Pristine Hospice LLC

“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; 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 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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed and home visit observations, it was revealed that the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 08/05/2024 for a diagnosis of Alzheimer’s disease. The patient resided in a group home. During the home visit with the Hospice Aide (Personnel Record 7) on 04/29/2025, the hospice medication profile (printed 04/28/2025) was compared to the group home medication profile (printed on 04/29/2025). The group home medication list contained the following medication not listed on the hospice medication list: “Aspirin EC 325 mg. Give 1 tablet at 8 AM.” The hospice drug profile did not include all of the patient’s medications in the review process. An interview and joint clinical record review was conducted with the Administrator/Executive Director on 04/30/2025 in which she confirmed the medication was not on the hospice profile. She stated the medications “should be reconciled at least every two weeks.””

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the individualized care plan included interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 02/10/2025. The Initial Plan of Care (POC). dated 02/10/2025) included the following: “Goal/Interventions: Assess that the patient is consuming enough fluids and fiber to maintain regular bowel movements without pharmacological methods,” and “Monitor for pain.” The following PRN (as needed) visits were documented: 02/11/2025 for Pain and bowel medication management; 02/15/2025 for severe constipation and pain. Patient having episode of severe constipation with pain and anxiety. Enema and digital impaction; 03/09/2025, for not feeling well, nausea, depression, loss of appetite. Zofran ordered and discussed antidepressant; 3/23/2025, for constipation and change fentanyl patch…added Senna; and 03/25/2025, for constipation. The POC, effective from 02/15/2025 to the date of review (04/30/2025) did not include problems, interventions, or goals for pain, anxiety, or depression. It was not revised or updated to include the patient’s constipation and bowel issues that resulted in several “as-needed” nursing visits, medications being ordered. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/17/2024. The following PRN nursing visits were documented: 12/03/2024 for a fall; 12/04/2024 change in condition, increased discomfort; 12/06/2024 for shortness of breath; 12/7/2024 pain follow up, 12/08/2024 pain follow up, and 12/12/2024 pain follow up. The POC effective from 10/17/2024 through 12/12/2024 did not include problems, goals, or interventions for fall prevention, pain, or shortness of breath. An interview and joint clinical record review was conducted with the Administrator/Executive Director and Director of Nursing on 04/30/2025, in which they stated, “we were having issues with our EMR (electronic medical record) and had to re-educate the nurses regarding updating the POC.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview and observation. In 5 of 18 (28%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1/Home Visit 1: The hospice aide care plan dated 08/05/2024 included a visit frequency of three times weekly and the following relevant tasks: “Apply barrier products after peri care, provide clothing assistance by helping with dressing and undressing, ensuring the patient’s comfort and dignity, shampoo hair, provide companionship to patient, clean fingernails, change adult brief, provide bed bath, provide oral care, ensure fall prevention.” During the home visit with the hospice aide (Personnel Record 7) on 04/29/2025, the patient was observed to have heel protectors in place. The aide plan of care did not include specific instructions for the heel protectors during tasks. CLINICAL RECORD 2/Home Visit 2: The hospice aide care plan dated 01/24/2025 included the following relevant tasks: “Ensure fall prevention, assist with range of motion (ROM), assist with standby bathroom needs, document bowel movement (BM), encourage fluids, provide clothing assistance by dressing and undressing, provide oral care, clean fingernails, check pressure areas and report to registered nurse (RN), provide skin care, provide companionship, bed bath, change bed linens” Aide frequency of three times weekly. During the home visit on 04/29/2025 with the RN (Personnel Record 4), the patient was observed to have heel protectors in place. The aide plan of care did not include specific instructions for the heel protectors during tasks. CLINICAL RECORD 3: The hospice aide care plan dated 02/11/2025 included the following relevant tasks: “Apply barrier products after peri care, change adult brief to manage urine and/or bowel incontinence, provide oral care, provide skin care, bed bath, provide clothing assistance.” Aide frequency of twice weekly. A nursing visit dated 03/30/2025 noted “Foley added.” The aide care plan was not updated to include the Foley being added. CLINICAL RECORD 18: The hospice aide care plan dated 06/13/2024 listed the tasks of “showering the patient and assist with ambulation every visit.” Aide frequency of twice weekly until 06/16/2024 then three times weekly. A nursing visit on 06/24/2024 noted “Patient no longer getting up for meals, bedbound now, according to GH (group home) caregiver.” A nursing visit on 06/28/2024 noted ‘Patient is now bedbound due to weakness and can no longer get up into wheelchair. “ A nursing visit on 06/29/2024 noted “She is bedbound due to weakness.” The aide care plan was not updated with specific instructions when the patient’s status changed from ambulatory to bedbound. During these visits the aide was charting “not able to complete shower. Reported to RN.” CLINICAL RECORD 19: The hospice aide care plan dated 04/06/2024 included the following relevant tasks: “Shower, help patient using walker, assist with passive ROM (range of motion), barrier cream, assist with bathroom needs.” Aide frequency of twice weekly. The nursing visit on 04/29/2024 noted “loss of mobility and ability to perform ADLs (activities of daily living).” The aide care plan was not updated with specific instructions when the patient’s status changed from ambulatory to bedbound. During these visits the aide was charting “not able to complete shower. Reported to RN.” An interview and joint clinical record review was conducted with the Director of Nursing (DON) and Executive Director (ED) on 04/29/2025 and 05/01/2025 in which they confirmed the aide care plans “should have been updated with the Foley and change in condition but didn’t realize about the heel protectors needing to be added.””

“It is required that a social worker has a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW and at least one (1) year of social work experience in a health care setting. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record for social workers reviewed, it was revealed that the agency did not ensure that a social worker that had a baccalaureate degree in social work, psychology, sociology, or other field related to social work, was supervised by an MSW (Masters Social Worker). Personnel Record 5: Date of hire 05/05/2022. The record included a Master of Science degree (2018) and not a Master of Social Work. The Administrator/Executive Director obtained a copy of her baccalaureate degree, which was in a field related to social work (family studies). The Administrator/Executive Director stated that from 05/05/2022 until 06/14/2023, she was the only social worker the agency had employed. There was no documentation of supervision by a master’s degree social worker (MSW) during that time, approximately 13 months. An interview and joint clinical record review was conducted with the Chief Executive Officer on 05/01/2025, in which she stated, “We hired her as she had worked at multiple other hospices. When they put me on the Governing Body, I read the regulations in detail and realized we needed an MSW. It was corrected immediately.””