All American Hospice Care, LLC

“Based on record review and interview, the Hospice agency failed to provide for the continued management of pain and symptom management for 1 (P-1) of 1 terminally ill patient who was discharged for cause (L512); and failed to provide a referral upon discharge for 1 (P-1) of 3 records reviewed to maintain continuity of care, resulting in the potential for patient decline and unmet care needs, (See L517). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR§418.52, Patient Rights.”

“Based on record review and interview, the Hospice agency failed to provide for the continued management of pain and symptoms for 1 (P-1) of 1 patient with a terminal illness and who was discharged for cause, resulting in the potential for decline in physiological functioning, unrelieved pain and overall unmet care needs at the end of life. Findings include: Patient #1 (P-1)’s start of care (SOC) was 12/24/25 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease and additional diagnoses that included Chronic Respiratory Failure with Hypoxia, Bipolar disorder and Chronic Pain. The Plan of Care (POC) ordered Skilled Nursing (SN), Medical Social Work (MSW) and Spiritual Care (SC) services to be provided. A review of the clinical record on 2/4/26 revealed the following: A SN visit note dated 1/2/26 documented, “Respiratory assessment findings: (Mark all that apply): Dyspnea (shortness of breath) on exertion, Decreased functional capacity, Abnormal breath sounds, cough, Diminished breath sounds, Oxygen dependent.” “No abnormal environmental/safety issues identified.” A SN visit Note dated 1/5/26 documented, “Diminished breath sounds, inspiratory/expiratory wheezing, abnormal breath sounds, moderate dyspnea, unable to tolerate any physical activity without discomfort, anxiety, reports taking Dilaudid (narcotic pain reliever) every 4 hours for breakthrough pain…, reports taking Clonazepam (sedative) for breakthrough anxiety.” “No abnormal environmental/safety issues identified.” A SN visit note dated 1/8/26, authored by the Registered Nurse/Case Manager (RN/CM/Staff-C) documented, “Her breathing is shallow and unlabored on 4L of Oxygen…, she has conversational dyspnea (shortness of breath). Lungs were diminished throughout and she has expiratory wheezes…, Earlier this week, writer ordered more Dilaudid for patient and she said it was never delivered. Her partner also confirmed it was never delivered. Writer called supervisor who called the pharmacy. The pharmacy stated it was delivered and was signed for by patient’s partner. Supervisor notified Physician and police department.” A SN visit note titled, “Hospice Unattended Live Discharge” dated 1/8/26 and authored by the Patient Care Manager (Staff-B) documented, “Patient had 42 tabs of Dilaudid 2mg at time of admission. Requested a refill on 12/30/25 at that time another 42 tabs were sent. On 1/5/26 RN/CM (Registered Nurse/Case Manager) sent 336 tabs. RN/CM (Staff-C) made a visit today 1/8/26 and patient stating she has not received the Dilaudid. I Phoned the Pharmacy and spoke with a pharmacist who confirmed the medication was delivered on 1/5 and signed by patient’s significant other. I spoke with Vice President of Clinical Operations to collaborate on missing medications, staff safety concerns and was recommended to D/C (discharge) for cause…, Patient was given phone number for another hospice for further needs.”On 2/4/26 at 4:02 p.m., during an interview, the Patient Care Manager (Staff-B) was asked what provisions were made for P-1 at discharge, specifically any continuing pain and symptom management care needs to which Staff-B responded, “Our care ends at discharge.” When asked if the Hospice assisted with referrals to another Hospice, Staff-B responded, “We gave her the number to another Hospice agency.” When asked if P-1 had a Primary Care Physician (PCP), Staff-B replied, “I’m not sure because she was transferred to us from another hospice.” When asked if he (Staff-B) checked to see if P-1 had a PCP, Staff-B replied, “No. I just looked at her referral papers.”The Hospice agency failed to ensure the patient’s pain and symptoms related to her terminal illness would be appropriately managed after discharge from the agency. Further, there was no documented evidence that the Hospice attempted to notify P-1’s PCP to ensure continuity of care.These findings were reviewed with, discussed and acknowledged by Staff-B during the above interview.”

