United Hospice Service

“Upon patient record review 3 of 21 (Patient #6, 11, 12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 06: The patient was admitted on 10/29/24, the initial comprehensive Psychosocial assessment was completed on 11/12/24. Patient 11: The patient was admitted on 2/12/25, the initial comprehensive Psychosocial assessment was completed on 2/21/25. Patient 12: The patient was admitted on 12/7/24, the initial comprehensive psychosocial assessment was completed on 12/16/24.”

“Upon patient record review 4 of 21 (Patient #1, 7, 10, 15) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 01: The patient was admitted on 4/1/25, a comprehensive spiritual care assessment has not been completed to date. Patient 07: The patient was admitted on 7/10/24, the patient declines spiritual care, but the record does not include a comprehensive spiritual care assessment to date. Patient 10: The patient was admitted on 4/22/25, the patient declines spiritual care, the record does not include a comprehensive spiritual care assessment performed by SW or RN. Patient 15: The patient was admitted on 5/12/25, the patient declines spiritual care, the record does not include a comprehensive spiritual care assessment performed by SW or RN.”

“Upon patient record review, 2 of 21 (Patient #7, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 07: The medication profile includes polyethylene glycol 17G packet, one packet by mouth daily. It does not include a diluent. Patient 09: The medication profile includes polyethylene glycol 17G packet, one packet by mouth daily. It does not include a diluent.”

“Upon patient record review, 9 of 21 (Patient #1, 7, 11, 12, 14, 15, 19, 20, 21) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 01: The patient was admitted on 4/1/25, the record does not include an initial bereavement risk assessment. Patient 07: The patient was admitted on 7/10/24, the record does not include a bereavement risk assessment to date. Patient 11: The patient was admitted on 2/12/25, the record does not include a bereavement risk assessment to date. Patient 12: The patient was admitted on 12/7/24, the initial bereavement risk assessment was completed on 4/29/25. Patient 14: The patient was admitted on 9/27/24, the initial bereavement risk assessment was completed on 4/25/25. Patient 15: The patient was admitted on 5/12/25, the record does not include an initial bereavement risk assessment to date. Patient 19: The patient was admitted on 5/1/24, the record does not include an initial bereavement risk assessment. Patient 20: The patient was admitted on 9/4/24, the record does not include an initial bereavement risk assessment. Patient 21: The patient was admitted on 12/11/14, the record does not include an initial bereavement risk assessment.”

“Upon patient record review, 3 of 21 (Patient #1, 3, 15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 01: Upon admit, the patient record includes documentation of 2+ edema to the right upper extremity and left lower extremity along with 3+ pitting edema to bilateral feet. The plan of care does not include interventions and goals for the management of the edema. Patient 03: The patient was admitted to the IPU on 4/30/25, with a primary diagnosis of colorectal cancer. She has a gastrostomy tube, nephrostomy tube, colostomy, a bowel obstruction with pain related symptoms and edema, the plan of care does not include any nursing related problems with interventions and goals. Patient 15: The patient was admitted on 5/12/24 with a diagnosis of pancreatic cancer, she has a secondary non-related diagnosis of diabetes mellitus type II and takes insulin Aspart Flex Pen 3 times daily per sliding scale, she also takes insulin Tresiba 7 units every morning, the patient record does not include a problem statement with interventions and goals for the management of the diabetes.”

“Upon patient record review, 1 of 21 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 03: The patient was admitted on 4/30/25, plan of care does not include frequency orders for skilled nursing or hospice aide visits.”

“Upon patient record review, 2 of 21 (Patient #7, 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 07: The medication orders upon admit for polyethylene glycol 17G packet, one packet by mouth daily, do not include a diluent. Patient 09: The patient record indicates that a foley catheter was placed “per family request” on 5/16/25, the patient record does not include an order for the foley catheter. Medication orders on 5/3/25 for polyethylene glycol 17G packet, one packet by mouth daily, do not include a diluent.”

