Passionate Care Hospice and Palliative Care, LLC

“Based on the review of policies and procedures, record reviews, and staff interviews, it was determined the hospice governing body and Administrator failed to organize, manage, and administer its resources to provide the hospice care and services to patients necessary for the management of the terminal illness and related conditions.Specifically, the administrator failed to do the following:Appoint a medical director that has admission privileges at one or more hospitals commonly serving the agency’s geographical area.Document the participation of all staff in fire drills and emergency exercises. Ensure the initial and continuous review and reconciliation of all patient drug profiles Findings included: 1. Review of the personnel file for the Medical Director failed to reveal documentation of admission privileges at one or more hospitals serving the agency’s geographical area.The requested policy from the agency regarding physician’s role/criteria does not address admission privileges. On 07/21/2026, at 1:30 PM, an in-person interview was conducted with the Executive Director (ED). The ED confirmed the contracted Medical Director did not have admission privileges in the agency’s geographical area. 2. Review of the agency’s binder titled “Emergency Preparedness,” failed to reveal documentation of all staff participation in fire drills and emergency exercises. Review of an undated “Emergency Operations Plan” policy revealed: Procedure: All new staff will be oriented to the emergency operations plan. Ongoing staff education will occur annually as part of an exercise or in response to an actual emergency. On 07/21/2026, at 11:30 AM, an office interview was conducted with the ED who acknowledged responsibility for the agency’s disaster plan. The ED confirmed the hospice agency failed to have drills and or emergency exercises that included participation from all staff. 3. Review of undated policy titled “Medication Reconciliation,” revealed the following: Policy: Hospice will reconcile patient’s medications at time of admission and on an ongoing basis. Procedure: At time of initial assessment, the RN will create and document a complete list of medications that patient is taking, including dose, route, and frequency.Any discrepancies will be reconciled by a RN with the patient’s physician.Discrepancies include duplications, omissions, changes, contradictions and/or unclear information. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. Record reviews for P1, P2, and P3 revealed the following: 1. Record review revealed P1 was admitted to hospice on 06/16/2026. Review of a document titled “Client Medication Report” revealed the following medications: Acetaminophen 650 mg (milligram) rectal suppository (for minor pain or fever)Dulcolax (bisacodyl) 10 mg rectal suppository (for constipation)Haloperidol 0.5 mg (for terminal agitation)Hyoscyamine 0.125 mg (for excessive secretions)Lorazepam 1mg (for terminal agitation)Morphine Concentrate 20 mg/ml (milligrams per milliliter) (for pain or shortness of breath)Promethazine 25 mg tablet (for nausea/vomiting) Further review of the clinical record at the facility where the patient resides failed to reveal updates or documentation of review or reconciliation by hospice nursing staff. 2. Record review revealed P2 was admitted to hospice on 04/25/2026. Review of document titled “Client Medication Report” revealed the following medications: Hyoscyamine 0.125 mg (used for excessive secretions)Lorazepam 1 mg (used for agitation)Morphine Concentrate 20 mg/ml (used for pain or shortness of breath)Promethazine 25 mg (used for nausea/vomiting) Further review of the clinical record at the facility where the patient resides failed to reveal updates or documentation of review or reconciliation by hospice nursing staff.3. Record review revealed P3 was admitted to hospice on 06/26/2026.Review of document titled “Client Medication Report,” revealed the following medications:Acetaminophen 650 mg rectal (used for a fever or pain)Dulcolax (bisacodyl) 10 mg rectal suppository (used for constipation)Hyoscyamine 0.125 mg (used for excessive secretions)Lorazepam 1 mg tablet (used for agitation)Morphine Concentrate 20 mg/ml oral syringe (used for pain/shortness of breath)Promethazine 25 mg (used for nausea/vomiting) Further review of the clinical record at the facility where the patient resides failed to reveal medication updates or documentation of reconciliation and ongoing monitoring of effectiveness by hospice nursing staff. On 07/21/2026, at 1:30 PM, an interview was conducted with the Executive Director (ED), who revealed that medications are supposed to be checked and reconciled by the nurse at every visit, but acknowledged that the medications have not been reconciled. The ED confirmed that all documentation had been received for P1, P2, and P3.”

