Affinity Hospice Care, Inc.

“Upon patient record review 3 of 14 (Patient #3, 4, 7) 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 #3: The patient was admitted 05/07/26. The initial psychosocial assessment was not completed until 5/15/26. The initial spiritual care assessment was not completed until 05/14/26. Patient #4: The patient was admitted 06/04/26. The initial psychosocial assessment was not completed until 06/11/26. Patient #7: The patient was admitted on 05/21/26. The initial psychosocial assessment was not completed until 05/30/26.”

“Upon patient record review 6 of 14 (Patient #1, 5, 6, 8, 9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: The patient was admitted on 04/25/26. There is no evidence of an initial psychosocial assessment being completed. Patient #5: There is no evidence in the record of an initial MSW or SC assessment. The RN did not include all required parts of a psychosocial or spiritual care initial assessment. Patient #6: There is no evidence in the record of an initial MSW or SC assessment. The RN did not include all required parts of a psychosocial or spiritual care initial assessment. Patient #8: Although it appears the MSW saw the patient on 06/09/26. The visit documentation is blank, leaving no evidence that there was a completed initial psychosocial assessment. Patient #9: The patient was admitted on 12/18/25. Although it appears the MSW saw the patient on 12/20/25. The visit documentation is blank, leaving no evidence that there was a completed initial psychosocial assessment.”

“Upon patient record review, 5 of 14 (Patients #1, 2, 3, 5, 8) 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 Patients #1, 2, 3, 5, 8: The patients are on oxygen. There is no evidence of oxygen on the medication profile.”

“Upon patient record review, 6 of 14 (Patients #1, 3, 4, 5, 8, 9) 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. Patients #1, 3, 4, 5, 8, 9: There is no evidence in the record of an initial bereavement assessment being completed by SC, RN, or MSW.”

“Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1: The patient is on Xarelto. There is no evidence of interventions and goals for the use of anticoagulants and teaching for bleeding precautions. The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #2: The patient is on Eliquis. There is no evidence of interventions and goals for the use of anticoagulants and teaching for bleeding precautions. The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #3: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #4: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #5: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #6: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. patient #7: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #8: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. The patient has a history of seizure disorder. There are no interventions or goals for seizure precautions. Patient #9: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items. Patient #10: The patient has orders for oxygen, nebulizer and suction machine there are no interventions or goals in the plan of care for use of each of these items.”

“Upon patient record review, 3 of 14 (Patient #3, 6, 8) 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 patient is prescribed diclofenac topical cream. The order does not include where the medication is to be applied. The patient is prescribed Lidocaine patches. There is no evidence that the order includes where this is to be applied. Patient #6: The patient has a reported surgical wound requiring a treatment order. The order reads, “Cleanse with NS, pat dry. Pack with Neosporin. The order does not include what to cover the wound packing with nor does it specifically state how often the hospice nurse will change or the caregiver will change. Patient #8: The patient is prescribed Chlorhexadine. The order does not specify where the medication is to be applied. The patient has an order for cortisone cream as needed for itching. There is no evidence as to where the cortisone cream is to be applied.”

“Upon patient record review, 4 of 14 (Patient #1, 5, 6, 8) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #1: The patient was started on Mucinex on 06/12/26 for worsening respiratory symptoms. There was no evidence of an update to the plan of care. Patient #5: On 02/10/26, the patient received Zofran and loperamide for complaints of nausea, vomiting and diarrhea. There is no evidence of any update to the plan of care. Patient #6: The patient was started on dextromethorphan for cough on 07/06/26. There is no evidence of any update to the plan of care. The patient was prescribed Norco per daughters request for stronger pain medication on 07/07/26. There is no evidence of any updates to the plan of care. Patient #8: During the IDG on 06/24/26, the medical director decreased carvedilol due to significant hypotension. There is no evidence of any update to the plan of care.”

“Upon client record review, 4 of 14 (Patient #1, 5, 7, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The MSW was ordered to see patient once monthly. There is no evidence of MSW visits in the record. Patient #5: The SC is ordered for once monthly visits. There is no evidence of spiritual care visits being completed. Patient #7: The Plan of care had orders for MSW monthly. There have been no MSW visits since 05/30/26. Patient #8: The plan of care contains orders for blood sugars to be between 70 and 90. There is no evidence of blood sugars being addressed during any nursing visits.”

