Community Hospice, Inc. - Hospice

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: The applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. Clothes dryers (Section 11.5. 1.11) shall be cleaned to maintain the lint trap and keep the mechanical and heating components free from excessive accumulations of lint. This standard was not met as evidenced by interview and observation. Observation of the facility’s laundry room revealed that the agency did not ensure fire safety and prevention by ensuring the mechanical and heating components were free from excessive accumulations of lint. Laundry Room: During the facility tour on 06/11/2025, observation of the inpatient facility laundry room revealed a significant accumulation of lint buildup in the dryer lint trap. Chief Clinical Officer observed the lint trap on 06/11/2025 and stated, “Don’t throw that away, I want to show it to the person responsible for cleaning it.” Observation of the facility’s laundry room revealed that the agency did not ensure fire safety and prevention through ensuring clean dryer trap without excessive accumulation.”

“It is required that the comprehensive assessment includes consideration of the following factors: The nature and condition causing admission, including the presence or lack of objective data and subjective complaints. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment documented all the objective data that would need to be considered for the plan of care and care of the patient. CLINICAL RECORD 22: The initial comprehensive assessment completed on 12/29/2024 did not document evidence of the infusion line. This patient was receiving GIP (general inpatient care) care and the following medications: Morphine 100mg in NACL 0.9%. Infuse 0-15mg IV continuous for pain; IV drip titration begins with 2mg/hr max increase by 1mg/hr and may increase the dose by 1 mg/1 hr; Morphine 1mg/ml injection. Infuse 0.5 - 1.5 mg IV every 2 hours as needed for pain. There was no description of the type of IV (intravenous) line, location of the line, dressing, or care of the line. During the interview with the clinical team, who reviewed the record with the site visit, stated that the patient was receiving care at a hospital, but agreed that the documentation should have included the line location and description of the site.”

“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, and herbal remedies. This standard was not met as evidenced by clinical record review and interview. In 2 of 30 (7%) clinical records reviewed revealed that the agency did not ensure that all over the counter medications were included on the medication profile. CLINICAL RECORD 12: The patient was admitted on 05/20/2025 with a diagnosis of end stage renal disease. The plan of care dated 05/20/025 included orders for Calmoseptine to buttocks every shift. Calmoseptine was not included on the medication profile. CLINICAL RECORD 14: Patient admitted on 05/02/2025 with a diagnosis of sepsis. The plan of care for 05/02/2025 - 07/30/2025 included an order for Calmoseptine to the inner thighs, bilateral groin, and scrotal irritation every shift. Calmoseptine was not included on the medication profile. The physician ordered on June 5, 2025, for Juven powder 1 pack mixed with 8 oz. of fluid PO BID for supplement and wound healing. Juven powder was not added to the medication profile. In a joint record review on 06/11/2025, the Chief Clinical Officer confirmed that the over-the-counter medication was not included on the medication list for patients 12 and 14.”

“It is required that each patient’s individualized written plan of care identify 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 1 of 1 (100%) clinical records reviewed which included an infusion, the agency did not ensure that the infusion line included documented interventions for care of the line to include assessment, line care, and dressing care. CLINICAL RECORD 22: The initial comprehensive assessment completed on 12/29/2024 did not include documentation of the infusion line. The patient was utilizing the GIP (general inpatient) benefit. The patient was receiving Morphine 100mg in NACL 0.9%. Infuse 0-15mg IV continuous for pain; IV drip titration begin with 2mg/hr max increase by 1mg/1 hr and may increase the dose by 1 mg/hr and morphine 1 mg/ml injection; Infuse 0.5 - 1.5 mg IV every 2 hours as needed for pain. There were no documented interventions for the infusion to include assessment of the line, care of the line, or dressing changes for the line. During the interview with the management team, who reviewed the record with the site visitor, stated that the interventions for the IV access were not documented.”

“It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) Clinical records reviewed in the community program, the agency did not ensure that the patient’s plan of care included all medical supplies to meet the patient’s needs. CLINICAL RECORD 14: The patient was admitted on 05/02/2025 with a left flank wound with a nephrostomy, a decubitus ulcer on the coccyx and a foley catheter. The plan of care dated 05/02/2025 did not include any supplies for wound care, or catheter care. During the interview with the management team, who reviewed the record with the site visitor stated that the supplies for patient care were missing from the plan.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) home visits observed, the agency did not ensure staff adherence to the hand hygiene policy. Hand Hygiene policy 9-010.1: Policy document Hand Hygiene 9-010.1 (effective date 5/19/2025) states in part that, “Personnel providing care in the hospice setting will regularly wash their hands.” “When hands are not visibly soiled, staff may use an alcohol-based hand rub.” “Hand Hygiene will be performed (1) before direct contact with patients.” HOME VISIT 5: During the observed visit on 6/10/2025, the chaplain was observed entering the room without utilizing hand sanitizer. He made hand contact with the patient during prayer and comfort. There was no hand sanitization after the visit before exiting the home. In an interview with the Clinical Manager of the home program, on 6/10/2025, it was stated that staff have been educated about hand hygiene but in this case, the chaplain forgot to use hand sanitizer. She stated that she spoke with the chaplain on 06/11/2025 and he stated that he sanitized his hands before he left his car. During home visit #5 completed”

