Compassionate Hospice Care, LLC

“Upon patient record review, 3 of 14 (Patient #1,7,10) 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 1: RN documentation indicated that the patient was using using Tylenol for pain management. No evidence that the medication profile contained Tylenol orders. The active medication profile contains entries for Morphine as needed without any instructions for usage, Diflucan oral one time dose was ordered in the September 2025 remains on the active medication profile. Bactrim oral antibiotic for 7 days was ordered in September 2025 remains on the active medication profile. Patient 7: Active medication profile contains orders for Triple antibiotic ointment to be used PRN. No evidence that instructions were given on what part of the body that the antibiotic ointment is to be used. Patient 10: Active medication profile contains entries for acetaminophen 650mg rectally every 6 hours PRN. No evidence that instructions were given for when to use the medication.”

“Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 5: SN documentation indicated that the patient was having increased pain after paracentesis on 04/23/2026. The nurse documented they spoke with 2 different NP’s at that time, NP A.K. ordered for a culture of the fluid at that time. No evidence that a follow-up was completed.”

“Upon patient record review, 3 of 14 (Patient #2,3,4) 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 2: The plan of care has SW frequency ordered as PRN only. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits. Patient 3: The plan of care has SW frequency ordered as PRN only. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits. Patient 4: The plan of care has SW frequency ordered as PRN only. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits.”

“Upon patient record review, 4 of 14 (Patient #1,4,7,10) 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 1: RN documentation indicated that the patient was using using Tylenol for pain management. No evidence that an order was obtained for Tylenol. Patient 4: RN documentation indicated that the patient has a 14fr suprapubic catheter at the time of admission. No evidence that orders were received from a the physician that included the catheter size at the time that the chart was surveyed. Patient 7: Plan of care has orders for Triple antibiotic ointment to be used PRN. No evidence that instructions were given on what part of the body that the antibiotic ointment is to be used. Patient 10: Plan of care contains orders for acetaminophen 650mg rectally every 6 hours PRN. No evidence that instructions were given for when to use the medication.”

“Upon patient record review, 3 of 14 (Patient #1,4,5) 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 equipment and supply needs. Patient 1: The medical record indicated that patient was incontinent and uses incontinent supplies daily. No evidence that those supplies were included on the supplies list. Patient 4: The medical record indicated that patient was incontinent and uses incontinent supplies daily. No evidence that those supplies were included on the supplies list. Patient 5: The medical record indicated that patient uses PleurX drain kits twice a week for paracentesis. No evidence that those supplies were included on the supplies list.”

“Upon patient record review, 1 of 14 (Patient #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 7: The aide POC has orders for both bed bath and bath assist with the patient up to the chair. Both ordered to be completed twice a week.”

“Upon patient record review 3 of 14 (Patient #1,2,9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 1: No evidence that a registered nurse made an aide supervisory visit every 14 days between 03/13/26- 04/08/26. Patient 2: No evidence that a registered nurse made an aide supervisory visit every 14 days between 03/20/26- 04/08/26 and between 04/08/2026-05/06/2026. Patient 9: No evidence that a registered nurse made an aide supervisory visit every 14 days between 03/17/26- 04/21/26 and between 04/08/2026-05/06/2026.”