Compassionate Care Hospice, LLC

“Upon patient record review, 2 of 19 (Patient #2,5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2 - The medication profile listed Miralax 17gm daily for constipation. There was no evidence of a diluent added. This was corrected onsite. Patient #5 - The medication profile contained a section to designate who will administer the medications to the patient. The profile contained a key utilizing numbers as to who would administer these medications. The profile listed “3&4” which according to the key included “fam & hospice nurse”. The profile did not include the facility nurse as a designated medication administrator.”

“Upon patient record review, 5 of 19 (Patient #6,8,9,11,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #6 - The medication profile listed ASA daily as a blood thinner. There were no problems, goals, or interventions listed related to bleeding risk. This was corrected onsite. Patient #8 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia. Patient #9 - The plan of care included an order for pureed food and thickened liquids. There were no problems, goals, or interventions listed related to dysphagia. Patient #11 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia. Patient #14 - The plan of care included an order for a mechanical soft diet. There were no problems, goals, or interventions listed related to dysphagia.”

“Based on record review and staff interviews, the hospice failed to ensure the completion of the clinical record to reflect the family member’s concern regarding a change in the patient’s condition for one of three sampled patients (Patient 1). This failure created the potential for not having the patient’s current condition to provide necessary care and services for this patient. Clinical record review for Patient 1 was initiated on 11/24/25. The clinical record showed Patient 1’s SOC was 8/31/25. Patient 1 was certified for home health services during the certification period from 8/31/25 to 11/28/25.The Report of Death and Disposal of Controlled Drug showed the hospice received a call on 9/22/25 at 0200 hours, and the date and time pronounced death was 9/22/25 at 0240 hours. Further review of the clinical record showed no documented evidence of what happened prior to the patient’s death, including the patient’s change of condition and communication between the family and hospice or hospice nurse.Review of Patient 1’s Call Log dated 9/22/25, showed Patient 1’s family called the hospice at 0116 and 0127 hours.On 11/26/25 at 1420 hours, an interview was conducted with Family Member 2. Family Member 2 stated around 0115 hours, the caregiver called and reported that the patient was making a loud rattling sound. The caregiver contacted the hotline and was instructed to administer Levsin (medication to treat the excessive secretion) but was unable to locate the medication. Later, around 0130 hours, Family Member 2 called and requesting for a nurse be sent immediately. She was told to wait for the nurse’s visit the following morning, but she insisted that a nurse had to see Patient 1.On 12/1/25 at 1100 hours, an interview and record review were conducted with the DPCS and Administrator. The DPCS was asked whether there was any documentation showing the family member had called around 0115 and 0130 hours. The DPCS and Administrator were unable to provide such documentation; however, both stated they reviewed the call log and confirmed the phone calls from the family member were received at 0116 and 0127 hours. The DPCS was also asked whether the nurse had documented any return call to the family informing them of the expected visit time. The DPCS and Administrator were unable to provide such documentation. The DPCS stated the staff member who received the call should have documented in the communication log as part of the medical record. Both the DPCS and Administrator verified these findings.Further review of the communication/progress log dated 9/22/25 at 0120 hours, showed a late entry by Receptionist 1 showing a call from the caregiver who reported that the patient had phlegm and was having difficulty breathing. The caregiver requested for advise on how to proceed. The SN advised elevating the patient’s head and increasing oxygen concentration. The caregiver was also instructed to suction or perform an oral sweep to remove phlegm from the mouth. The SN advised administering of Levsin; however, the caregiver reported no Levsin available at the bedside. The office was notified to send a STAT refill request to the pharmacy. The caregiver was also instructed to administer morphine to assist with breathing and DuoNeb (medication for opening airways and reducing respiratory inflammation) to help clear the airway. The SN confirmed the interventions and instructed the caregiver to call back if the patient’s condition changed. The caregiver verbalized understanding.Further review of the communication/progress log dated 9/22/25 at 0127 hours, showed another late entry. The patient’s daughter called and was informed that instructions had been provided to the caregiver regarding suctioning, repositioning, and medication administration, including removing phlegm from the patient’s mouth. She was advised that the patient should start Levsin, DuoNeb, and morphine (opioid pain medication), and that oxygen should be increased to 5 liters. It was explained that the caregiver had confirmed he would carry out the interventions and would call back if there was no improvement. A STAT order for Levsin was also being sent, as the caregiver reported none was available at the bedside.On 12/1/25 at 1630 hours, an interview and record review were conducted with the DPCS and Administrator. The DPCS stated Receptionist 1 made the late entries for 9/22/25 at 0120 and 0127 hours, today (12/1/25), after the issue was brought to their attention. The DPCS and Administrator verified these findings.”

“Based on staff interview and record review, the hospice failed to ensure the written addendum showing diagnoses and non-covered items was completed with the actual date completed/provided to the patient/family member for one of three sampled patients (Patient 1). This failure had to potential for not having an accurate information on the patient’s clinical record. According to CFR 418.24, (c), For hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual’s terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement. The election statement addendum must include the following:(9), Name and signature of the individual (or representative) and date signed, along with a statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not the individual’s (or representative’s) agreement with the hospice’s determinations.Clinical record review for Patient 1 was initiated on 11/24/25. The clinical record showed Patient 1’s SOC was 8/31/25. Patient 1 was certified for home health services during the certification period from 8/31/25 to 11/28/25.Review of the Admission Consent Form dated 8/30/25, showed the section titled “Patient Notification of Hospice Non-covered Items, Services & Drugs”—which should list diagnoses related or unrelated to the terminal illness, items/services/drugs, and reasons for non-coverage was originally left blank, with Family Member 1 initialing the page.On 11/26/25 at 1420 hours, an interview was conducted with Family member 2. Family member 2 stated they had expressed a concern about the blank section of the admission consent form. Although they signed the paperwork, the hospice had later added the information after signing.Review of another copy of Admission Consent Form dated 8/30/25, showed the Patient Notification of Hospice Non-Covered Items, Services & Drugs page was completed with diagnoses related to the terminal illness, diagnosis not related to terminal illness, and medications not related to the terminal illness and not covered. However, these diagnoses and medications were added to the original form that was signed/initialed by Family Member 1 on 8/30/25, which was not the actual date when the family member was informed or acknowledged the diagnoses and non-covered medications. On 12/3/25 at 1100 hours, an interview was conducted with the Administrator, DPCS, and Administrator’s designee. The Administrator stated the admission consent form was provided electronically to the family on 8/30/25, and the family was informed that the “Patient Notification of Hospice Non-covered Items, Services & Drugs” page was blank but still needed to be signed. The Administrator explained that the system required all pages to be signed in order to proceed and complete the form. On 9/3/25, the completed admission consent form, with the “Patient Notification of Hospice Non-covered Items, Services & Drugs” section filled out was sent to the family. When asked why the family was required to sign a blank form and whether any updates to the non-covered items, services, or drugs should have been signed after the form was completed, the Administrator acknowledged that there was a system issue with the clinical records. The Administrator verified the above findings.”