Faith Hospice & Palliative Care, 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: 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 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 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure a medication reconciliation was completed and medications were updated on the medication profile. CLINICAL RECORD 5/HOME VISIT 1: The election of benefits was completed 12/08/2025. The patient resided in an assisted living facility (ALF). The medication profile printed on 08/26/2026 included Vibegron (Gemtesa 75 mg tablet, 1 tablet daily oral started 12/24/2025, Equate vision formula with lutein, 1 tablet by mouth daily with food, started 07/13/2023, Ocuvite lutein capsule, 1 capsule by mouth daily for eye health, started 08/14/2025, and lidocaine (Lidocaine pain relief 4% patch) adhesive patch, apply 1 patch to area of pain every 8 hours as needed for pain, started 02/05/2024. During the home visit on 08/29/2026 with the hospice aide (Personnel Record 8), the medications at the facility were reviewed. The facility medication record did not include the Vibegron and lidocaine adhesive patch as needed for pain. The facility nurse stated that the Vibegron was discontinued on 03/16/2026 and there was no documentation for the lidocaine patch as needed. The agency medication record had duplicate medications ordered for Equate Vision Formula with lutein, 1 tablet by mouth daily with food, started 07/13/2023, and Ocuvite lutein capsule, 1 capsule by mouth daily for eye health, started 08/14/2025. The record lacked evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. CLINICAL RECORD 1/HOME VISIT 2: The election of benefits was dated 11/06/2025. The patient resided in an ALF. The medication profile printed on 08/28/2026 was reviewed. During the home visit on 08/29/2026 with the Chaplain (Personnel Record), the medication at the facility revealed Sacubitril-Valsartan 24-26 mg tablet, 1 tablet by mouth twice a day, started 04/01/2026, and Cranberry 250 mg capsule, 4 capsules (1000 mg) by mouth daily, started 02/18/2026. Sacubitril-valsartan and Cranberry were not included in the agency’s medication record. The record lacked evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 08/29/2026, the Director of Operations/Administrator (Personnel Record 1) confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview which revealed the agency did not provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Review of the volunteer program documentation revealed a volunteer percentage of 0.65% for 2025 and 2.61% for 2026 from January through July. The agency started a Performance Improvement Project initially on 06/19/2024 that focused on recruiting, training, and utilizing volunteers in the hospice operations. Another PIP was initiated in April 2026 to onboard new volunteers to assist with the increase in provided hours, coordinate with the Interdisciplinary Team to identify patients with volunteer opportunities and meet with the Volunteer Coordinator monthly to discuss progress. During a joint review and interview on 08/29/2026 with the Volunteer Coordinator (Personnel Record 9) and the Director of Operations/Administrator (Personnel Record 1) of the volunteer program records, the Volunteer Coordinator discussed the current state of the volunteer program and the efforts made to improve it since they started in the position in 2024. The Volunteer Coordinator and the Director of Operations confirmed that the agency did not meet the minimum requirement of volunteer hours equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2025. Upon reviewing the volunteer program, the documentation revealed a volunteer percentage of 0.65% for 2025 and 2.61% for 2026 from January through July. The agency started a Performance Improvement Project initially on 06/19/2024 that focused on recruiting, training, and utilizing volunteers in the hospice operations. Another PIP was initiated in April 2026 to onboard new volunteers to assist with the increase in provided hours, coordinate with the Interdisciplinary Team to identify patients with volunteer opportunities, and meet with the Volunteer Coordinator monthly to discuss progress.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) provided care in its entirety to meet the needs of the patient, in one of three records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Interdisciplinary Group Coordination of Care,” dated May 2024, showed in part:- The hospice interdisciplinary group will retain professional management responsibilities for the provision of services and will ensure services are furnished in a safe and effective manner;- The case manager will be responsible for coordination of services with the IDG from admission to discharge;- The type and scope of services provided by the IDG will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care (POC) that defines patient and family/caregiver problems, goals, and