Rainbow Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary comprehensive assessment was completed within 5 days after the election of hospice. CLINICAL RECORD 7: The patient was admitted to hospice on 01/22/2026. The chaplain assessment was completed on 01/26/2026. The psychosocial assessment was not completed by the social worker until 01/28/2026, 6 days after the election of hospice. On 03/18/2026, the Administrator confirmed finding and stated, “We knew we would have some opportunities to improve.””

“It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed it was revealed that the agency did not ensure the plans of care included at least one of the required elements. CLINICAL RECORD 8: The patient was admitted on 02/06/2026 with a diagnosis of dissecting aorta. The SN assessment on 02/06/2026 revealed that the patient was using 4Liters of continuous oxygen and that the patient was anxious and medication was ordered for anxiety. The plan of care dated 02/06/2026 included one intervention to educate patient/caregivers on signs/symptoms of emergency cardiac/pulmonary symptoms and when /how to contact them. The plan of care did not contain orders to assess or manage the oxygen and did not contain orders to manage the patient anxiety. CLINICAL RECORD 22: The patient was admitted on 03/17/2026 to hospice and the inpatient unit. The patient was transferred from a hospital with a secondary diagnosis of urinary retention and a 16fr catheter in place as noted in the skilled nursing assessment on 03/17/2026. The plan of care dated 03/17/2026 did not provide orders for the care and management of the foley catheter. On 03/18/2026, the administrator(Personnel Record 3) reviewed clinical record 22 and reported that the information should have been included in the plan of care.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient, family, or patient’s legal representative(s). The Interdisciplinary Group ensures that the safe use and disposal of controlled drugs is understood and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed of patients who died at home it was revealed that the agency did not ensure that staff followed agency policy related to documentation of disposal of narcotic medications. Admissions Packet: The agency admission packet was provided to each patient upon election of hospice which contained education related to medication safety and disposal of controlled substances on page 40. The patient handbook read in part, “Caregivers will be instructed of safe disposal of controlled substances following federal prescription disposal guidelines in the event drugs are disposed of while a hospice nurse is not in the home. If a hospice nurse is in the home at the time of a narcotic pain medication change or at the time of a patient’s death, the nurse will instruct the caregiver to count any remaining controlled substances that will no longer be used and dispose of them. The nurse will document the name of the medication(s), amount disposed and the method of disposal on a nursing progress note or drug disposal form. Both the caregiver and nurse witnessing the disposal will sign the document indicating their presence during disposal. CLINICAL RECORD 15: The patient died at home on 12/07/2025. The prescribed medications included Morphine concentrate and Lorazepam concentrate. The death note did not include information about disposal of narcotics consistent with policy and patient handbook information. The death note indicated that the nurse arrived at the patient home upon family reporting death. The electronic medical record read “Medications - was family instructed regarding the 800# for approved medication disposal site” and the nurse documented “YES.” There was no further documentation related to medication disposal. There was no documented confirmation that medications were disposed of or specific medications or amounts. CLINICAL RECORD 17: Patient elected hospice on 02/15/2026 and died at home on 02/22/2026. The patient had orders for liquid morphine in the home. The death at home nursing note did not include medication disposal information consistent with patient handbook. The clinical record stated, Medications disposed per facility protocol. The patient was not residing in facility and there was no documentation related to a specific drug or amount disposed of or the specific manner of disposal. The records were reviewed with the administrator (Personnel Record 3) on 03/19/2026, who stated, “You are right, they should have documented the drug and the amount.””

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that the hospice inpatient facility had documented, dated written reports of Life Safety Code (LSC) quarterly fire drills conducted at varying times on all shifts. Additionally, this references K712 “Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift....” The IPU facility operates two 12-hr shifts per day. A review of the IPU facility fire drill logs on 03/19/2026 revealed that the log dated 12/30/2025 documented that a fire drill for that quarter was conducted at 9:35 AM and included the day-shift staff. The review of documentation revealed no documented additional fire drills at the IPU during that time frame. During an interview on 03/19/2025, the Regional Physical Plant Operations Manager stated that they have been following another organization’s standard of one fire drill per quarter. During an additional interview on 03/19/2025, the Facilities Manager agreed that they had only been conducting fire drills for one shift per quarter. The Hospice Director of Operations, who was present during this review, stated that they will begin conducting their own internal drill to capture all shifts each quarter. Review of the fire drill logs conducted on 3/19/2026 revealed that the agency did not ensure that fire drills were being conducted once per quarter per shift for IPU staff. Agency currently utilizes 2 12 hr shifts per day. Review of the fire drill log from December 30, 2025 indicated that the drill for that quarter was conducted at 9:35AM and only included day shift staff. During an interview with the regional physical plant Operations Manager, he stated that they have been following Joint Commission standards of one fire drill per quarter. During an additional interview with the Facilities Manager, she agreed that they had only been conduction fire drills for one shift per quarter. Hospice Director of Operations, who was present during this review, stated that they will begin to conduct their own internal drill to capture all shifts per quarter.”

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. The hospice inpatient facility (IPU) did not ensure that plumbing fixtures included control valves that automatically regulated the temperature of the hot water used by patients. During the tour of the IPU on 3/29/2026, the water temperature was measured at 120 degrees in patient room 14 and 115 degrees in patient room 15. The water temperatures were verified with an additional thermometer. During an interview on 3/19/2026, the IPU Facilities Manager and the Physical Plant Regional Manager, who were present for the IPU tour, agreed with the observed temperature and that the building’s hot water temperature needed to be adjusted. This was done immediately after the tour. During the tour of the IPU on 3/29/2026, it was revealed that the agency did not ensure regulation of hot water in the IPU. Water temperature was tested in room 14 at 120’. Water temperature was additionally tested in room 15 at 115’. Water temperatures were verified with an additional thermometer. During an interview with the IPU Facilities Manager and the physical plant Regional Manager on 3/19/2026, who were present for the tour, they agreed with the observed temperature and that the hot water temperature for the building needed to be adjusted. This was done immediately after the tour.”