“A Re-certification survey was conducted at Passionate Care Hospice and Palliative Care on July 20, 2026, and concluded on July 22, 2026. At the time of the survey, the agency was not in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control. The census was 17. Findings included: Review of the agency’s binder titled “Emergency Preparedness”, failed to reveal documentation of all staff participation in fire drills and emergency exercises. Review of an undated “Emergency Operations Plan” policy revealed: Procedure: All new staff will be oriented to the emergency operations plan. Ongoing staff education will occur annually as part of an exercise or in response to an actual emergency. On 07/21/2026, at 11:30 AM, an office interview was conducted with the Executive Director who acknowledged responsibility for the agency’s disaster plan. The Executive Director confirmed the hospice agency failed to have drills and or emergency exercises that included participation from all staff.”

“Based on review of policy titled, “Medication Reconciliation,” record reviews, and staff interview, it was determined the agency failed to document medication reviews and reconciliation for three of three sampled patients (P) (P1, P2, and P3)... Findings included: Review of undated policy titled “Medication Reconciliation,” revealed the following: Policy:Hospice will reconcile patient’s medications at time of admission and on an ongoing basis. Procedure:1. At time of initial assessment, the RN will create and document a complete list of medications that patient is taking, including dose, route, and frequency.Any discrepancies will be reconciled by a RN with the patient’s physician.Discrepancies include duplications, omissions, changes, contradictions and/or unclear information.2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. 1. Record review revealed P1 was admitted to hospice on 06/16/2026. Review of a document titled “Client Medication Report” revealed the following medications:Acetaminophen 650 mg (milligram) rectal suppository (for minor pain or fever)Dulcolax (bisacodyl) 10 mg rectal suppository (for constipation)Haloperidol 0.5 mg (for terminal agitation)Hyoscyamine 0.125 mg (for excessive secretions)Lorazepam 1 mg (for terminal agitation)Morphine Concentrate 20 mg/ml (milligram per milliliter) (for pain or shortness of breath)Promethazine 25 mg tablet (for nausea/vomiting)Further review of the clinical record at the facility where P1 resides failed to reveal updates or documentation of review or reconciliation by hospice nursing staff. 2. Record review revealed P2 was admitted to hospice on 04/25/2026.Review of document titled “Client Medication Report” revealed the following medications:Hyoscyamine 0.125 mg (used for excessive secretions)Lorazepam 1 mg (used for agitation)Morphine Concentrate 20mg/ml (Used for pain or shortness of breath)Promethazine 25 mg (used for nausea/vomiting) Further review of the clinical record at the facility where P2 resides failed to reveal updates or documentation of review or reconciliation by hospice nursing staff. 3. Record review revealed P3 was admitted to hospice on 06/26/2026.Review of document titled “Client Medication Report,” revealed the following medications:Acetaminophen 650 mg rectal (used for a fever or pain)Dulcolax (bisacodyl) 10 mg rectal suppository (used for constipation)Hyoscyamine 0.125 mg (used for excessive secretions)Lorazepam 1 mg tablet (used for agitation)Morphine Concentrate 20 mg/ml oral syringe (used for pain/shortness of breath)Promethazine 25 mg (used for nausea/vomiting) Further review of the clinical record at the facility where P3 resides failed to reveal medication updates or documentation of reconciliation and ongoing monitoring of effectiveness by hospice nursing staff.On 07/21/2026, at 1:30 PM, an interview was conducted with the executive director (ED), who revealed that medications are supposed to be checked and reconciled by the nurse at every visit, but acknowledged that the medications have not been reconciled. The ED confirmed that all documentation had been received for P1, P2, and P3.”