Family First Hospice & Palliative Care LLC

“Based on policy titled “PC.H25 Hospice Aide/Personal Care Aide/Personal Aide Assignments and Duties,” record review and staff interviews, it was determined that the Certified nurse aide (CNA) failed to report significant condition changes to the Registered Nurse (RN) for one patient (P) P#1 of three sampled patients. Findings include: Review of the undated policy titled “PC.H25 Hospice Aide/Personal Care Aide/Personal Aide Assignments and Duties,” reveals the following:Policy:PC.H25 Hospice Aide/Personal Care Aide/Personal Aide Assignments and DutiesThe Hospice Aide/Personal Care Aide functions in a supportive relationship to professional disciplines and may function as an extension of these professional services with written instructions, appropriate supervision and specialized hospice training.Procedure:6. The duties of the Hospice Aide/Personal Care Aide may include but are not limited to, the following:g. Reporting changes in the patient’s condition and needs to a registered nurse.7. Hospice Aide/Personal Care Aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as changes relate to the plan of care and quality assessment and improvement activities. Review of the visit note dated 10/27/25 the certified nurse aide (CNA) BB revealed that P#1 had blood in his catheter and was short of breath. The note failed to reveal documentation that the changes in P#1 were reported. During an interview on 11/10/25 at 2:00 p.m. with CNA BB, who stated that on 10/27/25 she was late arriving to care for P#1. She stated that there was blood in his catheter, CNA BB stated that she noticed that P#1 was short of breath and she placed the oxygen cannula over his nose before leaving. CNA BB stated that she reported that P#1 had blood in his catheter and was short of breath to the business officer manager at the end of her visit at 12:00 p.m. She confirmed she failed to report the change in condition to the RN, CM per agency policy. During an interview on 11/10/25 at 3:00 p.m. with the business office manager (BOM) who confirmed that on 10/27/25 she received a call from CNA BB informing her that P#1 had blood in his catheter and was short of breath. The BOM confirmed that she failed to report to RN AA, and she failed to coordinate a visit to assess the changes in P#1. :”

“Based on clinical record reviews, and staff interviews, it was determined the agency failed to manage and provide hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions, specifically the facility failed to ensure the Certified Nurse Aide (CNA) reported the changes in P#1’s condition to the Registered Nurse (RN). Findings include: Cross Reference to L0628 related to hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities.”

“Based on policy titled “PC.C90 Coordination of Services,” record review, and staff interviews, it was determined that the agency failed to communicate and coordinate the needs for one patient (P) P#1 of three sampled patients. Findings include:Review of undated policy titled “PC.C90 Coordination of Services,” revealed the following:Policy:The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines.If, during the home care visit, there are observed or communicated significant changes in the patient’s condition or needs, such findings shall be communicated to the patient’s hospice care team in a sufficiently timely manner to ensure that the patient’s care and safety needs are addressed.Procedure:1. The hospice will maintain a system of communication and integration, in accordance with hospice’s own policies and procedures,c. Ensure that the care and services provided are based on all assessments of the patient and family needs. An office interview was conducted on 11/12/25 at 3:30 p.m. with the Administrator, who confirmed that the Certified Nurse Aide (CNA) failed to report significant changes with P#1 to Registered Nurse (RN) case manage per the hospice coordination of services policy. The Administrator confirmed that P#1 was admitted to the hospital with a diagnosis of septic shock. Review of emergency department documentation dated 10/27/25 revealed that P#1 was received unresponsive with bloody purulent urine output. P#1 was admitted with a diagnosis of septic shock (a life-threatening immune system reaction to an infection) in critical condition to the critical care unit.”