interventions;- The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice;- It will be the responsibility of the case manager to facilitate communication about changes in the patient’s status between IDG members and the patient’s attending physician;- Hospice personnel will communicate changes in a timely manner, documentation of all communication will be documented in the clinical record;- Written evidence of care coordination will be found in the POC and/or IDG meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician; and- The IDG (in collaboration with the patient’s attending physician, if any) will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 days. Review of the provider’s policy titled, “Interdisciplinary Group Meeting,” dated May 2024, showed in part:- The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC; and- An IDG meeting POC update form will note changes, response to treatment, and progresses toward targeted outcomes, which may include, but not (be) limited to nutritional status, pain management, and plan for changes in treatment or procedures. Review of the provider’s policy titled, “PEG (Gastrostomy)/Eternal Tube Management-Hospice,” dated 08/01/2025, showed in part:- Enteral Tube: PEG, G-tube, J-tube, GJ-tube used for nutrition, hydration, and/or medication delivery (PEG, G-tube, J-tube, enteral tube - a tube placed surgically through the abdominal wall into the stomach or intestine for the administration of food, fluids, and medication) ;- To establish safe, patient-centered, comfort-focused standards for assessment, care, medication administration, feeding, troubleshooting, and documentation for patients with percutaneous endoscopic gastrostomy (PEG) or other enteral access (G-tube, J-tube, GJ-tube) receiving hospice services;- Care aligns with goals of care (comfort/quality of life) and the hospice plan of care; - New tube placement after hospice admission is generally not pursued; any exception requires MD (medical doctor) approval, IDG review, and documentation that the intended benefit is palliative (comfort) rather than life-prolonging; - Care is provided per manufacturer IFU (instructions for use), evidence-based practice, and state nurse practice standards;- RN (registered nurse): Initial/ongoing assessment, education, competency validation, tube/skin care, feeding/med admin protocols, troubleshooting, documentation, escalation;- LPN (licensed practical nurse): Performs care within scope under RN supervision;- Medical Director/Attending: Orders, risk–benefit review, decisions on initiation/continuation/taper/discontinuation; and- IDG: Reviews goals, outcomes, complications, and POC at least every 15 days or with change in condition. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 12/06/2023 with a terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood). Other pertinent diagnosis included malignant neoplasm (a cancerous tumor) of the lower right bronchus (major air passages of the lung) or lung, malignant neoplasm of the larynx (the hollow muscular organ forming an air passage to the lungs and holding the vocal cords), presence of automatic cardiac defibrillator (a battery-powered device that monitors and treats abnormal heart rhythms with electrical impulses), and tracheostomy (trach) tube (a surgical opening in the airway in the windpipe to facilitate breathing). The patient resided at home with his/her spouse who was the primary caregiver. The patient revoked services on 06/04/2025 due to issues with the G-Tube that were not addressed during the hospice nurse visits. Review of the nurse’s note dated 05/08/2025 at 2:12 PM, showed the following:- The patient was short of air (SOA) and anxious;- The patient had a fall one week ago and had a skin tear on the left forearm and right eye;- The patient was complaining of pain in his/her back and rated the pain at a seven (7) on a pain scale of zero to 10 (zero representing no pain and 10 representing the worst pain possible);- The patient requested the nurse to apply Aspercreme (a topical pain reliever used for minor aches and pains in muscles and joints) patches to his/her back for relief;- The patient was hypertensive (had elevated blood pressure) 118/96 and one (1) plus edema (swelling of tissues) in the bilateral lower extremities (BLE);- The patches helped alleviate some pain and the patient rated the pain five out of six (5/6);- The patient denied chest pain but stated that he/she took a nitroglycerin tablet (used to treat certain heart conditions and to widen the opening in blood vessels) about a week ago for chest pain; - Wound care was provided to the skin tear on the right eye and left forearm; and- Shortness of breath, anxiety, chest pain, edema, hypertension, and SOA were secondary to decreased cardiac output. (The clinical record failed to show physician notification of the patient’s fall with injuries, use of Aspercreme, elevated blood pressure, edema, and chest pain.) Review of the nurse’s note dated 05/08/2025 at 