“Upon patient record review, 2 of 21 (Patient #1, 7) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 01: The patient record includes documentation that the patient was experiencing loose bowels and orders were requested from the skilled nursing facility for Imodium. An order was entered on 4-3-25 for the Imodium A-D, the plan of care does not include a problem statement with interventions and goals for the management of the diarrhea. On 5/8/25 the patient record indicates that her Lasix was increased due to increased BLE edema, the plan of care does not include a problem statement with interventions and goals for the management of the edema. Patient 07: The patient utilizes aspirin 81mg by mouth daily for anticoagulation, the plan of care does not include bleeding precautions.”

“Upon patient record review, 1 of 21 (Patient #21) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 21: The patient record does not include a plan of care for bereavement services being provided for the bereaved.”

“Upon patient record review, 2 of 21 (Patient #3, 7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 03: The plan of care for hospice aid task assignments does not include a frequency for performing tasks of linen changes, oral care, showering, nail care, hair care, shampooing, skin care. Patient 07: The patient takes aspirin 81mg daily for anticoagulation therapy, the hospice task assignment does not include bleeding precautions.”

“Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 “exception number 1 and 2 and 19.3.6.3.6 number 2”. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction NFPA 80 5.2.3.5.2 Fire labels that have been painted over are in violation of NFPA 80 Standard for Fire Doors and Other Opening Protectives. Labels must be clearly visible and legible. Upon inspection, the identifying fire label plate attached to the facility patient and family laundry room has been painted and does not present a clearly visible label. NFPA 80: 5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited. Upon inspection it was observed that the fire rated door to the medication room was being permanently held in the open position using the weight of a mini fridge in the medication room, obstructing the door from closing should the fire alarm system become engaged.”

“Upon observation, there was no evidence cooking equipment is properly aligned with the fire suppression system. Cooking equipment in the commercial kitchen are noted to be wheeled appliances that are frequently moved for cleaning purposes. Changes or modifications to the hazard after installation of the fire-extinguishing systems shall result in reevaluation of the system design by a properly trained, qualified, and certified person(s). NFPA 96 Chapter 10.2.7.4, where it states “Changes or modifications to the hazard after installation of the fire-extinguishing systems shall result in reevaluation of the system design by a properly trained, qualified, and certified person(s).” Nozzle Alignment and Coverage: Ensure nozzles are correctly aligned to cover the cooking equipment and appliances they are designed to protect. Large commercial kitchens are known to have appliances on wheels that are mobile to make cleaning and operational activities easier. It is important to place these appliances back in the same spot they were previously placed. Do not rearrange the equipment, as you would be exposing your building to the risk of serious fire damage. The fire suppression system is specifically designed to extinguish a fire on each of the different cooking surfaces. If equipment is not aligned properly under the hood suppression system nozzles, then the system may not protect these surfaces. Nozzles pointed at floors, walls or non-cooking surfaces are not providing the necessary protection. It is observed that the facility kitchen has multiple cooking appliances that are on wheels and upon verbal discussion, the staff admit to moving the appliances for cleaning. Multiple ansul nozzles are not in alignment with protected area.”

“Upon observation, there was no evidence the hospice inpatient facility provides a sanitary environment. Sanitation: Ice machines must be cleaned and sanitized regularly to prevent bacterial and mold growth. This typically involves cleaning food-contact surfaces and removing any limescale or mineral buildup. Coffee machines should be cleaned and sanitized routinely to prevent the build up of contaminants. Upon observation it is identified that the facility utilizes a portable ice maker in the family kitchen, the ice machine is noted to have contaminants in the water supply, along with particles, limescale, and residue in the water holding tank. The facility does not have a cleaning policy or schedule for the ice maker. Upon observation it is identified that the Bunn coffee maker in the family kitchen has a significant amount of mold and contamination built up around the coffee filtering system. The facility does not have a cleaning policy or schedule for the coffee maker.”