“Based on clinical record reviews, policy titled “PC.H25 Hospice Aide/Personal Care Aide/Personal Aide Assignments and Duties,” and staff interviews, it was determined the agency failed to ensure the Certified Nurse Aide (CNA) reported the changes in P#1’s condition to the Registered Nurse (RN). Findings include: Review of the undated policy titled “PC.H25 Hospice Aide/Personal Care Aide/Personal Aide Assignments and Duties,” reveals the following:The Hospice Aide/Personal Care Aide functions in a supportive relationship to professional disciplines and may function as an extension of these professional services with written instructions, appropriate supervision and specialized hospice training.6. The duties of the Hospice Aide/Personal Care Aide may include but are not limited to, the following:g. Reporting changes in the patient’s condition and needs to a registered nurse. Review of Certified Nurse Assistant (CAN) BB’s note dated 10/27/2025 for P#1 revealed that patient had shortness of breath and bloody urine in the foley catheter bag. CNA BB’s visit note failed to reveal that the findings were reported to Registered Nurse (RN) /Case Manager (CM). Review of the CNA BB note revealed that CNA BB left P#1’s home at 12:00pm. Review of P#1’s RN AA visit note dated 10/27/25, revealed that RN AA arrived at P#1’s home at 1:28 p.m. RN AA called the ambulance at 1:48 p.m. Ambulance arrived at 2:01 pm. P#1 transferred to hospital at 2:12 p.m.. P#1 was taken to the hospital via ambulance due to patient being unresponsive and bloody urine in the foley Catheter. Interview with RN AA on 11/10/25 at 1:39 pm., revealed that RN AA was not notified by the CNA BB of changes in patient’s condition. RN AA stated that the sitter of P# 1, who is employed at another health care agency, reported the change in condition to the RN AA at 12 noon. Interview on 11/10/25, approximately at 2:00 p.m., with the CNA BB revealed that on 10/27/25, CNA BB visited P#1 and observed foley bag with bloody urine and patient had shortness of breath. CNA BB verbalized that CNA BB did not report patient’s condition and the bloody urine in the foley catheter bag to the RN/CM, per agency policy. Interview with BOM at 3:00 p.m., revealed that RN/CM was not notified of the reported current assessment of the patient and P#1’s blood in urine foley catheter bag. Interview on 11/10/25, approximately at 3:30 p.m., with the Administrator revealed that P#1 was admitted to the hospital on 10/27/25 with septic shock (a life threatening immune system reaction to an infection) was placed on a ventilator (a type of breathing apparatus by moving breathable air into and out of the lungs).”

“Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, including failed to ensure the Certified Nurse Aide (CNA) reported the changes in P#1’s condition to the Registered Nurse (RN).Findings include: Cross Reference to L0628 related to hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a Registered Nurse, as the changes relate to the plan of care and quality assessment and improvement activities.”

“Based on record reviews and staff interviews, it was determined that the agency Interdisciplinary Team (IDT) failed to ensure the skilled nurse care and services were provided as ordered in the plan of care (POC) for one patient (P) (P7) of 14 sampled records reviewed. Findings include: Review of clinical record revealed a verbal order dated 8/22/2024 for P7. The skilled nurse received a physician’s order for an x-ray for anterior/posterior and lateral views of right hip due to patient fall on 8/19/2024. The clinical record failed to reveal documentation of the completion of the ordered x-ray and that physician was notified the x-ray ordered failed to occur. The SN failed to follow physician’s order to ensure the x-ray was completed as ordered. During an interview at the agency with the Administrator on 9/11/2024 at approximately 11:30 a.m., the Administrator was unable to provide evidence that the x-ray was completed as ordered. According the Administrator, the mobile x-ray unit was dispatched to the patient’s home on 8/22/2024 to complete the x-ray but were unable to get into the home as the caregiver did not allow them inside the gate to access the home. Administrator reports mobile x-ray attempted to contact the caregiver three times but were unable to access the home. The Administrator also revealed the clinical record lacks any evidence or documentation that Mobile X-ray was at the home or that the caregiver denied access to the patient. The Administrator acknowledged the plan of care was not followed as the order for x-ray has not been followed and the hospice team made no further attempts at a later date to ensure the physician’s order for x-ray was completed. During a telephone interview with Registered Nurse (RN) AA on 9/11/2024 at approximately 2:12 p.m., RN AA revealed she completed an as needed (PRN) visit to the patient on 8/22/2024 after receiving a call from caregiver on 8/22/2024 reporting the patient had fallen. RN AA reports assessing the patient and the caregiver stating the patient fell on 8/19/2024 and not on 8/22/2024. RN AA revealed she obtained an order from the physician on 8/22/2024 for an x-ray due to the patient’s complaint of right hip pain. RN AA revealed the x-ray was not completed as ordered and did acknowledge that as of 9/11/2024 the patient has not received an x-ray of hip. RN AA confirmed the plan of care was not followed as the order for x-ray has not been followed.”

