Next Care Hospice Inc.

“Based on observation, interview, and record review, the hospice failed to ensure the medication profile was reviewed to include all current medications for one of three sampled patients (Patient 3). This failure had the potential to result in the patient not receiving appropriate care and necessary services, which could negatively affect the patient’s well‑being. Findings: Review of the hospice’s P&P titled Medication Profile dated 11/2022 showed the following:-During subsequent hospice visits, the medication profile will be used as a care‑planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but is not limited to:A. Using the medication profile to evaluate the use of medications in the home setting.B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications.C. Using the medication profile as a communication tool for other clinicians involved in the patient’s care. 1. Review of Patient 3’s clinical record was initiated on 5/4/26. The clinical record showed the SOC was 12/27/25. The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.The Medication Profile showed the patient’s medications as follows:-Jardiance (used to lower sugar with diabetes) 10 mg one tablet orally daily for diabetes.-Norco 5 mg–325 mg (opioid analgesic) one tablet orally every 4 hours as needed for moderate to severe pain.A joint home visit with RN 1 was conducted on 5/5/26 at 1100 hours, at the patient’s residence.Review of the patient’s medications with RN 1 showed the following:• Jardiance 10 mg one tablet orally daily for diabetes, was not available in the patient’s home.• Norco 5 mg–325 mg one tablet orally every four hours as needed for moderate to severe pain, was also not available in the patient’s home.On 5/5/26 at 1110 hours, an interview and concurrent clinical record review were conducted with RN 1 and Patient 3’s family member. The family member stated the patient had not been taking Jardiance for approximately one month and did not believe it was needed. They further reported that they had not used Norco 5 mg–325 mg for almost one month. Instead, Patient 3 had been taking Norco 10–325 mg one tablet orally every 8 hours as needed for severe pain.On 5/5/26 at 1130 hours, an interview was conducted with RN 1. RN 1 stated the nurse should have notified the physician of the medication changes and updated the medication profile accordingly. RN 1 acknowledged and verified the findings.”

“Based on observation, interview, and record review, the hospice failed to ensure the coordination of care related to timely ordering of medication delivery and verifying the prescribed medications were available and in stock for one of the three sampled patients (Patient 3). This failure had the potential to result in delayed medication administration and compromised continuity of care. Findings: Review of the agency’s P&P titled “Interdisciplinary Group Coordination of Care’ dated 11/22 showed personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Review of Patient 3’s clinical record was initiated on 5/4/26. The clinical record showed the SOC was 12/27/26. The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of Patient 3’s current Medication Profile showed the following:-Enemeez Rectal Enema Suspension (laxative) 283 mg one dose rectally one time for no bowel movement in three days for constipation.-hydromorphone hydrochloride (opioid analgesic) 4 mg (one ml) oral/sublingual one ml (4 mg) orally or sublingually every four hours as needed for pain or shortness of breath. A joint home visit with RN 1 was conducted on 5/5/26 at 1100 hours, at the patient’s home. Review of the Patient 3’s medications with RN 1 showed the following medications:-Enemeez rectal enema suspension 283 mg one dose rectally one time for no bowel movement in three days for constipation. This medication was not available at the patient’s home.-hydromorphone hydrochloride 4 mg (one ml) oral/sublingual one ml (4 mg) orally or sublingually every four hours as needed for pain or shortness of breath. The remaining 12 ml was expired on 5/4/26. On 5/5/26 at 1115 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated she should have ordered the medication supplies rectal enema suspension after she had used the last dose. RN 1 stated she should have ordered the medication hydromorphone hydrochloride 4 mg before it expired. RN 1 acknowledged and verified the findings. On 5/6/26 at 1000 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the medication supplies should had to be ordered two days before the stock runs out. The DPCS verified the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for one of three sampled patients (Patient 3). This failure had the potential for not providing appropriate, consistent, and quality care to the patient. Findings: Review of the hospice’s P&P titled Volunteer Services dated 2018, showed the Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care. Review of Patient 3’s clinical record was initiated on 5/4/26. The clinical record showed the SOC was 12/27/25. The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of Patient 3’s current Treatment/Medication/DME list showed Volunteer Services were offered but declined. The Volunteer Services would continue to be offered at each recertification.Review of the Communication Log dated 12/28/25, showed the Volunteer Coordinator reported that the family was contacted on 02/27/26, to schedule a visit; however, the patient/family declined services at that time. The Volunteer Coordinator documented they would attempt to contact the patient/family again at recertification. The note further indicated the patient/family was aware the Volunteer Services remained available 24/7 and that they could contact either the Volunteer Coordinator or the office if they changed their minds. The Volunteer Coordinator planned to reassess at recertification.On 5/6/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was asked whether Volunteer Services had been reassessed and reoffered at recertification for the certification period from 3/27/26 to 6/24/26. The DPCS was unable to provide documentation and stated that it should have been documented in the Communication Log. The DPCS acknowledged and verified the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plan was developed for one of three sampled patients (Patients 3). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patient’s health condition. Review of the hospice’s P&P titled The Plan of Care dated 11/22 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis, no less than every fifteen (15) days. The plan will focus on identified problems, goals, and interventions.Review of Patient 3’s clinical record was initiated on 5/4/26. The clinical record showed the SOC was 12/27/26. The patient was certified for hospice services during the certification periods from 12/27/25 to 3/26/26 and 3/27/26 to 6/24/26.Review of the POC/IDG Reviews dated 4/15 and 4/29/26, showed an order for hydromorphone hydrochloride 4 mg/ml oral/sublingual every four hours as needed for pain or shortness of breath and an order for Norco 10 mg–325 mg 1 tablet orally every eight hours as needed for severe pain. However, the IDG/POC Reviews dated 4/15 and 4/29/26, failed to show documented evidence the IDG had developed an individualized plan of care to address Patient 3’s pain.On 5/5/26 at 1110 hours, an interview was conducted with Patient 3’s family member. The family member stated Patient 3 had chronic knee and hip pain.On 5/6/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the DPCS. The DPCS was informed and verified the finding.”

“Observed in Record Review. In 7 of 14 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient’s individualized plan of care. During review of records 1, 2, 3, 7, 8, 9, and 10 it was noted that the visits made by disciplines were not in accord with visit orders. For example in record 2 the orders stated skilled nurse to visit 1 time per week but 5 nursing visits were made in a one week period. This was confirmed by the DPCS.”