing visits, with the last comprehensive assessment, dated 08/25/2025, completed prior to the home visit on 08/26/2025. During the home visit with the Registered Nurse [Personnel Record 4] on 08/26/2025, the hospice medication profile, printed on 08/25/2025, and the SNF medication list, printed on 08/26/2025, were compared. The hospice medication profile documented: Celebrex 200 mg, take one (1) capsule twice daily (ordered 08/07/2025), vitamin D3, two (2) tablets daily (ordered 04/18/2025); meclizine 25 mg, take one (1) every 6 hours as needed (ordered 07/24/2025); and acetaminophen 325 mg, take two (2) three times daily (ordered 08/07/2025), which were not documented in the SNF medication list. The hospice medication profile documented gabapentin 600 mg, three times daily as needed, ordered on 06/05/2025, and the SNF medication profile documented gabapentin 600 mg, three times daily, ordered on the same date. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 01/05/2025 with a diagnosis of dysphagia following cerebral vascular accident (CVA). The patient resided in a group home (GH). The last comprehensive assessment was completed one (1) week prior to the home visit on 08/26/2025. During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 08/26/2025, the hospice medication profile, printed on 08/25/2025, and the GH medication list, printed on 08/26/2025, were compared. The hospice medication profile documented: olanzapine 5 mg tablet, one (1) tablet daily as needed (ordered 01/05/2025), which was not documented in the GH medication list. The hospice medication profile documented: morphine 100 mg/5 ml, give 0.25 ml every hour as needed, ordered 01/06/2025, and the GH medication list documented: morphine 100 mg/5 ml, give 0.25 ml every four hours as needed, ordered on the same date. During interviews on 08/26/2025, the Director of Nursing, who was present for the home visits, confirmed the findings, stating that "There had been difficulties with the staff at the group home keeping good records, and they would have another care conference."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 10 (50%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the services provided by the Hospice Aide were included in the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 05/28/2025 with a diagnosis of malignant neoplasm, unspecified. The patient resided in a skilled nursing facility (SNF). The plan of care ordered HA services twice weekly. The HA care plan dated 07/09/2025 assigned the HA the relevant tasks: "Apply lotion, apply barrier cream, apply powder, ask if patient has had any falls, assist patient to dress, back rub, changes in patient mental/physical condition, ear care, float heels, hair care, incontinence care, nail care, oral care, perineal care, shampoo, skin care, observe skin integrity, transfer client from chair/bed, transfer client from bed/chair, transfer to wheelchair, turn and position in bed, ADLS maximum assist, assist with transfers, bathing-bed bath, change linens, empty trash, ensure adherence to safe bathing techniques, tidy room, date of last BM (bowel movement), chairbound." All tasks were to be completed on every visit unless specified. The HA visit note dated 07/16/2025 documented: "empty trash, change linens, transfer client from chair/bed, transfer client from bed/chair, transfer to wheelchair-No. Task already completed. Shampoo, apply powder, apply barrier cream, float heels...No. Not required this visit." The HA visit note dated 08/13/2025 documented: "bed bath, empty trash, change linens, tidy room, shampoo, apply powder, apply barrier cream...no. Task already completed. Transfer client from chair/bed, transfer client from bed/chair, turn and position in bed, ear care...No. Not required this visit. Float heels...No. Patient preference." CLINICAL RECORD 2: The patient elected hospice care on 01/05/2025 with a diagnosis of dysphagia following cerebral vascular accident (CVA). The HA care plan dated 01/06/2025, revised 04/01/2025, 06/11/2025, and 07/07/2025 assigned the HA the relevant tasks: "Bathing-bed bath, offer fluids, empty trash, change linens, assist with personal care, shampoo, hair care, oral care, nail care-weekly, dressing, ask