9:39 PM, showed the following:- The patient was short of air (SOA) at rest and it took him three to five minutes to recover, wore oxygen as needed and mostly at night; and- The patient stated that he/she had chest pain over the weekend and had to take one nitroglycerin tablet. (The clinical record failed to show the physician was notified of the patient’s SOA and chest pain.) Review of the nurse’s note dated 05/15/2025 at 1:05 PM, showed the following:- The patient was sitting outside on his/her golf cart, was hunched over, and appeared weak and in pain;- The patient complained of pain in his/her back and rated the pain a nine (9);- The patient took an as-needed Norco (used to treat moderate to moderately severe pain) one hour prior to the nurse’s arrival;- The patient reported having chest pain yesterday that “came and went” but did not take anything for the pain, education was provided on utilizing nitroglycerin for chest pain;- The patient had three (3) plus edema in the lower left extremity and two (2) plus edema in the right lower extremity;- The patient forgot to take his/her furosemide (diuretic) that morning and education was provided on taking medications as prescribed;- Wound care was provided on the left arm laceration;- Education was provided on conserving energy and not over exerting self to prevent fall; and- The patient reported the pain had decreased to a tolerable level of 7. (The clinical record failed to show physician notification of the pain rated at a 9 despite taking Norco an hour prior to the nurse’s arrival, chest pain, increase in edema, and the fall with injuries.) Review of the nurse’s note dated 05/19/2025 at 2:55 PM, showed the following:- The patient’s spouse reported the patient had a varicose vein (a condition in which a vein becomes permanently enlarged, twisted, and painful) rupture a few days ago in the left leg. The patient had Tubigrips (brand, an elastic, tubular bandage) on and had increased edema for the last week. The spouse had to gently cut off the Tubigrip to get it off of the patient’s leg;- The patient had a pool of blood in his/her shoe and on the deck, where he/she had been sitting when this happened;- The patient’s toes were a bluish color on both feet with 2 plus edema to both lower extremities and feet;- The patient stated his/her tube feedings came back up last night, “it” (the feeding) came up into his/her throat and nose for approximately 2 hours after the feeding was finished;- He/she had difficulty catching his/her breath during that time; and- The nurse educated on the possible need to split tube feedings up into smaller amounts with more frequent feedings and the patient stated that he/she would do this if it kept happening. (The clinical record failed to show physician notification of the ruptured varicose vein, toes a bluish color, edema, the tube feeding coming up into his/her throat, and the patient’s difficulty catching his/her breath. The documentation failed to show whether the nurse checked the tube for placement). Review of the nurse’s note dated 05/26/2025 at 2:08 PM, showed the following:- The patient complained of 9/10 pain; - He/she took a Norco not long before this visit;- The patient stated that pain was worse, lately, and he/she was not getting much relief even with using the lidocaine patch (a topical pain medication) on his/her back;- The physician was notified to switch Norco to Oxycodone (used to treat moderate to severe pain), as needed (11 days after the patient’s pain had increased); and- The patient had conversational dyspnea (shortness of breath) and dyspnea with ambulation (walking), patient had oxygen as needed at 2 to 10 liters via trach. Trach care was performed per the patient’s request.(The documentation failed to show physician notification of the dyspnea. The nurse failed to offer education to the patient regarding adjustment of the flow rate (the physician orders failed to include specific adjustment of flow rate), and how to administer the oxygen (i.e. higher flow rate nasal cannula or mask) and if a humidifier was needed with use of a higher flow rate.) Review of the nurse’s note dated 05/29/2025 at 12:52 PM, showed the following:- The patient had still been having some tube feeding come up into his/her throat and was trying to split the feeding up in smaller amounts at a time;- Bowel sounds were hypoactive (decreased intestinal activity);- Trach care was completed per the patient’s request;- The patient had 3 plus edema to BLE and his/her toes were light purple in color;- The patient was SOA with ambulation and conversation and had oxygen and nebulizer as needed; and- He/she was standing at the kitchen sink today and the next thing he/she knew he/she felt a sharp pain in his/her chest, he/she stated that he/she was not sure if his/her defibrillator went off or what it was, but he/she stated it hurt. (The documentation failed to show physician notification of the tube feeding coming up into the patient’s throat, edema