Faith Hospice Care

“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, document review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure the initial comprehensive assessments were completed within five calendar days after the election of hospice care. The agency’s policy 1-014 titled, Comprehensive Assessment dated May 2024 stated in part, “ A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care” CLINICAL RECORD 11: The patient’s representative signed the election of benefit on March 6, 2025. A review of the clinical record revealed the nursing assessment was conducted on March 6, 2025; the psychosocial visit was conducted on March 7, 2025; and the spiritual care assessment was completed on March 12, 2025. The spiritual care assessment was one day outstanding. An interview with the hospice Administrator (Personnel Record 7) and Clinical Director (Personnel Record 8) was conducted on June 24, 2026. The Clinical Director, after reviewing the clinical record, agreed the spiritual assessment was not completed within 5 calendar days of the election of benefit.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s prescription medication and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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, document review, interview and observation. In 1 of 3 (33%) home visits, the agency did not ensure the comprehensive assessment included an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. The agency’s policy 1-014, titled Comprehensive Assessment, dated May 2024, stated in part, “Review of current and related past medications, including prescription over-the-counter medications, supplements, herbal remedies, and alternative treatment.” HOME VISIT 3: The patient elected the hospice benefit on 05/12/2026. A review of the clinical record revealed the comprehensive assessment completed on 05/12/2026 and medication reconciliation documented haloperidol lactate 2mg/ml 0.5 ml (1 mg) every 4 hours as needed. During the home visit observation on 06/24/2026 with the Medical Social Worker (Personnel Record 3) the patient’s medications in the home were compared to the agency’s medication profile dated 05/12/2026. The caregiver reported during the observation visit that the drug was stopped “a long time ago” and is not present in the patient’s home. An interview was conducted with the hospice Administrator (Personnel Record 7) and Clinical Director (Personnel Record 8) on June 24, 2026. A review of the observation home visit revealed the medication profile compared to the medications in the home did not match.”

“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 or family or patient’s legal representative(s). The Interdisciplinary Group 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 3 of 3 (100%) clinical records reviewed, in which controlled medications were ordered, it was revealed that the agency did not ensure that a copy of the written policy and procedure for the management and disposal of controlled medications was provided to the patient, family, or legal representative. The agency policy MM.12 titled, Controlled Drug Disposal, dated September 15,2023, was available to the interdisciplinary group members to provide to patient or family or patient’s legal representative(s). CLINICAL RECORD 3: The patient’s representative elected the hospice benefit on May 12, 2026. A review of the clinical record revealed an order for Morphine concentrate 20 mg/ml 0.25 ml by mouth every hour as needed for pain or shortness of breath on May 12, 2026. The RN documented on May 12, 2026, that the patient’s representative was informed and agreed to the new medication order; however, there is no documentation that hospice’s written policies and procedures for the management and disposal of controlled medications were provided to the patient, family, or legal representative. CLINICAL RECORD 4: The patient elected the hospice benefit on November 3, 2025. A review of the clinical record revealed an order for Fentanyl 50 mcg/hour patch transdermal every 72 hours on February 12, 2026. The RN documented on February 12, 2026, that the patient was informed and agreed to the new medication order; however, there is no documentation that hospice’s written policies and procedures for the management and disposal of controlled medications were provided to the patient, family, or legal representative. CLINICAL RECORD 5: The patient elected the hospice benefit on July 10, 2025. A review of the clinical record revealed an order for Morphine concentrate 20 mg/ml 0.25 ml by mouth every hour as needed for pain or shortness of breath on July 10, 2025. The RN documented on July 10, 2025, that the patient was informed and agreed to the new medication order; however, there is no documentation that hospice’s written policies and procedures for the management and disposal of controlled medications were provided to the patient, family, or legal representative. An interview was conducted with the Administrator (Personnel Record 7) and Clinical Director (Personnel Record 8) on June 23, 2026. The finding was explained in relation to the condition of participation. They acknowledged that the policy and procedure for the management and disposal of controlled medication were not provided to the patient, family, or legal representation when the controlled medication was ordered.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) records reviewed, it was revealed that the agency did not ensure each patient’s individualized plan of care included interventions based on problems identified in the comprehensive assessment. Clinical Record 3: The election of benefit was dated 9/29/23. The initial comprehensive assessment dated 9/29/23, documented the terminal diagnosis of senile degeneration of the brain. The following care plan problems were initiated on 9/30/23: depression; fall risk; Genitourinary; impaired ADL’s; impaired mobility; pain; and neurological/memory/confusion. There were identified goals for each problem. However, the care plan did not include planned interventions for these problems. A joint record review was completed with the agency Electronic Medical Record (EMR) Specialist. During an interview on 11/10/23, the EMR Specialist and Director of Nursing confirmed the finding and stated, “The nurse was new when she did this, but the preceptor and IDG (interdisciplinary group) should have caught it.””

“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 1 of 5 (20%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the registered nurse (RN) provided written care instructions for the hospice aide to follow. Clinical Record 3: Election of benefit was 9/29/23, with a terminal diagnosis of senile degeneration of the brain. RN initial assessment (9/29/23) documented that hospice aide services were requested, and the patient needed assistance with activities of daily living. The plan of care (POC), effective 9/29/23 to date, listed the hospice aide visit frequency order as two times a week, effective 10/1/23. The hospice aide care plan revealed the RN “opened the problem” for aide services on 9/30/23. However, the care plan goal(s) and interventions were blank. Therefore, no written care instructions were prepared for the hospice aide. Hospice aide visits were documented on 10/3/23, 10/5/23, 10/10/23, 10/13/23, 10/19/23, 10/24/23, 10/26/23, 10/31/23, 11/2/23, 11/7/23, and 11/9/23. The hospice aide visits documented the following: 10/3/23, “Coordinated cares with hospice RN and facility staff. Shower given, two persons assist for transfers and cares due to behaviors, oiled skin after shower, transferred to wheelchair and brought to living room”; 10/10/23, “Coordinated with facility staff. no concerns”; and 10/19/23, “Patient refused shower. coordinated with facility staff and case manager.” A joint record review was completed with the agency Electronic Medical Record (EMR) Specialist. During an interview on 11/10/23, the EMR Specialist and Director of Nursing confirmed the finding and stated, “The nurse was new when she did this, but the preceptor and IDG (interdisciplinary group) should have caught it.””