Elite Hospice

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to complete a Spiritual Needs Assessment as part of the Initial Comprehensive Assessment within five (5) days following the election of hospice services for two (#6 and #9) of nineteen (#1-#19) clinical records reviewed. This failed practice had the potential to affect all hospice admissions, as it may delay the identification of patient and family spiritual and psychosocial needs. Such delays could place patients and/or families at increased risk for inadequate coping with end-of-life issues, lack of appropriate spiritual resources, and insufficient emotional or familial support. A review of clinical record #6, with a start of care (SOC) date of 04/23/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of the document titled “Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report,” dated 04/28/2026, showed the chaplain documented, “SPIRITUAL CAREGIVER WILL CALL TO SET UP VISIT WITH PATIENT/CAREGIVER.” Further review revealed the chaplain completed the initial spiritual assessment on 04/29/26, one day beyond the required timeframe.A review of clinical record #9, with a SOC date of 04/30/26, revealed a patient diagnosed with Malignant Neoplasm of Lower Lobe Right Bronchus or Lung. Review of the document titled “Client Coordination Note Report,” dated 05/07/26, showed the chaplain documented, “chaplain was out on medical emergency.” Further review revealed the chaplain was scheduled to complete the initial spiritual assessment on 05/08/26, three days beyond the required timeframe.During an interview conducted on 05/08/26 at 10:10 AM, Agency Personnel #1and #2 confirmed that the Spiritual Assessment had not been completed within the required five (5) calendar days from the SOC, as required by the Medicare Hospice Conditions of Participation as part of the comprehensive assessment.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for one (#8) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: A review of clinical record #8, with a start of care (SOC) date of 03/19/26, revealed a patient diagnosed with Other Cirrhosis of Liver. Review of the “Visit Note Report” dated 03/19/26 showed the Skilled Nurse (SN) documented that oxygen was to be delivered to the patient’s home. On a subsequent visit dated 04/22/26, the SN documented oxygen administration via nasal cannula at 2 LPM (liters per minute). Review of a form titled “Medicine List” did not reflect oxygen as an active medication. Additionally, there was no documentation in the clinical record indicating that oxygen had been reviewed for actual or potential medication side effects or interactionsDuring an interview conducted on 05/08/26 at 09:30 AM, Agency Personnel #1 and #2 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure the development and implementation of individualized plans of care for two (#6 and #10) of nineteen (#1-#19) clinical records reviewed. This deficient practice had the potential to affect all patients currently receiving services and could result in inconsistent, non-individualized care, increased risk for treatment errors, unmet patient needs, inadequate symptom management, and adverse patient outcomes. A review of clinical record #6, with a start of care (SOC) date of 04/23/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of the skilled nurse visit note dated 04/23/26 revealed the nurse documented the patient “has a Foley catheter in place.” Review of the visit note dated 04/29/26 revealed the patient contacted the agency reporting “abdominal pain and clogged catheter.” The nurse subsequently made a visit and replaced the catheter with a 16 FR (French) coude catheter with a 30 cc (cubic centimeter) balloon; however, the balloon was inflated with only 10 cc of saline. Further review of the clinical record revealed no documented physician orders specifying catheter management, including catheter size, balloon volume, frequency of catheter changes, or indications for catheter replacement.A review of clinical record #10, with a SOC date of 04/27/26, revealed a patient diagnosed with Gastroparesis. Review of a document titled “Hospice Certification and Plan of Care” for the certification period 04/27/2026 through 07/25/2026 revealed an order to “Instruct caregiver on administration of tube feeding.” Review of the skilled nursing visit note dated 04/27/2026 revealed the nurse documented the patient’s “nutrition comes from feedings through J-tube (jejunostomy tube) due to malabsorption.” Further review of the clinical record revealed no specific physician orders for the tube feeding regimen, including the name and strength of the formula, administration method (bolus or continuous), rate of infusion for continuous feedings, and water flushes to be administered before, after of between feedings and/or medications administered via the tube.During an interview conducted on 05/08/26 at 10:10 AM, Agency Personnel #1and #2 confirmed that not all plans of care were specific, complete, and individualized to meet the patients’ identified needs.”