if patient has had any falls, pain inquiry, back rub, shave (weekly), non-weight bearing status, incontinence care, observe skin integrity, apply lotion, apply barrier cream. All tasks were to be completed on every visit, unless otherwise specified. The plan of care ordered HA services twice weekly. The HA visit note dated 02/25/2025 documented: "change linens...No. Not required this visit. Non-weight-bearing status...No. Task already completed." The HA visit note dated 05/06/2025 documented: "empty trash, change linens, apply barrier cream task...No. Already completed." The HA visit note dated 05/20/2025 documented: "shower with assist, change linens, dressing, shave, apply barrier cream...No. Task already completed. Shampoo...No. Not required this visit." The HA visit dated 06/10/2025 noted "empty trash, change linens, apply barrier cream...No. Task already completed." CLINICAL RECORD 3: The patient elected hospice care on 07/17/2025 with a diagnosis of Wegener's granulomatosis. The plan of care ordered HA services three times weekly. On 08/08/2025, the frequency of HA visits was increased to five times weekly, and on 08/18/2025, the frequency of HA visits was changed to twice weekly. The HA care plan dated 07/17/2025, revised 07/22/2025, 07/31/2025, 08/18/2025, and 08/19/2025 assigned the HA the relevant tasks: "ask if patient has had any falls this visit, assist patient to dress, assist to bedside commode, dressing, ear care, float heels, hair care, keep non-sterile dressing dry, oral care, nail care, peri care shampoo, skin care empty trash, change linens, transfer from bed/chair, transfer from chair/bed, transfer to commode, transfer to wheelchair, changes in patient mental/physical condition, shower with assist, offer fluids, chairbound." The HA care plan revision dated 08/19/2025, changed the bath from a shower with assistance to a bed bath. All tasks were to be completed on every visit unless otherwise specified. The HA visit note dated 07/21/2025 documented: "empty trash, change linens task...No. Already completed. Transfer from bed/chair, transfer from chair/bed, transfer to commode, transfer to wheelchair, assist patient to dress, assist to bedside commode, shampoo, peri care, oral care, ear care, nail care, dressing, ask patient if any falls this visit, changes in patient mental/physical condition, keep non-sterile dressing dry...No. Not required this visit." The HA visit note dated 08/08/2025 documented: "shower, empty trash, transfer from bed/chair, transfer from chair/bed, transfer to commode, transfer to wheelchair, assist patient to dress, assist to bedside commode, shampoo, haircare, oral care, ear care, nail care, dressing...No." The HA visit dated 08/19/2025 documented: "shower with assist...No. Task already completed. Empty trash, change linens, transfer from bed/chair, transfer from chair/bed, transfer to commode, transfer to wheelchair, oral care...No. Not required this visit." CLINICAL RECORD 4: The patient elected hospice care on 03/24/2025 with a diagnosis of dysphagia following cerebral infarction. The plan of care ordered HA services twice weekly. The HA care plan dated 05/12/2025 assigned the HA the relevant tasks: "Shower with assist, assist with ambulation, ADLs moderate assist, oxygen necessary for safe showering, offer fluids, empty trash, change linens, tidy room, date of last BM, assist patient to dress, assist to toilet, shampoo, hair care, perineal care, oral care, ear care, ask if patient had any falls since last visit, back rub, patient may ambulate with assistance, incontinence care, observe skin integrity, apply lotion, apply powder, apply barrier cream, float heels." All tasks were to be completed on every visit. The HA visit note dated 06/23/2025 documented: "empty trash, change linens, tidy room, apply powder of patient's choice-task already completed; apply barrier cream, float heels...not required this visit." The HA visit note dated 08/04/2025 documented: "change linens-task already completed." CLINICAL RECORD 6: The patient elected hospice on 07/15/2025 with a diagnosis of hypertensive heart disease and chronic kidney disease. The plan of care ordered HA services twice weekly. The HA care plan