“Upon patient record review 2 of 14 (Patients #2, 8) 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 #2: The patient has aide services ordered. The only evidence in the record of an aide supervision is on 11/25/25. That supervision visit was completed by an LVN. Patient #8: The patient was admitted 06/06/26 and is receiving aide services. There is no evidence of aide supervision in the record.”

“Observed in Leadership Session. the organization’s quality assessment and performance improvement program (QAPI) did not reflects the complexity of the organization and its services and involves all services provided by the organization, including those provided under contract or arrangement. In review of the organization’s QAPI plan there was no evidence that the hospice had included indicators or collected data for contracted services including DME, Pharmacy and Skilled Nursing Facilities providing GIP and Respite Care as well as Volunteer Services and Bereavement Services. This was discussed with and validated by the DPCS/Admin. 
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“Observed in Record Review. In 1 of 4 patient records reviewed, for patients who had expired documentation was found to be inaccurate. In review of the medical record for RRDC #1 the surveyor noted that the LVN documentation included pronouncement of the death of the hospice patient as evidenced by the visit note which stated, Pt seen and examined at 0815AM Pt lying on her back. Heart and lung sounds are absent. No spontaneous cardiac or respiratory activity. The patient is nonreactive to verbal or tactile stimuli. No pupillary reflex is present. Pupils fixed and dilated. Absent vital signs Pronounced dead at 0820. The physician was notified at 0830AM.. The DPCS/Admin produced the death certificate signed by the Medical Director which demonstrated that the pronouncement of death was actually 0830AM and the clinical note was not accurate. This was discussed with and validated by the DPCS/Admin. 
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“Observed in Record Review. In 1 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient’s progress toward desired outcomes and outcomes were not specific and measurable. For RRHV #1 the care plan included a problem of falls risk related to weakness and impaired balance with a goal for facility staff will demonstrate improved knowledge of fall prevention strategies and facility staff will verbalize at least three fall prevention strategies during education sessions.. The communication notes in the medical record documented a patient fall 8 weeks following the start of care where the patient sustained a head wound. The communication notes documentation included; cut/trim hair around wound. Patch him up/apply dressing, he needs neuro checks and although there were orders for wound care there were no orders for neuro checks and the care plan was not updated with patient specific goals and interventions. This was discussed with and validated with the DPCS/Administrator. Observed in Record Review. In 2 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient’s progress toward desired outcomes and outcomes were not specific and measurable. For RRHV #2 the care plan included the problem: Integumentary/Skin with a goal; Comfort will be promoted as skin integrity changes throughout disease and dying process, minimize risk of bedsores, and prevent potential skin problems for comfort however the care plan remained unchanged with no revisions or updates since the start of care 10 weeks ago. For example the IDG team failed to update the Integumentary/Skin problem and include newly ordered treatments for skin/wound care 4 weeks following the start of care, 6 weeks following start of care and 10 weeks following start of care. This was reviewed and validated with the DPCS/Admin. Observed in Record Review. In 3 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient’s progress toward desired outcomes and outcomes were not specific and measurable. In review of the medical record for RRHV #3 the care plan included the problem: Integumentary/Skin with the goal; comfort will be promoted as skin integrity changes throughout disease and dying process, minimize risk of bedsores, prevent potential skin problems for comfort. In review of the medical record a communication note 4 weeks following the start of care documented a call from the facility where the patient was residing reporting the patient was experiencing right hand swelling. An LVN visit occurred the next day and the facility staff was instructed to use rest, ice, compression, elevation (RICE) however there was no evidence of physician orders, communication with MD and revisions to the plan of care. This was discussed with and validated by the DPCS/Admin.”

“Observed in Record Review. In 3 of 10 patient records reviewed, the registered nurse did not conduct an on-site visit to the patient’s home no less frequently than every 14 days to supervise the hospice aide in accordance with the organization’s policy and law and regulation. In review of the medical record the surveyor noted that for RRHV #1 the eighth supervisory visit was conducted at 15 days. Supervisory visits by the RN were also found to be a day late and conducted on day 15 for RRHV # 3, and RRNHV #4. This was discussed with and validated with the DPCS/Administrator. 
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