New Madison Hospice and Palliative Care, Inc.

“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. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 3 (33%) home visits, 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 09/17/2025 for a diagnosis of Parkinson’s disease. The patient resided in a skilled nursing facility (SNF). During Home Visit 1 with Personnel Record 10 (Hospice Aide) on 08/05/2026 the hospice medication profile (printed on 08/05/2026) was compared to the SNF medication profile (printed on 08/05/2026). The hospice medication profile contained the following medications not listed on the SNF medication profile: “Acetaminophen 325 mg tablet. Two tablets every four hours as needed (ordered 09/17/2025). Acetaminophen 650 mg rectal suppository. One every six hours as needed (ordered 09/17/2025).” The SNF medication profile contained the following medications not listed on the hospice medication profile: “Narcan nasal liquid 4 mg. One spray as needed for drug overdose (ordered 07/10/2026). Triamcinolone cream 1%. Apply to face/ears every day and evening shift for four weeks. (ordered 07/16/2026).” An interview and joint clinical record review was conducted with the Director of Patient Care Services on 08/06/2026 during which time he confirmed the medications had not been reconciled and “that it should have been done at least every IDG.””

“It is required that 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 2 of 13 (15%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan dated 09/20/2025 included the following relevant tasks: “Turn and reposition; incontinent care-bedpan, briefs, chux; record bowel movements; fall precautions; change patient linens; report any skin breakdown to nurse; assist to dress; bedbath; brush, comb and shampoo hair; shave; brush teeth; clean nails; apply deodorant; apply lotion; visualize condition of skin and report to nurse; peri care.” All tasks were to be completed every visit with an aide frequency of twice weekly. During Home Visit 1 with Personnel Record 10 (Hospice Aide) on 08/05/2026, the patient was observed to have a G-tube, a wound on his left lateral foot with a dressing, right hand contractures and bilateral leg contractures. These items were not specified on the aide care plan. The aide did advise the she would “contact the facility nurse if the dressing on the patient’s foot came off during her bed bath” but agreed there was not notification of any of those items on her care plan. CLINICAL RECORD 7: The hospice aide care plan dated dated 02/25/2025 included the following relevant tasks: “”Turn and reposition; incontinent care; record bowel movements; fall precautions; change patient linens; report any skin breakdown to nurse; assist to dress; bedbath; brush teeth; empty trash; apply lotion; comb and shampoo hair.” All tasks were to be completed every visit with an aide frequency of twice weekly. A physicians order dated 10/7/2025 noted the following; “Left lateral ear. Cleanse wound with cleaner and pat dry with gauze. Apply medical grade honey to the wound bed and hydrogel. Cover with bordered gauze 3x weekly and prn (as needed).” A physician’s ordered dated 12/19/2025 noted the following: “Wound care to left ear. Refer to wound specialists.” This wound was not noted on the hospice aide care plan nor were specific instructions provided to the aide for notification to the nurse if the dressing became soiled, dislodged or wet. An interview and joint clinical record review was conducted with the Director of Patient Care on 08/06/2026 during which time he agreed the “aide care plans needed to included more specific instructions for the care of each patient and should’ve been updated more frequently.’”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 12 (25%) personnel records reviewed revealed the agency did not ensure the skills and competencies of all individuals providing care, including volunteers were assessed. Document 2: Agency Policy titled “Competency Program Policy No 3-001” stated in relevant part(s): “2. The organization will establish and annually evaluate a group of specific skills related to the patient care/service responsibilities and complexity of care/service........6. After completion of orientation, competency will be monitored annually thereafter as part of the ..........” Personnel Record 5: A personnel record review was conducted on 08/06/2026, for an employee (NP/DPCS) hired on 03/04/2024 which revealed that there were no documented skills competencies for 2025. Personnel Record 8: A personnel record review was conducted on 08/06/2026, for an employee (Social Worker) hired on 06/07/2021 which revealed that there were no documented skills competencies for 2024 or 2025 Personnel Record 10: A personnel record review was conducted on 08/06/2026, for an employee (Hospice Aide) hired on 04/16/2026 which revealed that there were no documented skills competencies for 2026. An interview and joint personnel record review was conducted on 08/06/2026 with the Administrator who advised they would get these skills competencies in the employee’s files updated immediately.”

“It is required that a patient clinical record contains correct clinical information that is available to the patient’s attending physician and hospice staff including physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) clinical records reviewed of patients that required recertification revealed the agency did not ensure the clinical record contained clinical information for the recertification of terminal illness. CLINICAL RECORD 4: The recertification of terminal illness for Benefit Period 2 (starting 10/14/2025), Benefit Period 3 (starting 01/12/2026), Benefit Period 4 (starting 03/13/2026) and Benefit Period 5 (starting 05/12/2026) included the following physician narrative: “Prognosis for the patient life expectancy is less than 6 months and patient is appropriate for hospice care with comfort measures.” CLINICAL RECORD 7: The recertification of terminal illness for Benefit Period 2 (starting 05/26/2025), Benefit Period 3 (starting 08/24/2025), Benefit Period 4 (starting 10/23/2025), Benefit Period 5 (starting 12/22/2025), Benefit Period 6 (starting 02/20/2026) and Benefit Period 7 (starting 04/21/2026) included the following physician narrative: “Prognosis for the patient life expectancy is less than 6 months and patient is appropriate for hospice care with comfort measures.” CLINICAL RECORD 9: The recertification of terminal illness for Benefit Period 2 (starting 04/01/2025), Benefit Period 3 (starting 06/30/2025), Benefit Period 4 (starting 08/29/2025) and Benefit Period 5 (starting 10/28/2025), Benefit Period 6 (starting 12/27/2025), Benefit Period 7 (starting 02/25/2026) and Benefit Period 8 (starting 04/26/2026) included the following physician narrative: “Prognosis for the patient life expectancy is less than 6 months and patient is appropriate for hospice care with comfort measures.” CLINICAL RECORD 12: The recertification of terminal illness for Benefit Period 3 (starting 05/05/2026) included the following physician narrative: “Prognosis for the patient life expectancy is less than 6 months and patient is appropriate for hospice care with comfort measures.” An interview was conducted with the Administrator on 08/05/2026 during which time he explained he had hired new consultants who had explained the certifications of terminal illness needed to have more information and they had been “working with the physician to make sure the Certificates of Terminal Illness included the required information.””