“Based on review of records, staff interviews, and policy review, it was determined the hospice failed to ensure care planning and coordination of services maintain a system of communication and integration in accordance with the hospice’s own policies and procedures; the care and services are provided in accordance with the plan of care; care and services provided are based on all assessments of the patient and family, and the ongoing sharing of information between all disciplines providing care and services in all settings were met for one patient (P) (P7) of 14 sampled patients. Findings include: Review of the clinical record for P7 revealed the patient sustained a fall on 8/19/2024. Registered Nurse (RN) AA completed an as needed (PRN) visit on 8/22/2024 to assess the patient for the fall as the patient was complaining of right hip pain. The physician was notified of the fall and patient’s complaint of pain and received a physician’s order for an x-ray for anterior/posterior and lateral views of right hip due to patient fall on 8/19/2024. The clinical failed to reveal documentation of the completion of the ordered x-ray and documentation that the physician was notified of the x-ray ordered failed to occur. The agency staff failed to coordinate with the physician to ensure the patient was evaluated for a hip fracture or other injury. Review of the undated policy titled “ PC.C90 Coordination of Services,” reveals the following: Procedure: a. ensure that the team maintains responsibility for direction, coordination and supervising the care and services provided. d. to ensure the ongoing sharing of information between all disciplines providing care and services in all settings The clinical record lacked coordination of care between care team members to ensure the patient received care and services for optimal care, comfort and safety. During a telephone interview on 9/11/2024 at approximately 2:55 p.m. with the Medical Director (MD), it was confirmed that the mobile x-ray was ordered on 8/22/2024 due to the patient’s complaint of right hip pain. The MD reported that she was under the assumption that the x-ray had been done and was not made aware that as of 9/11/2024 the patient still had not had an x-ray of the right hip. The MD did acknowledge that the mobile x-ray would be reordered on 9/11/2024 and if the mobile x-ray could not be done then the order would be written for the hospice to send the patient to the emergency room to ensure the x-ray was completed to rule out injury. On 9/11//2024 at 12:00 p.m., an office interview with the Administrator confirmed the clinical record was incomplete in that it did not reflect agency policy to ensure coordination of care regarding the patient’s health status and caregiver response to the current care plan with the hospice care team. The Administrator further confirmed the clinical record lacked communication with the physician regarding the failure to complete the x-ray as ordered.”