“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 7 of 25 (28%) clinical records reviewed with home health aides revealed that the agency did not ensure that the aide care plan provided clear instructions to meet the patient needs. CLINICAL RECORD 1: The patient was admitted on 01/15/2025 with a diagnosis of senile degeneration of the brain. The physician orders included oxygen. The aide plan of care did not include instructions to the aide regarding the oxygen safety or use. CLINICAL RECORD 9: The patient was admitted on 01/21/2025 with a diagnosis of heart failure. The plan of care dated 01/21/2025 included orders for oxygen and wound care covered with gauze three times per week to the right foot. The aide care plan developed by RN on 01/22/2025 did not inform the aide that the patient had oxygen and there were no oxygen precautions on the aide care plan. The aide care plan included “foot care’ but did not provide direction to the aide related to how to manage bath and foot care with the dressing on the right foot. CLINICAL RECORD 12: The patient was admitted on 05/20/2025. The skilled nursing assessment documented that the patient was incontinent and utilized a pure wic system continuously. The aide care plan developed by the RN on 05/21/2025 included a complete bed bath but did not mention the poure wic system or provide the aide with any direction related to the pure wic system. CLINICAL RECORD 14: The patient was admitted on 05/02/2025 with a diagnosis of sepsis. The initial skilled nursing comprehensive assessment completed on 05/02/2025 described a decubitus ulcer of the coccyx, a left-sided surgical flank wound dressing with a nephrostomy tube and a Foley catheter in place. The aide care plan developed on 05/09/2025 included a complete bed bath but did not include instructions to the aide related to the Foley catheter, nephrostomy, or bandages on decubitus. CLINICAL RECORD 16: The patient was admitted on 10/14/2024 with a diagnosis of malignant neoplasm of the colon. The plan of care dated 06/11/2025 included continuous oxygen 2-10 liters per nasal cannula. The aide care plan was revised on 04/06/2025 and did not include any instructions to the aide related to oxygen use or safety. CLINICAL RECORD 19: The patient resided in a skilled nursing facility and elected hospice on 05/13/2025 with metabolic encephalopathy. The skilled nursing assessment on 05/13/2025 indicated that the patient had unstageable pressure ulcers to the left lower back and midline lower posterior medial spine with wound care orders on the plan of care. The aide plan of care included a complete bed bath but did not provide the aide any direction related to the wound care and dressing areas. CLINICAL RECORD 20: The patient resided at home and elected hospice on 04/09/2025 with a diagnosis of chronic obstructive pulmonary disorder. The plan of care dated 04/09/2025 included oxygen 5.5 liters per minute per nasal cannula continuous. The aide care plan created 04/09/2025 did not include mention of oxygen or oxygen precautions. In a joint review of clinical records on 06/11/2025 and 06/12/2025, the Chief Clinical Officer confirmed that the aide care plans did not include required elements to meet the patient needs.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records in which a hospice aide was accepted and had a change to be reported to the nurse, revealed the agency did not ensure that documentation of the change was documented. CLINICAL RECORD 13: The aide plan of care documented on 04/21/2025 ordered incontinent care, perineal care and brush teeth every visit. The frequency for the hospice aide was 2 times a week. The following visit dates the above tasks were documented as refused: 05/09/2025, 05/13/2025, 05/16/2025, and 06/03/2025. There was no documented notification of the nurse, and the nursing assessments did not document that the aide had notified her. During the interview with the clinical team, who also reviewed the record together, stated that nurse notification was not documented.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or the patient’s legal representative(s). The Interdisciplinary Group discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand, ensures that the safe use and disposal of controlled drugs is understood, and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 4 (25%) clinical review of death records, the agency did not ensure that the disposal of medications was documented at death per the agency policy. AGENCY POLICY: Policy 3-006.1 [review date 05/19/2025] Stated in part, “upon the patient’s death, the nurse will offer verbal and written instructions on how to appropriately dispose of medications and will document such in the patient EMR.” “The hospice nurse will review methods of disposal with patient/caregiver or designee” CLINICAL RECORD 22: The patient received GIP (general inpatient care) with a date of death of 12/29/2024. The hospice nurse visit documented the notification of the team and death, but no documentation of medication disposal for a patient receiving morphine, lorazepam. During the interview with the clinical team, who reviewed the record with the site visitor, it was stated that drug disposal was discussed on admission, but no documentation at death for the drug disposal. They thought that the facility would have disposed but agreed there was no documentation of drug disposal.”

