Majestic Hospice & Home Health LLC

“Based on observation, record review, interviews, and review of the facility “Hospice & Home Health Handbook,” the facility failed to obtain written confirmation of receipt of the notice of patient rights and responsibilities and/or election of hospice benefits for two of 13 patients (Patients (P1 and P8) whose clinical records were reviewed. This had the potential to cause patients and representatives to be unaware of their rights and responsibilities. Findings include: 1. Review of P1’s electronic medical record (EMR) revealed P1 was admitted to hospice services on 07/07/25 with a terminal diagnosis of congestive heart failure. During a home visit observation and interview conducted on 12/16/25 at 12:00 PM, P1 was observed in his/her apartment. At this time, P1 was observed to be alert and oriented and could verbalize his/her needs. When P1 was asked if he/she received any written or verbal information regarding patient rights regarding hospice services, P1 stated, “I don’t know. Ask my daughter.” Review of the white folder with the hospice agency name that was provided to P1 and representative upon admission revealed no evidence that P1 or the representative of P1 signed they received the information pertaining to patient rights. The last page of the hospice handbook where a patient and/or representative would sign acknowledging all information regarding patient rights was received was blank. During a phone interview on 12/16/25 at 12:30 PM, when Family Member (FM) 1 of P1 was asked if he/she recalled receiving information regarding patient rights and also signing documentation that he/she received information, FM1 stated that he/she could not specifically remember anything about information on resident rights. FM1 then stated, “I recall a binder, but do not recall signing anything specific in it.” During an interview and review of P1’s EMR on 12/16/25 at 12:30 PM, the Administrator confirmed he/she could not provide documentation in the EMR to show that P1 or FM1 had signed acknowledging the receipt of patient rights information. 2. Review of P8’s EMR revealed P8 was admitted to hospice services on 09/24/25 with a terminal diagnosis of congestive heart failure. During record review of P8’s EMR and interview with the Administrator on 12/16/25 at 2:00 PM, the Administrator confirmed there was no documentation P8 or their representative had signed the election of hospice benefits form. The Administrator confirmed there was no documentation in the EMR to show that P8 or their representative had signed acknowledging the receipt of patient rights information. Review of the Hospice agency’s undated “Hospice & Home Health Handbook,” provided to hospice patients and their representatives upon admission, indicated all the hospice patient rights while receiving hospice services on Section 6-Bill of Patient Rights and Responsibilities- 6.1 “Patient Rights.” Further review of the handbook indicated a section at the end where the patient and/or representative would sign indicating they had received all the information provided to them regarding the patient’s rights and election of hospice benefits.”

“Based on interview, record review, and policy review, the agency failed to ensure the Interdisciplinary Group (IDG) collaborated to develop and revise care plans for one of two active patients (Patient (P) 2). This deficient practice had the potential to affect P2’s care needs. Findings include: Review of P2’s electronic medical record (EMR) revealed P2 was admitted on 08/28/25 with a terminal diagnosis of nontraumatic subarachnoid hemorrhage (brain bleed). On 12/17/25 at 10:00 AM, the Administrator provided a copy of P2’s “Comprehensive Care Plan” and a list of medications prior to P2’s home visit. a. Review of P2’s “Pain Care Plan,” dated 08/28/25 and provided by the Administrator, revealed, “Patient has chronic generalized pain related to terminal diagnosis and increased weakness.” Interventions included “Educate patient and/or care giver (s) on pain reduction and prevention techniques” and “Educate patient and/or care giver on pain medication regimen.” On 12/17/25 at 11:30 AM, P2 was observed to be alert but severely cognitively impaired as he/she was unable to answer simple questions. RN 2 asked P2 what his/her pain level was on a 0-10 pain scale (0 being no pain through 10 being severe pain). P2 could not answer the question. P2’s “Pain Care Plan” was not updated/revised to include an alternative method to assess pain based on P2’s declining mentation. b. During a random interview on 12/17/25 at 11:40 AM, an unnamed person who resided in the home stated, “I have to help [P2] up the stairs each night as [his/her] mind is getting worse. I tuck [him/her] in and make sure [he/she] is safe.” Review of P2’s “Falls Care Plan,” dated 08/28/25 and provided by the Administrator, revealed, “Patient confused and disorganized though (sic) process.” The care plan did not address the need for P2 to navigate stairs. There were no interventions to aid in the prevention of falls for P2. During an interview on 12/17/25 at 11:50 AM, RN 2 was asked if P2 lived upstairs. RN 2 stated, “Yes, [he/she] does.” RN2 was asked if P2 had any falls. RN 2 stated he/she was not aware of any falls. RN2 was asked if there had been any discussion regarding moving P2 to the first floor for safety. RN2 stated, “No, I don’t think the care giver has room as there are other people in those rooms.” RN2 stated there were no fall interventions in place for P2. c. Review of P2’s “CVA (cerebral vascular accident-stroke) Care Plan,” dated 08/28/25 and provided by the Administrator, revealed, “Pt will be free from injury pt/pcg [patient/care giver] will demonstrate improved coping behavior.” Interventions included “Instruct the pt/cg to monitor blood pressure daily especially before administering medication” and “Clinician to teach pt/cg the importance of Aspirin medication to CVA prophylaxis.” Review of P2’s current medication list revealed that P2 was not administered blood pressure medication or aspirin. During a phone interview on 12/18/25 at 8:45 AM, RN2 was asked how he/she addressed updates/revisions to the “Care Plan” to ensure it was patient-centered and individualized. RN2 stated, “I do not develop the care plan or revise it, but the QA [Quality Assurance] nurse does. They just send it back to me and I sign it.” Review of the agency’s policy titled, “IDG Care Planning Process,” revised 2014, revealed, “. . . In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems, Hospice will utilize data information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with . . . patient’s needs and goals as a priority . . .””

