Superior Hospice Inc.

“Upon patient record review 3 of 14 (Patient #2, #6, #8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2: Start of care date was 1-6-26. The psychosocial comprehensive assessment was completed on 1-12-26. There is no evidence the psychosocial comprehensive assessment was completed within the first 5 days of admission. Patient #6: Start of care date was 10-30-25. The psychosocial comprehensive assessment was completed on 11-10-25. There is no evidence the psychosocial comprehensive assessment was completed within the first 5 days of admission. Patient #8: Start of care date was 12-19-25. The psychosocial comprehensive assessment was completed on 12-27-25. There is no evidence the psychosocial comprehensive assessment was completed within the first 5 days of admission.”

“Upon patient record review, 3 of 14 (Patient #3, #7, #9) 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 #3: The medication profile indicates patient is to receive refresh plus eye drops to install 1-2 drops in affected eye. The medication profile does not define which eye for administration. Patient #7: During home visit, the facility medication record indicated the patient was to receive Aleve as needed and Lorazepam scheduled at bedtime but was not present on the hospice medication profile. Patient #9: The medication profile indicates patient is to receive MiraLAX 17 gm scheduled daily for constipation. The medication profile does not indicate the amount of liquid required for reconstitution prior to administration. During the home visit the caregiver stated he has not needed to administer MiraLAX at this time. The medication profile states the medication is scheduled daily.”

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: Start of care date was 12-19-25. The bereavement risk assessment was completed on 12-27-25 which is outside of the 5 day requirement.”

“Upon patient record review, 4 of 14 (Patient #3, #7, #8, #9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: The record indicated an order for refresh plus eye drops to install 1-2 drops in affected eye. There was not evidence indicating which eye to administer the medication. Patient #7: Aleve as needed and Lorazepam scheduled at bedtime were noted on the facility mar but there was no evidence of an order in the hospice record. Patient #8: On 5-18-26 the patient had a stage II wound on coccyx and a stage III to the right outer lateral knee with wound assessments and dressing changes being performed by the patient’s caregiver and the hospice clinical team. There is no evidence of wound orders present in the medical record indicating location of wound, treatment, frequency of dressing changes and who is responsible for completing. Throughout the medical record it is noted the patient has a nephrostomy tube. Documentation states tube maintenance is being performed daily and dressing changes to be completed weekly without an active order. Patient #9: The record indicated an order for MiraLAX 17 gm scheduled daily for constipation. The order did not include the quantity of liquid to reconstitute the medication prior to administration.”

“Upon patient record review, 4 of 14 (Patient #1, #2, #5, #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Documentation was present stating this patient utilizes both a wheelchair and walker for mobility. There is no evidence the aide plan of care was updated to include the equipment and was lacking instructions for when the aide was to utilize this equipment. Patient #2: Documentation was present noting the patient was a diabetic and utilized oxygen therapy as needed for shortness of breath. There is no evidence the aide care plan was updated to reflect diabetic precautions or oxygen @ 2liters via nasal cannula as needed. Patient #5: Documentation noted in by the registered nurse that the patient was a high aspiration risk. There is no evidence the aide plan of care was updated to reflect aspiration precautions. Patient #8: Documentation in the medical record states patient has a wound with an adhesive dressing in place and nephrostomy tube with a dressing in place. There is no evidence the aide plan of care was updated to reflect the location of the wounds and lacking additional instructions to notify the nurse if the dressings are soiled, becomes wet or dislodged during cares. The medical record indicates the patient is to utilize heel protectors while in bed. There in no evidence the aide plan of care provided instructions on application of heel protectors.”

“Upon patient record review 2 of 14 (Patient #5,#8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5: On 7-2-26 the aide visit note does not indicate that bathing cares were provided. Patient #8: The aide plan of care bathing tasks indicated the aide to provide a bed bath, shower and shower chair at every visit. The aide documented all 3 bathing tasks were completed.”

“Upon patient record review 2 of 14 (Patient #5, #7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #5: The registered nurse completed a hospice aide supervisory visit on 6-16-26 and not completed again until 7-14-26. This is outside of the 14 day requirement. Patient #7: A registered nurse completed a hospice aide supervisory visit on 6-26-26 and not completed again until 7-14-26. This is outside of the 14 day requirement.”

“Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #7. During a home visit the hospice binder and facility hard chart was reviewed for the required paperwork. There was no evidence the signed certification and recertification CTI, initial and most recent hospice plan of care and current hospice medication record was present in facility binder at the time of survey.”