Elements of Elder Care LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, CLINICAL RECORD 4: The patient elected the hospice benefit on 07/02/2026 with a diagnosis of Heart disease, unspecified. A review of the clinical record revealed that the psychosocial assessment was conducted on 07/08/2026, which exceeded 5 days after the election of hospice care. There was no documented evidence explaining a reason for the delay, a missed visit, or attempts to complete the assessment within the first five days. During an interview on 08/20/2026, the Executive Director/Director of Clinical Services (Personnel Record 1) stated, “I have reviewed the clinical record and agree that there is no documentation explaining why the psychosocial assessment was not completed in a timely manner.””

“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 identifying 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 medication side effects in the hospice population are anticipated and, as appropriate, preventive measures are implemented to manage them. 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 14 (7%) clinical records reviewed revealed that the agency did not ensure that the documented comprehensive assessment included a drug profile that contained the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy, and the medication review process included the identification of actual or potential drug interactions. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/27/2026 with a diagnosis of acute-on-chronic combined systolic and diastolic congestive heart failure. A review of the clinical record revealed that the medication profile dated 07/27/2026 included a lidocaine 4% patch 1 (topical) to the affected area 1 time per day. The instructions did not specify the lidocaine patch was to be applied. During an interview on 08/20/2026, the Director of Clinical Services (Personnel record 1) stated, “I have reviewed the medication profile and agree that the documentation does not include the part of the body that is affected.””

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), review, revise, and document the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/06/2025 with a diagnosis of atherosclerosis of the native coronary artery and died on 08/26/2026. A review of the clinical record revealed that a comprehensive Interdisciplinary Group (IDG) assessment was completed on 08/12/2026. The IDG assessment dated 08/26/2026 did not provide documented evidence of a review of the plan of care for the patient’s discharge status or bereavement needs and was not signed by the IDG members. This was not completed within 15 days of the previous IDG assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/27/2025 with a diagnosis of cerebral infarction and died on 09/08/2025. A review of the clinical record revealed that the comprehensive IDG assessment dated 09/09/2025 did not provide documented evidence of the discussion of the patient’s admission status, review of the plan of care, medication review, or discharge status, including bereavement needs, and was not signed by the IDG members. CLINICAL RECORD 13: The patient elected the hospice benefit on 04/29/2026 with a diagnosis of atherosclerosis of the native coronary artery and revoked the hospice benefit on 05/29/2026. A review of the clinical record revealed that a comprehensive Interdisciplinary Group (IDG) assessment was completed on 05/05/2026 and 05/19/2026. The IDG assessment dated 05/29/2026, did not provide documented evidence of a review of the plan of care for the patient’s discharge status and was not signed by the IDG members. During an interview on 08/20/2026, the Executive Director/Director of Clinical Services (Personnel Record 4) stated, “I have reviewed the clinical record and agree that the IDG assessments were not completed. We do, however, always discuss the discharges in IDG.””

“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 and interview. In 6 of 14 (43%) clinical records reviewed revealed that the agency did not ensure that written patient care instructions for a hospice aide are prepared by a RN (Registered Nurse) who is responsible for the supervision of the hospice aide. DOCUMENT 1 : (Name of State) Revised Statutes Title 32. Professions and Occupations §32-1650. Certified medication assistants; medication administration; delegation, “32-1650. Certified medication assistants; medication administration; delegation states in relevant parts, “A. A nurse who is licensed pursuant to this chapter may delegate medication administration to a licensed nursing assistant who is also certified by the board as a medication assistant or to a student in an approved medication assistant program.” CLINICAL RECORD 1: The patient elected the hospice benefit on 07/26/2026 with a diagnosis of acute on chronic systolic and diastolic congestive heart failure. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment dated 07/26/2026 that the patient required aspiration precautions for dysphagia and that a supra pubic catheter was present. The hospice aide care plan did not include documented evidence that written instructions for aspiration precautions or how to care for the suprapubic catheter site during bathing. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/20/2025 with a diagnosis of cerebrovascular disease. A review of the clinical record revealed that the Registered Nurse documented written instructions in the aide plan of care dated 08/11/2026 for the aide to apply nystatin cream to the abdomen, buttocks, and lower back. There was no documented evidence that the aide was certified by the board as a medication assistant or a student in an approved medication assistant program according to the (Name of State) Revised Statutes Title §32-1650 CLINICAL RECORD 5: The patient elected the hospice benefit on 04/22/2026 with a diagnosis of heart disease, unspecified. A review of the clinical record revealed that the registered nurse documented in the initial plan of care dated 04/22/2026 that the patient was receiving oxygen. A physician’s order dated 4/22/2026 ordered oxygen 2-3 liters per minute via nasal cannula continuously. The hospice aide care plan dated 04/22/2026 and the updated hospice aide care plan dated 08/01/ 2026 did not include did not include documented evidence of written instructions for oxygen use and precautions. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/02/2026 with a diagnosis of cerebral infarction, unspecified. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment dated 06/02/2026 that the patient had dysphagia and difficulty swallowing. The hospice aide care plan dated 06/02/2026 and the updated hospice aide care plan dated 08/10/2026 did not include did not include documented evidence of written instructions for aspiration precautions. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/06/2025 with a diagnosis of atherosclerosis of the native coronary artery. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive nursing assessment dated 08/06/2025 that the patient was using oxygen at 2-3 liters per minute via nasal cannula for shortness of breath as needed. The hospice aide care plan dated 08/06/2025 did not include documented evidence of written instructions for oxygen use or safety precautions. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/27/2025 with a diagnosis of cerebral infarction. A review of the clinical record revealed that the registered nurse documented in the comprehensive nursing assessment dated 08/27/2026 that the patient was using oxygen 2-4 liters per minute via nasal cannula for shortness of breath. The hospice aide care plan dated 08/27/2025 did not include did not include documented evidence of written instructions for oxygen use and precautions. During an interview on 08/20/2026, the Director of Clinical Services (Personnel Record 1) stated, “I have reviewed Clinical Records 1, 3,5,10,11, and 12, and agree that the written instructions for precautions are not documented as noted. I have entered the missing information and instructed the nurses accordingly.””

“It is required that the hospice medical director, physician-designee, or physician member of the IDG provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the recertification of the terminal illness was completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/02/2026 with a diagnosis of atherosclerotic heart disease. A review of the clinical record revealed that the recertification of terminal illness for benefit period 3 dated 08/01/2026 - 09/29/2026 did not include a physician’s narrative and was not signed and dated as of 08/18/2026. This exceeded the 2-day requirement by 16 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/25/2025 with a diagnosis of cerebrovascular disease and was recertified on 09/18/2025, 12/17/2025, 02/15/2026, 04/16/2026, 06/15/2026, and 08/14/2026. A review of the clinical record revealed that the Physician’s certification of terminal illness (CTI) for the recertification dated 09/18/2025-12/16/2025 was completed on 09/30/2025, which exceeded two (2) calendar days after the first day of the benefit period. The CTI for the recertification dated 02/15/2025-04/15/2025 was completed on 02/27/2026, which exceeded two (2) calendar days after the first day of the benefit period. The CTI for the recertification dated 04/16/2026-06/14/2026 was completed on 04/30/2026, which exceeded two (2) calendar days after the first day of the benefit period. The CTI for the recertification dated 08/14/2026-10/12/2026 was completed on 08/18/2026, which exceeded two (2) calendar days after the first day of the benefit period. During an interview on 08/18/2026, the Executive Director (Personnel Record 1) stated, “We always have a discussion in the IDG prior to the recertification date. The physician provides a verbal certification and then signs everything by the end of the month.””