dated 07/24/2024, updated 08/25/2025 and 09/24/2024, assigned the HA the relevant tasks: "empty trash, transfer client from bed/chair, apply barrier cream, change linens, oral care, nail care." All tasks were to be completed on every visit. The HA visit note dated 01/24/2025 documented: "empty trash, transfer client from bed/chair, apply barrier cream...no... not required this visit, change linens....no...task already completed." The HA visit note dated 03/07/2025 documented: "transfer client from bed/chair.... no task already completed, nail care, apply barrier cream...no-patient preference." The HA visit note dated 06/13/2025 documented: "change linens ....no task already completed, oral care, nail care....no-patient preference, apply barrier cream...no not required this visit. The hospice aide visit dated 07/18/2025 noted the following: "change linens, empty trash, nail care no task already completed, transfer client from bed/chair not required this visit, apply barrier cream no-patient preference." During a joint clinical record review and interview on 08/27/2025, the Administrator and Director of Nursing confirmed that the HA did not follow the care plan.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the volunteer program on 08/27/2025 with the Administrator and Volunteer Coordinator revealed the volunteer percentage for the last twelve (12) months (August 2024 to July 2025) averaged 2.30%. The percentages have improved since the Volunteer Coordinator assumed the role in November 2024; however, they still fall below the required 5%. A review of the volunteer program was conducted with the Administrator and Volunteer Coordinator on 08/27/2025, during which time the volunteer percentage for the last twelve (12) months (August 2024 to July 2025) averaged to 2.30%. The Volunteer Coordinator was given that role in November 2024 and the percentages have been improving since she has been in her position, however still fell below the required 5%. The Volunteer Coordinator reported she has "brought one volunteer back they lost during co-vid and recruited a new one."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary; This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #AP-111 "Discharge and Transfer" (revised 02/15/2024) stated in relevant part: "When a patient revokes services, are discharged, or transferred to another setting, service, practitioner or level of care within or outside the organization, relevant transfer information will be provided to ensure continuity of care, the hospice must forward to the receiving facility and/or the attending physician or other practitioner, a copy of: i. The hospice discharge summary......." In 2 of 2 (100%) clinical records reviewed of patients with a live discharge, the agency did not ensure that the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 15: The patient was discharged for extended prognosis on 11/15/2024. A clinical record review revealed no evidence that a discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 16: The patient revoked the hospice benefit on 04/15/2025. A clinical record review revealed no evidence that a discharge summary was forwarded to the patient's attending physician. During a joint clinical record review and interview on 08/28/2025, the Administrator and Post-Acute Care Executive confirmed the findings. They stated, "The former director just clicked through workflow and didn't follow up with the faxing of the discharge summaries."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 1 of 6 (17%) personnel records reviewed for criminal background checks, the agency did not ensure that a criminal background check was obtained for hospice employees with direct patient contact or access to patient records. Personnel Record 9: The Volunteer was hired on 12/22/2024. A review of the personnel record revealed no documentation of a criminal background check. During an interview on 08/27/2025, the Administrator, Volunteer Coordinator, and Post Acute Executive confirmed the finding and stated that the volunteer had previously been a Volunteer but had "taken a leave of absence for over 2 years during COVID and should have had a new background check when they returned in 2024."