“Based on record review and interview, the agency failed to provide a referral upon discharge for 1 (P-1) of 3 records reviewed to maintain continuity of care for dependence on supplemental oxygen, resulting in the potential for patient decline and unmet care needs. Findings include. Policy: Patient discharge, PE.20, 10/14/24 stated, “IX. Discharge for cause: A. If the Hospice determines, under a policy set by the Hospice and state and federal law, for the purpose of addressing discharge for cause that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the Hospice to operate effectively is seriously impaired, the Hospice will do the following before it seeks to discharge a patient for cause:1. Advise the patient that a discharge for cause is being considered.2. Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation to include members of the IDG/IDT;3. Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and4. Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the medical records.5. The Hospice must notify the Medicare contractor and State Survey Agency of thecircumstances surrounding the impending discharge. The Hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate. Patient #1 (P-1) had a start of care (SOC) date of 12/24/25 and a certification period from 12/24/25-2/21/26. P-1 had diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. During review of P-1’s record on 2/4/26, it was noted that the discharge visit note dated 1/8/26 documented that P-1 was discharged for cause (P-1’s hospice services were terminated due to alleged behavior by the patient or someone in their home being disruptive, abusive, or uncooperative behavior) on 1/8/26. There was no documented evidence in P-1’s record that any disruptive, abusive, or uncooperative behavior had taken place in the patient’s home to justify the hospice agency discharging P-1 for cause.Review of P-1’s SOC comprehensive assessment on 2/4/26 had documented under the assessment section, “Patient is alert and oriented X3. She is also lethargic at times She does complain of depressed mood and did state that she has occasional manic episodes. Her manic episodes present as increased anger which are triggered by feelings of that she has angered or let someone down. She also states that she has blacked out at times. Her significant other has not been able to state how long these episodes last, as he has PTSD, which is at times triggered by her anger. She complains of anxiety frequently, exacerbated by shortness of breath.“Patient is short of breath with any exertion. At rest her SPO2 (Oxygen saturation) is 83% on 2 liters and increased to 88% on 3 liters with respirations 22-24/minute with increased accessory muscle use. Patient needs assistance much of the time to stand and is able to ambulate with walker slowly for short distances but often needs 1 assist for stability. Patient does have occasional falls related to trying to get up by herself. Patient does complain of shortness of breath with minimal exertion. Patient has occasional expiratory wheezes with diminished lungs throughout.”“Patient does have hypotension, which can make patient dizzy and nauseated at times. Blood pressure 90/46 with heart rate 94. Patient has increased pain complaints from back neck and sacral area, as well as generalized pain. Pain is fairly well controlled with fentanyl 125 MCG every 72 hours, gabapentin, 800 MG three times a day, nabumetone 800 MG twice a day, cyclobenzaprine 5 MG 3 times a day and as needed, and dilaudid 2 MG 3 tablets every 4 hours as needed (which she uses average [sic] 2 times a day).”Under the Environmental section, environmental/safety assessment findings: “No abnormal environmental/safety issues identified.”Under the Respiratory section, abnormal respiratory findings: “Abnormal breath sounds, dyspnea (difficulty breathing) on exertion, dyspnea at rest, diminished breath sounds, and expiratory wheezes.”Under the Cardiovascular section, cardiovascular assessment findings: “Unable to tolerate any physical activity without discomfort, evidence of hypoxemia (low blood oxygen), exercise intolerance, inability to carry out tasks, increased symptoms with activity.”Under the Equipment/supplies ordered by hospice section, “Oxygen concentrator, oxygen cylinder, walker (wheeled) wheelchair.”Under the Medication management & administration section, “Reviewed DME (durable medical equipment) and patient currently has oxygen, wheelchair, and walker from metro medical. Will have new DME company deliver same [sic]. Will have previous DME picked up.”A registered nurse (RN) visit note dated 12/26/25 under Head to Toe assessment documented, “P-1 is laying on her couch oriented x3 but confused at times. P-1’s breathing is shallow and unlabored at rest on 4 liters nasal cannula. She has conversational dyspnea and will begin using accessory muscles. She fatigues extremely easily with conversation or activity. Her