Elite Hospice

“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 four (#5,#6,#11,and #13) 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 #5, with a start of care (SOC) date of 07/03/25, revealed a patient diagnosed with Atherosclerotic Heart Disease. On a form titled “Visit Note Report” and dated 07/03/25 the Skilled Nurse (SN) documented the patient was currently utilizing oxygen. Review of a form titled “Client Medication Report” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions.A review of clinical record #6, with a SOC date of 08/30/25, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. On a form titled “Visit Note Report” and dated 07/03/25 the SN documented the patient was currently utilizing Dilaudid pain pump. Review of a form titled “Client Medication Report” did not reflect Dilaulid as part of the patient’s active medications. There was no documentation in the chart to indicate that Dilaudid had been checked for actual or potential drug interactions.A review of clinical record #11, with a SOC date of 03/16/22, revealed a patient diagnosed with Hypertensive Heart Disease with Heart Failure. On a form titled “Visit Note Report”, dated 09/04/25 the SN documented “OXYGEN APPLIED TO PT (patient) VIA NASAL CANNULA AT 2LPM (liters per minute).” Review of a form titled “Client Medication Report” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions. A review of clinical record #13, with a SOC date of 09/10/25, revealed a patient diagnosed with Malignant Neoplasm of Brain. On a form titled “Visit Note Report” and dated 09/15/25 the SN documented patient utilizing oxygen. Review of a form titled “Client Medication Report” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions. During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions.”

“Based on clinical record review and staff interview, it was determined the Agency failed to perform an Initial Bereavement Assessment in one (#14) of nineteen ( #1 - #19) clinical records reviewed. This failed practice had the potential to negatively impact the grieving process for the patient and family in that social, spiritual and cultural factors which could interfere with coping mechanisms might not be discovered and/or addressed. Findings follow: A review of clinical record #14, with a start of care date of 07/18/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “Visit Note Report” and dated 07/21/25 revealed Bereavement Assessment not completed due to “CONTACT NOT BEING PRESENT AT THE TIME OF VISIT.” No evidence an Initial Bereavement Assessment has been completed as of 09/13/25.During an interview on 09/19/25 at 4:00PM, Agency Personnel #1 confirmed Initial Bereavement Assessment has not been conducted.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure that the Interdisciplinary Group (IDG) updated and coordinated individualized plans of care in response to changes in the condition or needs of the patient in two (#4 and #9) of nineteen (#1 - #19) clinical records reviewed. This failure of the IDG to comprehensively assess, coordinate, and revise the plan of care in a timely manner placed all patients currently on census at risk for receiving care that does not reflect their current clinical status and unmet clinical, emotional, and comfort care needs. Findings follow: A review of clinical record #4, with a start of care (SOC) date of 08/27/25, revealed a patient diagnosed with Hemiplegia following Cerebral Infarction. A document titled “Client Coordination Note Report,” dated 09/01/25, showed that the patient was admitted to the Emergency Room for hematemesis and hypertension. This hospitalization and change in patient’s condition was not reflected in the IDG Summary Report dated 09/03/25.A review of clinical record #9, with a SOC date of 07/28/2025, revealed a patient diagnosed with Alzheimer’s Disease. A Visit Note Report dated 07/31/2025 documented that the Skilled Nurse (SN) communicated with facility staff regarding “starting IV antibiotics.” The note stated, “Dr. Pace (Hospice Physician) reviewed the urinalysis (UA) during IDG and ordered Ertapenem 1 g IV daily for 7 days.” Review of the IDG Summary Report dated 07/30/2025 revealed no documentation of any discussion, review, or orders related to a UA, infection, or IV antibiotic therapy. A Visit Note Report dated 08/05/2025 documented that a facility nurse attempted an in-and-out catheterization to obtain a urine specimen but was unable to complete the procedure due to patient discomfort. A urine specimen was subsequently collected via hat catch. Facility staff reported that the patient received Fosfomycin on 08/01/2025 per Dr. Keel’s orders and that UA results were pending. On 08/07/2025, the SN documented, “UA culture should result late Saturday or Sunday. This SN will follow up on results and coordinate with MD.”A follow-up note dated 08/12/2025 stated, “UA results still not in system.” Review of the record found no physician orders for urinalysis, in-and-out catheterization, or antibiotic therapy. There was no documentation that a UA was performed or that any antibiotic was formally ordered or