Starlight Hospice

“Upon patient record review 4 of 14 records reviewed (Patient #2, #5, #6, #7) 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 #2: The record indicated the start of care was on 09/25/24. There was no evidence of the spiritual and or psychosocial comprehensive assessments being completed within 5 calendar days after the election of hospice care at the time of the survey. Patient #5: The record indicated the start of care was on 07/23/24. There was no evidence of the spiritual comprehensive assessment being completed being completed within 5 calendar days after the election of hospice care at the time of the survey. Patient #6: The record indicated the start of care was on 07/18/25. There was no evidence of the spiritual and or psychosocial comprehensive assessments being completed within 5 calendar days after the election of hospice care at the time of the survey. Patient #7: The record indicted the start of care was on 04/28/25. There was no evidence of the psychosocial comprehensive assessment being completed within 5 calendar days after the election of hospice care at the time of the survey.”

“Upon patient record review, 3 of 14 records reviewed (Patient #1,3,4) 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 #1: Upon home visit when the caregiver was asked about medication administration, he was giving his mother Acetaminophen 500mg one tab at bedtime, Ibuprofen 200mg one tab every a.m., adding Benefiber 2 teaspoons to her coffee daily, AREDS one tab twice a day and applying arnica gel to her left shoulder and left hip daily and as needed. These medications were not listed on the medication profile. Patient #3: Upon home visit when the caregiver was asked about medication administration she stated she was giving Lispro 100 units/ml SQ 2 or 3 units daily. The Lispro was prescribed to be given SQ 5 units daily. She stated the Hydralazine 25mg was being given twice a day, this was ordered Q6hours. She stated the Isosorbide Dinitrate 20mg was being given twice a day, this was ordered 3 times a day. Patient #4: The patient was receiving oxygen 1-2 LPM as needed for SOB or wheezing, there was no route of administration listed. COS.”

“Upon patient record review, 3 of 14 charts reviewed (Patient #2, #3, #6) 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 #2: There was no initial bereavement assessment completed within 5 days from the election date of hospice. Patient #3: There was no initial bereavement assessment completed within 5 days from the election date of hospice. Patient #6: There was no initial bereavement assessment completed within 5 days from the election date of hospice.”

“Upon patient record review, 1 of 14 records reviewed (Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #5: The record indicated an RN Comprehensive assessment update was complete on 7/30/25 and on 08/22/25. There was a comprehensive assessment due on 08/14/25 that was not completed.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #1: Upon home visit when the caregiver was asked about medication administration, he was giving his mother Acetaminophen 500mg one tab at bedtime, Ibuprofen 200mg one tab every a.m., adding Benefiber 2 teaspoons to her coffee daily, AREDS one tab twice a day and applying arnica gel to her left shoulder and left hip daily and as needed. There was no evidence of education to the patient/family on these medications.”

“Upon patient record review, 3 of 14 records reviewed (Patient #1, #3, #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: The record indicated the Chaplain and Social Worker visits were ordered as “prn” there was no scope and frequency to meet the patient and family needs. COS. Patient #3: The record indicated the Chaplain, Social Worker and Volunteer visits were ordered as “prn” there was no scope and frequency to meet the patient and family needs. COS. Patient #5: The record indicated the Chaplain visits were ordered initially and “prn”, there was no scope and frequency to meet the patient and family needs. COS.”

“Upon patient record review, 3 of 14 records reviewed (Patient #1, #2, #4) 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 #1: Upon home visit when the caregiver was asked about medication administration, he was giving his mother Acetaminophen 500mg one tab at bedtime, Ibuprofen 200mg one tab every a.m., adding Benefiber 2 teaspoons to her coffee daily, AREDS one tab twice a day and applying arnica gel to her left shoulder and left hip daily and as needed. There were no orders for these medications. Patient #2: The record indicated easy mix simply thick instant food thickener 200 packs, there was no order to include what fluid or how much to mix in each serving. COS. Patient #4: The record indicated the order for oxygen 1-2 LPM as needed for SOB or wheezing, the order did not include the route of administration. COS.”

“Upon patient record review, 4 of 14 records reviewed (Patient #1, #2, #3, #5) did not have evidence the hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: 1. All physician employees and those under contract must function under the supervision of the hospice medical director. 2. All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. 3. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. Patient #1: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date. Patient #2: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date.. Patient #3: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date. Patient #5: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date.”

“Upon patient record review 3 of 14 records reviewed (Patient #1, #5, #6) 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 #1: The record indicated an aide supervisory visit was due on 02/25/25 and was not completed. Patient #5: The record indicated an aide supervisory visit was due on 10/20/24 and was not completed. Patient #6: The record indicated an aide supervisory visit was due on 08/05/25 and was not completed.”

“Upon contract review, 1 of 3 contracts (Medical Director contract) reviewed did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care The written agreement under section 2.2 titled Duties and Responsibilities of the Medical Director states under (d) the Medical Director will perform face-to-face encounters as necessary. The medical director has been making face-to-face visits in the home and has board orders restricting him in making home visits.”

“Upon client record review, 5 of 14 (Patient #1, #2, #3, #5, #10) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #1: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date and would not be valid for CTI. Patient #2: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date and would not be valid for CTI. Patient #3: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date and would not be valid for CTI. Patient #5: The medical director made face-to-face visits and is currently on home visit restrictions due to board orders, effective 03/20/25, visit made after effective date and would not be valid for CTI. Patient #10: The record indicated the patient was in their 2nd benefit period from 04/16/25 to 07/14/25 there was no narrative and no physician signature on the CTI at the time of the survey.”

“Upon patient client record review, 9 of 14 charts reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: There was no evidence the patient chose a health care provider to include an attending physician, there was a place to chose or not to chose on the election of benefits form but the form was left blank. Patient #1, #2, #3, #4, #5, #6, #7, #8, #10: There was no evidence the patient received Notice of Non-covered items, services, and/or drugs determined by the hospice to be unrelated to the terminal illness and related conditions as to why items, services, and/or drugs are not covered. A form was given with signed receipts, all were blank, although there were non-covered drugs recorded in the patient’s records.”