“Based on interview, record review, and policy review, the agency failed to ensure a psychosocial assessment was performed to facilitate a patient’s changing psychosocial needs and end-of-life care for one of two current patients (Patient (P) 2). This failure placed patients at risk of unmet care needs and a diminished quality of life. Findings include: Review of P2’s electronic medical record (EMR) revealed P2 was admitted to hospice services on 08/28/25 with a terminal diagnosis of nontraumatic subarachnoid hemorrhage (brain bleed). According to the election of benefits page, P2 was able to consent. During a home visit on 12/17/25 at 11:30 AM with Registered Nurse (RN) 2, P2 was noted to be unable to answer questions or communicate clearly. RN 2 confirmed that P2 had declined in cognition. RN2 stated that P2 lived in a group home (board and care) as he/she had no next of kin to be involved in his/her care. RN 2 stated, “There is only the caregiver here and other residents of the home.” RN2 was asked if Social Services was involved in P2’s care. RN 2 stated, “No, [he/she] declined services when [he/she] was admitted.” RN 2 was asked if he/she had communicated to the Interdisciplinary Group (IDG) regarding P2’s decline in an attempt to find a family member or attempt to obtain guardianship to assist P2’s end-of-life services. RN2 stated, “No.” Review of the EMR revealed no documentation that social services were involved in P2’s care. The administrator confirmed that there was no psychosocial assessment completed by social services since P2’s admission to hospice services. During the survey, Social Services was unavailable for an interview. There was no other Social Worker to fill her role. During an interview on 12/17/25 at 2:33 PM, the Administrator stated, “[P2] is not seeing Social Services, and there is no family or next-of-kin to assist him.” The Administrator confirmed that Social Services should have been involved in P2’s declining health and should have been assisting in end-of-life concerns. Review of the agency’s policy titled, “Coordination of Patient Care,” revised March 2013 revealed, “. . . Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement . . .””

“Based on record review, interview, and policy review, the facility failed to ensure Home Health Aide Registered Nurse (RN) Supervisory visits were conducted every 14 days as required for one of 13 sampled patients (Patient (P8). This had the potential to cause the patient not to receive quality care and services. Findings include: Review of P8’s “Plan of Care Physician Order,” located in the electronic medical record (EMR) and dated 09/24/25, indicated P8’s Start of Care (SOC) was on 09/24/25. The document indicated the coordination of care would include a Hospice aide to help with activities of daily living (ADLs). It further indicated P8 would receive hospice aide visits two times per week. Review of P8’s “Aide Care Visits,” located in the EMR, indicated the Hospice Aide visits began on 09/26/25 and continued as ordered twice a week (10/03/25, 10/07/25, 10/10/25, 10/14/25, 10/17/25, 10/21/25, 10/24/25, 10/28/25, 10/31/25, 11/04/25, 11/07/25, 11/11/25, 11/14/25 and 11/18/25) until the end of hospice services on 11/20/25. Review of P8’s EMR indicated only two “Hospice Aide RN (Registered Nurse) Supervisory Visits” were completed; on 10/24/25 and on 11/11/25. There was no documented evidence in the EMR that a RN Hospice Aide Supervisory visit was conducted within the required 14-day period on 10/08/25. During an interview and review of P8’s EMR with the Administrator on 12/16/25 at 2:00 PM, when asked if the Hospice Aide Supervisory visits were being completed every 14 days by the RN as required, the Administrator reviewed P8’s EMR and confirmed the Hospice Aide visits were to be provided twice a week. He/She stated, “The only RN supervisory visits that I could see completed were on 10/24/25 and on 11/11/25. There were no other visits.” He/She further stated, “There should have been one completed on 10/08/25 but I don’t see that was done.” Review of the agency’s policy titled, “Hospice Aide Supervision,” revised March 2013, indicated, “. . . All Hospice aide supervisory visits will be made at least every 14 days . . . To assure the appropriateness of Hospice Aide services and to maintain quality of care . . . At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met . . . In addition to ensuring the Hospice Aides furnish the care identified in the plan of care, RNs must assess the adequacy of the aide services in relationship to the needs of the patient and family. The supervisory visits must be documented in the patient’s clinical record . . .””