administered. Additionally, there was no evidence of nursing follow-up regarding pending results. The IDG Summary Report dated 08/13/2025 contained a note by the Registered Nurse stating the patient “has not had a recent UA from the facility.” The IDG Summary Report dated 08/27/2025 recorded that the Medical Director documented, “getting UA today.” However, the clinical record contained no documentation confirming that a UA was obtained. The next IDG Summary Report dated 09/10/2025 did not address the patient’s urinary status, infection concern, pending UA, or any follow-up regarding potential infection or antibiotic use. During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the agency failed to document updates to the plan of care in response to new or ongoing clinical needs.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure that the plan of care (POC) developed and reviewed by the Interdisciplinary Group (IDG) specified the frequency and scope of services to be provided for eleven (#1, #2, #4, #5, #6, #7, #9, #10, #11, #12, and #14) of nineteen (#1 - #19) clinical records reviewed This failed practice had the potential to result in uncoordinated care, unmet patient/family needs, and inconsistency in service delivery, as staff do not have clear guidance regarding the frequency and scope of hospice services. Findings follow: A review of clinical record #1, with a start of care (SOC) date of 05/30/25, revealed a patient diagnosed with Malignant Neoplasm of Right Kidney. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 09/03/25 and 09/17/25 failed to include Skilled Nurse (SN) or Chaplain visit frequency. A review of clinical record #2, with a SOC date of 08/07/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 08/13/25, 08/27/25 and 09/10/25 failed to include SN, Social Worker (SW), or Chaplain visit frequency. A review of clinical record #4, with a SOC date of 08/27/25, revealed a patient diagnosed with Hemiplegia following Cerebral Infarction. Review of a document titled “IDG SUMMARY REPORT” with a meeting date of 09/03/25 failed to include SN or Chaplain visit frequency. A review of clinical record #5, with a SOC date of 07/03/25, revealed a patient diagnosed with Atherosclerotic Heart Disease. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 07/16/25, 07/30/25, 08/13/25, and 08/27/25 failed to include SN, HA, or Chaplain visit frequency. A review of clinical record #6, with a SOC date of 08/30/25, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a document titled “IDG SUMMARY REPORT” with a meeting date of 09/10/25 failed to include SN, SW, or Chaplain visit frequency. A review of clinical record #7, with a SOC date of 02/26/25, revealed a patient diagnosed with Parkinsonism Unspecified. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 09/03/25 and 09/17/25 failed to include SN, HA, or SW visit frequency. A review of clinical record #9, with a SOC date of 07/28/2025, revealed a patient diagnosed with Alzheimer’s Disease. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 07/30/25, 08/13/25, 08/27/25 and 09/10/25 failed to include SN, HA, SW, or Chaplain visit frequency. A review of clinical record #10, with a SOC date of 09/06/25, revealed a patient diagnosed with Malignant Neoplasm Right Bronchus or Lung. Review of a document titled “IDG SUMMARY REPORT” with a meeting date of 09/10/25 failed to include SN, HA, or Chaplain visit frequency. A review of clinical record #11, with a SOC date of 03/16/22, revealed a patient diagnosed with Hypertensive Heart Disease with Heart Failure. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 08/27/25 and 09/10/25 failed to include SN, HA, or Chaplain visit frequency. A review of clinical record #12 with a SOC date of 09/02/25, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a document titled “IDG SUMMARY REPORT” with a meeting date of 09/10/25 failed to include SN or Chaplain visit frequency. A review of clinical record #14 with a SOC date of 07/18/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “IDG SUMMARY REPORT” with meeting dates of 07/23/25, 08/06/25, 08/20/25, and 09/03/25 failed to include SN, HA, or Chaplain visit frequency. During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the agency failed to include the specific scope and frequency of visits on the patient’s plan of care updates.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in one (#5) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: A review of clinical record #5, with a start of care date of 07/03/25, revealed a patient diagnosed with Atherosclerotic Heart Disease. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with certification dates of 07/03/25 to 09/30/25 revealed orders for “CATHETER TO BE CHANGED MONTHLY.” On a form titled “Visit Note Report” and dated 07/31/2025 the skilled nurse documented “SUPRAPUBIC CATHETER CHANGED OUT TODAY.” There was no documentation in the chart to indicate the catheter had been changed in the month of August. During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the skilled nurse failed to change the catheter monthly as ordered.”