“Based on record reviews, review of policy “PC.C90 Coordination of Services,” and staff interviews, it was determined the hospice governing body failed to ensure the plan of care had been followed, failed to ensure effective coordination of care efforts were made to ensure care and services were provided as ordered for the necessary palliation and management of the terminal illness and failed to ensure the clinical record contained clear, completed and accurate information for one patient (P) (P7) of 14 sampled patients. Findings include: 1. Review of a verbal order dated 8/22/2024 for P7 revealed the skilled nurse (SN) received a physician’s order for an x-ray for anterior/posterior and lateral views of right hip due to patient fall on 8/19/2024. The clinical record failed to reveal documentation of the completion of the ordered x-ray and documentation that the physician was notified that the x-ray ordered failed to occur. The SN failed to follow the plan of care and physician’s order to ensure the x-ray was completed as ordered. During an interview at the agency with the Administrator on 9/11/2024 at approximately 11:30 a.m., the Administrator was unable to provide documentation that the x-ray was completed as ordered. According the Administrator, the mobile x-ray unit was dispatched to the patient’s home on 8/22/2024 to complete the x-ray but was unable to get into the home as the caregiver did not allow them inside the gate to access the home. Administrator reports mobile x-ray attempted to contact the caregiver three times but were unable to access the home. The Administrator also revealed the clinical record lacks any evidence or documentation that Mobile X-ray was at the home or that the caregiver denied access to the patient. Administrator further confirmed the hospice team made no further attempts at a later date to ensure the physician’s order for x-ray was completed and the plan of care was not followed as the order for x-ray has not been followed. During a telephone interview with Registered Nurse (RN) AA on 9/11/2024 at approximately 2:12 p.m., RN AA revealed she completed an as needed (PRN) visit to the patient on 8/22/2024 after receiving a call from caregiver on 8/22/2024 reporting the patient had fallen. RN AA reports assessing the patient and the caregiver stating the patient fell on 8/19/2024 and not on 8/22/2024. RN AA revealed she obtained an order from the physician on 8/22/2024 for an x-ray due to the patient’s complaint of right hip pain. RN AA revealed the x-ray was not completed as ordered and did acknowledge that as of 9/11/2024 the patient has not received an x-ray of hip. RN AA confirmed the plan of care was not followed as the order for x-ray has not been followed. 2. Review of the clinical record for P#7 revealed the patient sustained a fall on 8/19/2024. RN AA completed an as needed (PRN) visit on 8/22/2024 to assess the patient for the fall as the patient was complaining of right hip pain. The physician was notified of the fall and patient’s complaint of pain and received a physician’s order for an x-ray to anterior/posterior and lateral views of right hip due to patient fall on 8/19/2024. The clinical record failed to reveal documentation of the completion of the ordered x-ray and that the physician was notified that the x-ray treatment ordered failed to occur. The agency staff failed to coordinate with the physician to ensure the patient was evaluated for a hip fracture or other injury. The clinical record failed to reveal coordination of care notes to indicate an effective interchange of information regarding the status of the patient. Review of the undated policy titled; “ PC.C90 Coordination of Services,” reveals the following: Procedure: a. ensure that the IDG maintains responsibility for direction, coordination and supervising the care and services provided. d. to ensure the ongoing sharing of information between all disciplines providing care and services in all settings The clinical record lacked coordination of care between care team members to ensure the patient received care and services for optimal care and safety. During a telephone interview on 9/11/2024 at approximately 2:55 p.m. with the Medical Director (MD), it was confirmed that the mobile x-ray was ordered on 8/22/2024 due to the patient’s complaint of right hip pain. The MD reported that she was under the assumption that the x-ray had been done and was not made aware that as of 9/11/2024 the patient still had not had an x-ray of the right hip. The MD did acknowledge that the mobile x-ray would be reordered on 9/11/2024 and if the mobile x-ray could not be done then the order would be written for the hospice to send the patient to the hospital to ensure the x-ray was completed to rule out injury. On 9/11/24/2024 at 12:00 p.m., an office interview with the Administrator confirmed the clinical record was incomplete in that it did not reflect agency policy to ensure coordination of care regarding the patient’s health status and caregiver response to the current care plan with the hospice care team. 3. Review of the clinical record for P7 revealed a physician order dated 8/22/2024 for P7 to have an x-ray of the right hip after complaining of right hip pain from a fall on 8/19/2024. Further review of the clinical record indicated RN AA visited the patient on 8/22/2024 for a post fall assessment. The physician was then notified of the fall and ordered and x-ray of the right hip. However, the clinical record failed to reveal documentation that mobile x-ray was called or attempted to see the P7 and documentation to indicate P7 was assessed at the Emergency Room for the fall. The skilled nurse (SN) visit note dated 8/22/24 reveals the fall happened on 8/22/2024 however, later in the note the SN documents the fall occurred on 8/19/2024 per the caregiver. The agency failed to ensure the clinical record contained clear, complete and accurate documentation. On 9/11/24 at 10:00 a.m., during an interview at the office with the Administrator it was confirmed the clinical record lacked documentation to show that the mobile x-ray had been called to perform the x-ray and it was also confirmed that RN AA failed to clearly document in the record when the fall actually occurred. It was confirmed the clinical record also lacked coordination of care notes to ensure the physician was made aware that orders for the x-ray had not been carried out. Additionally, it was confirmed the record lacked follow up with the physician regarding the need reorder the x-ray to rule out fracture or other injury. The Administrator was unable to provide any documentation of communication with Mobile x-ray. On 9/11/24 at 10:15 a.m., during a telephone interview with RN AA, RN AA revealed having spoken with Mobile X-ray at least three times to coordinate the x-ray however, RN AA failed to document any Mobile x-ray communications in the record.”