lungs have inspiratory and expiratory wheezes, and they are diminished throughout.”Under the Environmental/Safety Assessment Findings: “No abnormal environmental/safety issues identified.”A medical social worker (MSW) note dated 12/30/25 documented under the Environmental section, “Patient describes caregiver as supportive and helpful. Caregiver willing and able to take care of patient.”Under the Narrative section, “Patient is a 58 y/o widowed female, newly admitted to hospice. Patient reports financial stress related to an electric bill totaling approximately $1,800. Patient and significant other (Boyfriend) report desire to move to a lower-level house/condo/apartment due to patient’s physical decline. Patient reports her drivers license is expired, which is preventing approval for anew residence. Patient expressed appreciation for MSW assistance and is agreeable to ongoing social work 1-2 times per month. Patient lying on couch with oxygen in place. Alert and oriented x4. Patient appears weak and conserving energy, as evidenced by intermittently closing eyes while speaking. Patient presents with multiple psychosocial stressors, including financial strain, housing instability, transportation/identification barriers related to expired drivers license.”MSW scheduled an appointment with the secretary of state (SOS) to assist patient with renewing drivers license. MSW to complete a charity application through the foundation for potential assistance with moving costs when relocation planning progresses. MSW to continue providing psychosocial support, resource coordination, and assistance with housing and financial concerns. Patient agreeable to MSW visits 1-2 times per month or as needed.A chaplain visit dated 12/30/25 documented under Assessment, “Patient’s mother is in the hospital and her father is ill as well. They both live in Kentucky and the patient struggles with feeling so far away from them.”Under the Environmental section, “Patient describes caregiver as supportive and helpful. Caregiver willing and able to take care of patient.” Under the Narrative section, “Patient is laying on couch when chaplain arrived. Spouse present as well as the MSW. Patient is alert and able to have conversation. Patient shared history of illness, financial needs as well as spiritual needs. Not many supportive relationships locally.”An RN visit note dated 1/5/26 documented under vital signs, “Oxygen saturation 92% on 4 liters of oxygen. Under the Environmental section, Environmental/Safety Assessment Findings: No abnormal environmental/safety issues identified.” Under the Respiratory section, Respiratory Assessment Findings: dyspnea on exertion, decreased functional capacity, frequent rest periods, abnormal breath sounds, cough, increased recovery time, diminished breath sounds, expiratory and inspiratory wheezing, exercise intolerance, limited ability to carry out tasks, fatigue/weakness limits ability to talk, oxygen dependent.” Under the Narrative section, “Patient is laying on her couch in living room watching television accompanied by her partner. Her breathing is shallow and unlabored on 4 liters of oxygen via nasal cannula. She has conversational dyspnea and becomes extremely dyspneic with activity. Her lungs have inspiratory and expiratory wheezes and are diminished throughout.”An RN visit note dated 1/8/26 documented, “Patient is alert and oriented X3. Her breathing is shallow and unlabored on 4 liters of oxygen at rest, with conversational dyspnea. Lungs are diminished throughout with expiratory wheezes. Patient reports 3/10 generalized pain. She is taking dilaudid 6 MG every 4 hours as needed and it is effective. Earlier this week writer ordered more dilaudid for patient and she said it was never delivered. Her partner also confirmed it was never delivered. Writer called supervisor who called the pharmacy. The pharmacy stated it was delivered and was signed for by patient’s partner. Supervisor notified physician and police department.”An RN unattended Live discharge note documented, “Spoke with vice president of clinical operations to collaborate on missing medications, staff safety concerns and was recommended to discharge for cause. This writer and the executive director/administrator (Staff-A) phoned patient and informed her of decision and why. Patient was given phone number for another Hospice for further needs.”P-1 was discharged from the hospice agency with multiple physical, home, medication (O2), DME, and support needs. There was no documentation in P-1’s record of a hospice agency referral to a new hospice agency for continuity of care regarding all the patient’s extensive needs, including the much-needed O2.P-1’s DME note (undated) from company contracted by the hospice agency, had documented they picked up from the patient’s home an O2 concentrator, wheelchair, walker, O2 backup, O2 carry bag, O2 cylinder, and gel seat cushion on 1/20/26.”

