Atl Hospice and Palliative Care

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1/Clinical Record 1/Personnel Record 3 (Nurse Practitioner): The patient elected the hospice benefit on 01/29/2026 for a diagnosis of Alzheimer’s disease. The patient resided in a personal care home (PCH). During Home Visit 1 with the Nurse Practitioner on 04/07/2026 the hospice medication profile (printed on 04/07/2026) was compared to the PCH medication profile (printed on 04/07/2026). The Hospice medication profile contained the following medication(s) not listed on the PCH profile: Morphine 10mg/5ml, take 0.5 ml every 2 hours as needed (dated 03/09/2026); Acetaminophen 650 mg suppository every 4 hours as needed (dated 01/29/2026); Promethazine 25 mg every 4 hours as needed (dated 01/29/2026); Hyoscyamine 0.125 mg every four hours as needed (dated 01/29/2026); Bisacodyl 10 mg every day as needed (dated 01/29/2026). The following discrepancies were noted: Hospice had Depakote Sprinkles 125 mg, take 1 capsule twice daily (dated 01/29/2026) and PCH had Depakote Sprinkles 125 mg, take 4 capsules twice daily (dated 01/29/2026). The last comprehensive nursing visit was 04/03/2026. An interview was conducted with the Director of Nursing (Personnel Record 3) on 04/07/2026 during the Home Visit in which the medication discrepancies were confirmed. She responded it was the expectation that medications “were reconciled every visit by the registered nurse and that it appeared the Depakote had not been entered correctly upon admission by the admission nurse.” She further went on to explain that the “medications other than the Depakote were part of the hospice comfort kit and not placed on the PCH medication list as the care staff at the home were expected to call hospice before using.” She then agreed to place them on the medication list with instructions to call before using.”

“It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided clear and specific written instructions for the hospice aide’s plan of care. CLINICAL RECORD 3: The hospice aide care plan dated 01/06/2026 included the following relevant tasks: “Aspiration precautions, feeding assistance, encourage fluids, bed bath, comb hair, shampoo, shave with safety razor, brush teeth, clean and file nails, apply deodorant, apply lotion, visualize condition of skin and report to RN (registered nurse), peri care, change patient’s linens, tidy patient’s room.” All tasks were to be completed every visit with a visit frequency of five times weekly. Additional instructions were “patient receives wound care and patient has a colostomy.” The hospice aide care plan did not notify the aide of the location of the wound(s), nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. The patient had a Foley catheter placed 01/17/2026. The hospice aide care plan did not provide the aide with instructions for the care of the Foley. CLINICAL RECORD 17: The hospice aide care plan dated 01/31/2026 included the following relevant tasks: “Aspiration precautions, feeding assistance, encourage fluids, bed bath, comb hair, shampoo, brush teeth, clean and file nails, apply deodorant, apply lotion, visualize condition of skin and report to RN (registered nurse), peri care, change patient’s linens, tidy patient’s room.” All tasks were to be completed every visit with a visit frequency of seven times weekly. The patient was admitted on 01/31/2026 with a Stage IV wound on coccyx, covered with bordered foam dressing. The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. An interview and joint clinical record review was conducted with the Director of Nursing on 04/09/2026 during which time she agreed the aides should have notification of the wounds and wasn’t sure how the Foley wasn’t placed on the aide care plan.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program was conducted with the Volunteer Coordinator, (VC) Quality, Administrator and Director of Nursing on 04/08/2026, during which time the volunteer percentage for the last twelve (12) months (April 2025 to March 2026) averaged to 4.22%. The Administrator advised they were low in the summer quarter due to volunteer availability. They had changed the VC when they saw the data and have shown significant improvement beginning in the first quarter of 2026, with percentages above 5.5%. A review of the volunteer program was conducted with the Volunteer Coordinator, Quality, Administrator and Director of Nursing on 04/08/2026, during which time the volunteer percentage for the last twelve (12) months (April 2025 to March 2026) averaged to 4.22%. The Administrator advised they were low in the summer quarter due to volunteers being out traveling. They had changed the VC when saw data and have shown significant improvement beginning in the first quarter of 2026, with percentages above 5.5%.’”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed that required recertification revealed the agency did not ensure recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. CLINICAL RECORD 8: A review of the clinical record on 04/08/2026 revealed that Benefit Period 2 began on 12/29/2025, and the recertification of terminal illness was signed on 01/01/2026, one day outstanding. An interview and joint clinical record review was conducted with the Director of Nursing on 04/07/2026 during which time she agreed that it was signed late but did not have a reason as the “patient was reviewed in a timely manner.””