Legacy Hospice LLC

“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, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviewed, in which the patient received oxygen, it was revealed that the agency did not ensure that oxygen was included on the medication profile. CLINICAL RECORD 8: The patient was admitted on 12/09/2024 with a diagnosis of Alzheimer’s Disease. The initial skilled nursing assessment dated 12/09/2024 noted that the patient was utilizing oxygen at 2 L (liters) and was dyspneic at rest. Skilled nursing note on 12/10/2024 documented that the patient required oxygen and that dose may be titrated 2-4 LPM (liters per minute) to keep oxygen levels above 90%. Oxygen was not included on the medication profile and there was no documentation the medication was included in the review process. In an interview with the Clinical Director, Administrator, and Clinical supervisor on 04/29/2025, the administrator stated that they were told by their consultant that oxygen no longer needed to be on the medication profile.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 2 (100%) clinical records reviewed, in which the patient had a wound and received aide services, it was revealed that the agency did not ensure the Registered Nurse (RN) provided specific instructions to the aide. CLINICAL RECORD 1: Patient elected the hospice benefit on 04/23/2025 with a diagnosis of unspecified severe protein-calorie malnutrition. The skilled nurse admission assessment revealed that the patient had a pressure ulcer on the sacrum which was covered with a dressing. A hospice aide was ordered for one time a week to provide the patient with a shower. The aide care plan, developed on 04/23/2025, did not include direction to the aide related to the dressing and what to do if the dressing became wet or dislodged. CLINICAL RECORD 4: The clinical record included physician orders on 04/15/2025 to perform wound care on the patient’s left shin skin tear. The order included covering the wound with an adhesive foam dressing. The hospice RN was ordered to change the dressing three times a week, facility staff is to change the dressing if it becomes soiled or dislodged. The aide was ordered two times per week and the tasks included skin care at every visit and showering on the first visit of every week. The aide care plan was updated on 04/16/2025 and 04/23/2025, neither update provided the aide with direction related how to manage the patient’s left shin and area with the dressing while showering. During an interview on 04/29/2025, the Clinical Director confirmed that the aide’s care plans did not provide direction to the aide related to how to provide personal cares while the patient had a wound dressing.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that the aide reported changes to the Registered Nurse (RN) as they related to changes to the plan of care. CLINICAL RECORD 1: A home health aide plan of care was developed by the RN upon admission to hospice on 04/23/2025. The aide services were ordered one time per week and included weighing the patient at the first visit of the month, transfer client from bed to chair and chair to bed every visit, assist to toilet every visit, shampoo weekly, hair care every visit, change linens weekly, document date of last BM every visit. The first aide visit of the month was 04/24/2025. The aide documented completion of a shower but documented that the patient’s weight was not completed due to patient preference, transfer from bed to chair, and chair to bed was not completed as the patient refused. The aide also documented that the patient refused assistance with toileting, shampooing, hair care, and that changing linens was not required during the visit, and no one was available to get an update on the patient’s last bowel movement BM. The aide did not document that a report was given to the RN related to the ordered tasks that were not provided. CLINICAL RECORD 3: The patient was admitted on 02/26/2025 with a diagnosis of Alzheimer’s Disease. The skilled nurse created an aide care plan on 02/26/2025 which ordered visits two times per week and included the task to weigh the first visit of every month. The first aide visit of March was completed on March 3, 2025. The aide documented that she did not weigh the patient because there was no aide available to assist with the weight. There was no documentation that the aide notified the RN that the aide could not obtain a required weight on the patient. In an interview with the administrator, clinical director and clinical supervisor on 04/29/2025, the leadership team reported that the aide had called and reported to the Registered Nurse but did not document the phone call.”

“It is required that a patient’s clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that all physician orders were included in the clinical record. CLINICAL RECORD 8: The patient was admitted on 12/09/2024 with a diagnosis of Alzheimer’s Disease. The skilled nurse assessment on 12/09/2024 and the nursing note on 12/10/2024 described the patient’s requirement for oxygen. The plan of care included oxygen precautions and an oxygen concentrator. The clinical record did not contain physician orders for the administration, dose, route and frequency of oxygen. In an interview and joint chart review on 04/29/2025, the clinical supervisor confirmed that the clinical record did not contain physician orders for oxygen therapy.”