“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: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] 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 measures 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, document review, and interview. Agency policy #TX.17 Medication List and Monitoring” stated in part, “The medication profile will also include dosage, frequency, route, schedule, allergies, verification of review” “Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order and in Plan of care, as well as communicated to the patient and/or caregiver. Changes in medication regimen will be updated as frequently as necessary to keep the profile accurate.” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications for actual or potential drug interactions. Clinical Record 1: The patient elected hospice care on 01/17/2024 with a diagnosis of coronary artery disease (CAD). The skilled nursing (SN) assessment dated 06/25/2024 documented that the patient was doing well with “Bumex QOD” (every other day). The medication profile was documented on 01/18/2024, with Bumex daily for five (5) days, and on 05/06/2024, with Bumex 0.5 mg daily. The medication profile was not updated with QOD frequency. A clinical record review revealed no physician order documented for this dose. Clinical Record 14: The patient elected hospice care on 04/15./2024 with a diagnosis of Alzheimer’s disease. The SN updated assessments dated 06/03/2024 and 06/17/2024 documented that cream was applied to a reddened area on the head of the patient’s penis. The medication profile did not document the cream. The nursing comprehensive visit dated 08/13/2024 documented that a peripheral catheter 22 gauge was inserted in the right hand for daily infusion of Rocephin (antibiotic). The medication profile was updated to include “Rocephin 1 gr daily,” delivered by infusion through a catheter in the patient’s right hand. The medication profile documentation did not include the diluent, the infusion rate, or what should be used to flush the intravenous (IV) catheter in which the antibiotic was infused. During an interview, the Area Clinical Manager stated that the medication profiles were not updated per agency policy.”

“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, document review, and interview. In 4 of 17 (24%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the HA received clear and specific written instructions for all patient care required. Clinical Record 4: The patient elected hospice care on 06/13/2024 with a diagnosis of cerebral vascular accident (CVA). The HA care plan dated 06/14/2024 assigned the HA the relevant tasks: bed bath and dressing each visit. The initial comprehensive assessment completed on 06/13/2024 documented wounds with dressings in place. The HA care plan did not provide the HA with instructions for what to do with the dressings on the left foot and heel, including the kerlix wrap and ace wrap, should the dressings become wet or fall off during personal care. Clinical Record 6: The patient elected hospice care on 04/01/2024 with a diagnosis of brain anoxia. The patient resided in a skilled nursing facility (SNF). The skilled nursing (SN) assessment visit note dated 05/17/2024 documented wounds on the patient’s coccyx and right gluteus with an order for border dressings. The SN visit note dated 06/04/2024 documented a wound on the patient’s left heel with a kerlix dressing. The HA care plan updated on 05/07/2024, 06/17/2024, and 06/27/2024 assigned the HA the relevant task: bed bath every visit. The HA care plan did not provide the HA with instructions for what to do should the dressings become wet or fall off during the bed bath. HA services were discontinued on 08/07/2024. Clinical Record 7: The patient elected hospice care on 10/11/2023 with a diagnosis of colon CA with metastasis (mets). The patient resided in a SNF. The patient initial comprehensive assessment documented that the patient had wound dressing on the coccyx and sacral area. The HA care plan was documented on 10/12/2024 with no documented updates. The HA care plan assigned the HA the relevant task: bed bath each visit. The HA care plan did not provide the HA with instructions for what to do should the dressings become wet or fall off during the bed bath. Clinical Record 14: The patient elected hospice care on 05/18/2024 with a diagnosis of coronary artery disease (CAD). The HA care plan was documented on 05/18/2024 with no documented updates. The HA care plan assigned the HA the relevant task: shower each visit. The SN comprehensive assessment dated 06/17/2024 documented that the patient had a skin tear on the right forearm with a dressing. The dressing was documented as present in the SN visit notes through 07/02/2024. The HA care plan did not include instructions for what to do should the dressings become wet or fall off during the shower. In addition, the SN visit note dated 08/13/2024 documented “RN inpatient unit initial assessment “ and the insertion of an intravenous (IV) catheter for infusion of daily antibiotics in the patient’s right hand. The HA care plan was not updated to include instructions for the HA to cover or protect the right hand during the shower. During an interview, the Area Clinical Manager stated that the care plans did not include directions for managing the patient’s dressings during the bath. A process improvement plan was put in place.”