“Based on clinical record review and interview with Agency staff, it was determined the Agency failed to facilitate visits by local clergy, pastoral counselors, or other individuals to support the patient’s/family’s spiritual needs in three (#2, #12, and #14) of nineteen (#1 - #19) clinical records reviewed. This failed practice had the likelihood of affecting all patients on census from obtaining relief from spiritual and/or emotional conflict in order to improve the quality of life for the patient and/or family. Findings follow: A review of clinical record #2, with a start of care (SOC) date of 08/07/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “VISIT NOTE REPORT”, dated 08/08/2025 states patient has a faith community and belongs to “Cowboy Church.” There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient’s/family’s spiritual needs.Review of Clinical Record #12 with a SOC date of 09/02/25, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a document titled “VISIT NOTE REPORT”, dated 09/04/2025 states patient has a faith community, belongs to “New Life Church”, and “HAS RECENTLY BEEN BAPTIZED.” There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient’s/family’s spiritual needs.Review of Clinical Record #14 with a SOC date of 07/18/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “VISIT NOTE REPORT”, dated 07/21/2025 states “PATIENT IS OF CATHOLIC FAITH AND NOTES THAT SHE RECEIVES COMMUNION AT HER HOME EVERY FRIDAY THROUGH ST. JUDES CATHOLIC CHURCH.” There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient’s/family’s spiritual needs.During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the Chaplain did not facilitate visits or coordinate care with the patient’s local faith community.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in two (#5 and #14) of twelve (#4, #5, #7, #8, #9, #10, #11, #14, #15, #17, #18, BS #19) clinical records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: A review of clinical record #5, with a start of care (SOC) date of 07/03/25, revealed a patient diagnosed with Atherosclerotic Heart Disease. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 07/03/2025 to 09/30/2025 revealed orders for a HA. First SAV conducted 07/31/25 (ten days past the required14-day time frame).A review of clinical record #14, with a SOC date of 07/18/25, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 04/08/2025 to 07/06/2025 revealed orders for a HA. Supervisory aide visits conducted 05/13/25 and 05/28/25 (One day past the required14-day time frame).During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the Registered Nurse failed to conduct Supervisory Aide Visits every fourteen days as required.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure coordination of care and services for three (#8, #9, and #14) of four (#8, #9, #11, and #14) residents residing in a skilled nursing facility (SNF). This failed practice had the potential to affect all residents receiving hospice services in a SNF, as a lack of communication between hospice and nursing facility staff may result in unmet care needs and inadequate symptom management. A review of clinical record #8, with a start of care (SOC) date of 09/09/25, revealed a patient diagnosed with Chronic Respiratory Failure. On a form titled “Visit Note Report” and dated 09/10/2025 the skilled nurse (SN) documented “WOUND CARE IS CURRENTLY BEING PROVIDED BY FACILITY STAFF.” There was no documentation within the clinical record to support the presence of a wound or any corresponding wound care orders.A review of clinical record #9, with a SOC date of 07/28/2025, revealed a patient diagnosed with Alzheimer’s Disease. On a form titled “Visit Note Report,” and dated 07/31/2025, the SN indicated she spoke with facility staff regarding “starting IV (Intravenous) antibiotics.” The note further stated, “Dr. Pace (Hospice Physician) reviewed the urinalysis (UA) during IDG (Interdisciplinary Group) and ordered Ertapenem 1g (gram) IV daily for 7 days.” Facility staff reported that Dr. Keel (Attending Physician) did not agree with this order and preferred to administer either Meropenem IV or Ertapenem IM (Intramuscular), requesting to retain authority over all patient orders. A “Visit Note Report” dated 08/05/2025 documented that the facility nurse attempted an in-and-out catheterization to obtain a urine specimen but was unable to do so due to patient discomfort. A urine specimen was instead collected via hat catch. Facility staff reported that the patient received Fosfomycin on 08/01/2025 per Dr. Keel’s orders, and that the urinalysis results were expected on Saturday. On 08/07/2025, the SN documented, “UA culture should result late Saturday or Sunday. This SN will follow up on results and coordinate with MD.” A subsequent note dated 08/12/2025 stated, “UA results still not in system.” There was no documentation within the clinical record of any physician orders for a urinalysis or for in-and-out catheterization to collect a urine specimen. Additionally, there was no evidence that any of the referenced medications were formally ordered or administered. No urinalysis results were found in the clinical record, and there was no documented nursing follow-up regarding the pending results.A review of clinical record #14, with a SOC date of 07/18/25, revealed a patient diagnosed with Congestive Heart Failure. The patient was residing at home at the time of admission and was later transferred to a skilled nursing facility (SNF). Documentation indicates that the patient arrived at the SNF on 08/02/25 for admission to hospice care; however, the facility had not yet received the corresponding physician orders from the agency. Multiple phone calls were placed from the SNF to the agency’s triage center on 08/02/25, requesting the necessary hospice admission orders. A “Client Coordination Note Report” dated 08/02/25 at 11:03 AM includes a note from the caller indicating that there were “no available orders for patient.” The clinical record contained no documentation of coordination between the agency and the SNF regarding the patient’s transfer from home and subsequent admission for hospice care within the facility. During an interview on 09/19/25 at 4:00 PM, Agency Personnel #1 confirmed the agency failed to coordinate care and services of patients residing in a contracted nursing facility.”