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires but no less frequently than every 15 [-21 days during the PHE]. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed requiring an update of the comprehensive assessment, the agency did not ensure that the assessment update occurred no less frequently than every 15 [-21 days during the PHE]. Clinical Record 4 Start of Care 4/13/22 in a private residence, Benefit Period #3 effective 10/10/22. DX: Multiple Sclerosis. RN comprehensive assessment performed/documented 10/11/22. Subsequent RN comprehensive assessment performed 11/2/22, 22 days later. Coordination notes include documentation of weekly RN missed visit notes stating the reason as "RN had COVID". During a joint clinical record review, the agency Administrator/DPCS and a Clinical Manager confirmed 22 days between comprehensive assessments. The Clinical Manager remarked that the agency has been tracking RN comprehensive assessments with the goal that updates be completed at least weekly, however, during the period between 10/11/22 and 11/2/22 the agency was short-staffed due to staff illnesses. During joint clinical record review, the agency Administrator/DPCS and a clinical manager confirmed a 22-day span between comprehensive assessments. The clinical manager remarked that the agency has been tracking RN comprehensive assessments with the goal that updates be completed at least weekly, however, during the time period between 10/11/22 and 11/2/22 the agency was short-staffed due to staff illnesses.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 1 (100%) personnel record of a hospice aide reviewed, the hospice did not ensure that a competency assessment was completed upon hire. Staff 2: Aide Date of Hire 9/28/22-record did not include an initial orientation competency evaluation. During a joint staff record review with the agency Office Manager and an interview with the agency Administrator/DPCS, it was determined that the agency was unable to locate documented assessment of skills and competencies for the following newly hired staff.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 7 (14%) personnel records reviewed for individuals providing care, the agency did not ensure the assessment of skills and competencies at the time of hire. Staff 1: RN Date of Hire 6/22/22; record did not include an initial orientation competency assessment at the time of hire. During a joint staff record review with the agency Office Manager and an interview with the agency Administrator/DPCS, it was determined that the agency was unable to locate documented assessment of skills and competencies for the following newly hired staff. During joint staff record review with the agency office manager and in interview with the agency Administrator/DPCS, it was determined that the agency was unable to locate documented assessment of skills and competencies for the following newly hired individuals:

It is required that Hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. All hospice care is provided in the facility in accordance with the hospice plan of care. This standard was not met as evidenced by a review of clinical records, observations, and interviews. 1 of 1 (100%) observations during a home visit in a skilled nursing facility, the agency did not ensure that all hospice care and services provided to patients followed the patient's hospice plan of care. Clinical Record 3: Start of Care 7/15/22, Benefit Period #2 effective 10/13/22. Home Visit 3 with Staff 3 in SNF. DX: CVA. For a coccyx wound, Stage 4-signed physician order effective 10/17/22 orders for a prescribed dressing change to be performed daily. There is no documented evidence in the record that wound care is being performed daily according to physician orders. The patient record contains a wound record summary where hospice nurse performance of assessments, measurements, and dressing changes may be documented. Skilled nurse visits dated 10/17/22, 10/26/22, 10/27/22, and 11/2/22 document "Caregiver completed care." During a joint clinical record review, the agency Administrator/DPCS and Clinical Manager also confirmed there was no documented evidence in care coordination notes or skilled nurse visit notes that wound care was being performed daily by facility or hospice staff as ordered by the Hospice MD effective 10/17/22.

It is required that Hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records, observations, and interviews. 1 of 1 (100%) observations during a home visit in a skilled nursing facility, the agency did not ensure that the hospice plan of care identified the care and services needed and which provider is responsible for performing the functions included in the plan of care. Clinical Record 3: Start of Care 7/15/22, Benefit Period #2 effective 10/13/22. Home Visit 3 with Staff 3 in SNF. DX: CVA. The Physician signed a Plan of Care (dated 8/2/22) that had blank areas where the size (Fr) and bulb capacity (CC) The Skilled Nurse documented the insertion of a Foley catheter 20FR/10CC on 10/27/22. There was no plan of care updates or interim orders indicating that the Foley catheter is to be inserted monthly, by whom, and is a Foley 20FR/10CC catheter. For a coccyx wound, Stage 4, the physician order effective 10/17/22 orders a prescribed dressing change to be performed daily. There is no documented evidence in the plan of care as to whom is responsible for the wound care being performed. The patient record contains a wound record summary where hospice nurse performance of assessments, measurements, and dressing changes may be documented. Skilled nurse visits dated 10/17/22, 10/26/22, 10/27/22 and 11/2/22 document "Caregiver completed care." During a joint clinical record review, the agency Administrator/DPCS and Clinical Manager confirmed that the patient's individualized plan of care, plan of care updates, or interim physician orders did not include the size or bulb capacity required by the patient. The agency Administrator/DPCS and Clinical Manager also confirmed there was no documented evidence in care coordination notes or skilled nurse visit notes that wound care was being performed daily by facility or hospice staff as ordered by the Hospice MD effective 10/17/22.