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed that included additional physician orders, the agency did not ensure all required physician orders were documented. Clinical Record 1: The patient elected hospice care on 1/17/2024 with a diagnosis of coronary artery disease (CAD). The referral documented orders for a “16FR/10cc catheter” that could be changed for leakage or s/sx (signs or symptoms) of infection. The updated SN assessment dated 04/15/2024 documented that the catheter was irrigated with 30cc NS (normal saline). The updated SN comprehensive assessment dated 06/24/2024 documented that an “18FR /10cc” catheter was inserted. A clinical record review revealed no physician order documented for catheter irrigation or inserting the “18FR/10cc” catheter. Additionally, the skilled nursing (SN) assessment dated 06/25/2024 documented that the patient was doing well with “Bumex QOD” (every other day). The medication profile was documented on 01/18/2024, with Bumex daily for five (5) days, and on 05/06/2024, with Bumex 0.5 mg daily. A clinical record review revealed no physician’s order documented for “Bumex QOD.” Clinical Record 7: The patient elected hospice care on 10/11/2023 with a diagnosis of colon cancer with metastasis (mets). The initial plan of care dated 10/11/2023 ordered wound dressing to be changed daily for displacement or spoilage, and clean skin with wound cleaner, dab dry, and cover with ABD (abdominal pad) and paper tape. The location of the wound was not identified. The SN assessment dated 10/16/2024 documented that the coccyx and sacral area wound was cleaned, and calcium alginate and an absorbent dressing were applied and secured with tape. The plan of care orders did not document the wound care provided. Additionally, the patient was admitted with a Foley catheter identified on the initial comprehensive assessment dated 10/11/2023. There were no orders for the Foley catheter, a 16 Fr/10cc catheter. There were no physician orders for the frequency of catheter changes or potential flushing of the catheter. Clinical Record 8: The patient elected hospice care on 05/18/2022 with a diagnosis of congestive heart failure (CHF). The initial comprehensive assessment dated 05/18/2022 documented that the patient had a “16Fr/10cc” Foley catheter. In the SN assessment dated 04/04/2023, an 18FR/ !0cc Foley was inserted and continued with an every-other-week catheter change until 06/27/2023, when a “16Fr” catheter was inserted during an updated nursing assessment visit and was changed monthly until discharge. A clinical record review revealed no physician’s order documented for the “18 FR/10cc” Foley catheter or the determined frequency of catheter changes. Clinical Record 9: The patient elected hospice care on 06/08/2024 with a diagnosis of breast cancer. The initial SN comprehensive assessment dated 06/08/2024 documented that the patient had a 22FR/30cc Foley catheter that was a 3-way in place. The SN assessment dated 06/29/2024 documented that the catheter was flushed with 100 cc NS (normal saline). The patient then went to the emergency room for catheter placement, and a 16FR/10cc catheter was placed. A clinical record review revealed no physician’s order documented for flushing the catheter as of 08/15/2024. Clinical Record 14: The patient elected hospice care on 04/15./2024 with a diagnosis of Alzheimer’s disease. The SN updated assessments dated 06/03/2024 and 06/17/2024 documented that cream was applied to a reddened area on the head of the patient’s penis. The medication profile did not document the cream. A clinical record review revealed no orders were documented for the cream or application of the cream. The SN assessment dated 06/17/2024 documented the patient’s recent fall and a dressing applied to the right forearm. The SN assessment visit note dated 06/27/2024 documented that the area was cleaned, and steri-strips and a dressing were applied. A clinical record review revealed no physician’s order documented for this wound care. The SN comprehensive assessment dated 08/13/2024 documented that a peripheral catheter 22 gauge was inserted into the patient’s right hand for a daily infusion of Rocephin (antibiotic). The medication profile was updated to include the “Rocephin 1 gr daily.” A clinical record review revealed no physician’s order documenting the diluent, the infusion rate, or what should be used to flush the intravenous (IV) catheter in which the antibiotic was infused. During an interview, the Area Case Manager stated that the orders were not documented in the clinical records.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient who revoked hospice care, the agency did not ensure that the hospice forwarded a copy of the discharge summary to the physician. Clinical Record 8: The patient elected hospice care on 05/18/2022 and signed a revocation on 08/13/2023 to seek aggressive treatment at the hospital. The family took the patient to a hospital due to catheter trouble and frequent urinary infections. There was no documentation that the discharge summary was sent to the physician or the facility. During an interview, the Area Clinical Manager confirmed the finding.”