“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/IID 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 clinical record review and interview. In 3 of 9 (33%) clinical records reviewed of patients in a skilled nursing facility revealed that the agency did not ensure the care plan identified which provider was responsible for performing functions of the care plan CLINICAL RECORD 17: The patient was admitted to a skilled nursing facility on 06/02/2025 and elected hospice on 06/03/2024. The plan of care for the certification period 06/03/2025-08/31/2025 included orders that read, “Decubitus pressure ulcer stage II midline posterior buttocks gluteal fold: cleanse with normal saline or wound cleanser, rinse, pat dry and cover with foam dressing twice a week or as needed for soiling or dislodging. Paracentesis drain 3 x week using Pleurex 1000 ml bottle. Monitor blood pressure before and after. May also weigh (initial 3160) or abdominal circumference (initial 103 cm at navel). Change dressing to the drain site RLQ using saline/wound cleanser rinse, pat dry, place a drain sponge, and cover dressing. May crush medications that are crushable. The plan of care does not specify which provider was responsible for each intervention. CLINICAL RECORD 18: The patient resided in a skilled nursing facility and elected hospice on 05/21/2025. The plan of care dated 05/21/2025 included orders for a Foley catheter as needed with a 60 ml flush as needed for patency. SN assesses for falls, SN assesses cognitive status. The plan of care did not provide any clarification and direction to specify which provider was responsible for performing ordered care plan tasks. CLINICAL RECORD 19: The patient resided in a skilled nursing facility and elected hospice on 05/13/2025. The plan of care dated 05/13/2025-08/10/2025 included daily wound care for two unstageable wounds. The plan of care did not include any clarification or direction to specify which provider is responsible for performing the ordered care plan tasks. During the interview with the management team, who reviewed the record with the site visitor stated that there was no indication as to who was performing which task.”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. Observation of the facility’s patient kitchen and family kitchen revealed that the agency did not ensure that food items were not expired and stored properly. Observation on 06/11/2025 of the inpatient unit kitchen revealed that the refrigerator included cream cheese that expired on 06/04/2025, and cottage cheese that expired on 06/06/2025. The freezer included 5 bags of vegetables that were open and unsealed with no labels. The family kitchen refrigerator contained an egg carton with 11 eggs. The expiration date on the egg carton was April 11, 2025. The Chief Nursing Officer observed the kitchen and refrigerator with the site visitors and confirmed that the cottage cheese and the cream cheese were expired. The Chief Nursing Officer observed and confirmed that 5 bags of vegetables were open in the freezer with no seal and no label. The Chief Clinical Officer observed the expired eggs and confirmed the finding. Observation of the facility’s patient kitchen and family kitchen revealed that the agency did not ensure that food items were not expired and stored properly.”

“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 an RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This is a Continued Required Action. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared a hospice aide plan of care that contained clear and specific instructions for care that the patient required. Clinical Record 1: The patient elected the hospice benefit on 03/31/2023 with a terminal diagnosis of senile dementia. The nurse documented on the nursing visit note dated 04/10/2023, a Foley catheter was placed. The aide plan of care assigned the tasks of peri care but did not include Foley catheter care and emptying of the catheter bag. Clinical Record 2: The patient elected the hospice benefit on 12/03/2022. At the start of care, it was documented that the patient was wheelchair (w/c) dependent and required 1 person to assist with transfer. The aide plan of care assigned the tasks of transfer bed to chair and chair to bed but was not specific to 1-person or 2-person assistance with transfer. Clinical Record 4: The patient elected the hospice benefit on 03/20/2023. Documentation at the start of care showed the patient had an ileostomy in a location that leaked, and bag sealing was very difficult. The aide plan of care assigned the aide visit frequency of two times a week and assigned a bed bath but did not include directions to the aide on how to care for the ileostomy, the skin around the ostomy site, and if the bag should be emptied while providing care to the patient. During an interview with the Management Team of Clinical Patient Care Managers, the Vice President of Clinical Services, Education, and Quality team, stated that the aide plans did not have the specifics but that the team coordinated care but agreed that this was not documented.”

“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 is a Continued Required Action This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that reside in a skilled facility, the agency did not ensure the hospice plan of care identified the care and services that would be provided by the hospice and the nursing facility. Clinical Record 1: The patient elected the hospice benefit on 03/31/2023 with a terminal diagnosis of senile dementia. The patient resided in a nursing facility. The nurse documented on the nursing visit note dated 04/10/2023, a Foley catheter was placed. The hospice plan of care did not identify the care and services that each provider would be responsible for related to the foley catheter. Clinical Record 7: The patient elected the hospice benefit on 03/20/2024. The patient resided in a nursing facility. The patient had an ulcer on the left heel and left calf. Nursing visit notes document wound worsened on the left calf and required 3 times a week wound care. The hospice plan of care did not identify the care that each provider would be responsible to provide related to the wound care. During an interview with the Management Team of Clinical Patient Care Managers, they stated that they had a facility plan. They brought a blank one that identified duties and was used at all facilities but agreed that a copy of the plan was not in the clinical records and that a copy did not get placed in the clinical record, it was kept only at the facility.”