and toes purple, SOA, and sharp chest pain. The documentation failed to show whether the nurse checked the feeding tube placement).Review of the nurse’s note dated 06/04/2025 at 8:30 AM, showed the following:- The patient went to the emergency room (ER) after having tube feeding come up his/her esophagus (the tube connecting the throat to the stomach) into his/her nose and trach;- The patient stated that he/she felt like he/she was drowning;- This was the second time during the night that this happened;- The patient’s spouse notified the nurse and stated that he/she thought the patient would be admitted; and- The nurse met the patient in the ER and had him/her sign a revocation (a patient or representative must provide a signed written statement to the hospice agency with the effective date of the revocation, revoking hospice means the patient is no longer covered under Medicare for hospice care but can resume coverage for other Medicare benefits) form.Review of the hospice revocation statement dated 06/04/2025 at 4:50 PM, showed the reason for revocation was “Tube feeding came up esophagus and patient felt” (the documentation was incomplete). The clinical record failed to include documentation that showed IDG coordination to meet the needs of the patient and family. During an interview on 10/08/2025 at 12:18 PM, RN-A stated that:- He/she was the case manager for the patient;- The patient’s caregiver called RN-A and reported that the patient threw up and felt like his/her “trach was clogged”, he was aspirating (to accidentally inhale a substance into the lungs), and they were at the hospital emergency room (ER);- The patient signed the hospice revocation in the ER and the patient kept throwing up;- RN-A cleaned the trach at each visit unless the patient cleaned it;- There was a disposable inner cannula (single-use, sterile tube that fits inside a tracheostomy tube’s outer tube to keep the airway open and clean) and he/she would change this at times;- The patient’s pulmonologist (a medical doctor who specializes in treating diseases of the respiratory system) changed the whole trach every three months; and- The patient was very independent, and he/she could clean and suction his/her trach. During an interview on 10/08/2025 at 12:55 PM, the administrator stated that:- There was no further documentation regarding the G-Tube feeding coming back up into the patient’s throat, whether the nurse checked for feeding tube placement, and physician notification;- Active issues with the G-Tube should be on the plan of care; and- The clinician should have reached out to the physician who inserted the feeding tube with any issues (this was not on the POC). During an interview on 10/08/2025 at 2:32 PM and 2:45 PM, the registered nurse coordinator, known by the provider as the clinical director, stated that:- There was no further documentation to show physician notification or coordination with IDG;- He/she received the patient’s defibrillator report and the patient was not “shocked”. There was no further follow up;- The patient’s chest pain was managed with nitroglycerin;- The patient had not complained of chest pain until the hospice provider talked about discharge due to the patient not having enough of a decline;- The patient had a cardiologist (a medical doctor who specializes in treating diseases of the heart and circulatory system) who was not listed on the POC;- The patient also had a pulmonologist who was not listed on the POC; and- He/she would have expected staff to notify the gastrointestinal (GI) clinic specialist with any problems/complications with the feeding tube.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care (POC) was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in one of three records reviewed (Record/Patient #3). This deficient practice has the potential to affect the provision of care to all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Interdisciplinary Group Coordination of Care,” dated May 2024, showed in part:- The type and scope of services provided by the IDG (interdisciplinary group) will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions;- Written evidence of care coordination will be found in the POC and/or IDG meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician; and- The IDG (in collaboration with the patient’s attending physician, if any) will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 days. Review of the provider’s policy titled, “Interdisciplinary Group Meeting,” dated May 2024, showed in part:- The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC; and- An IDG meeting POC update form and will note changes, response to treatment and progresses toward targeted outcomes, which may include, but not (be) limited to nutritional status, pain management and plan for changes in treatment or procedures. Review of the provider’s policy titled, “PEG (Gastrostomy)/Eternal Tube Management-Hospice,” dated 08/01/2025, showed in part:- Enteral Tube: PEG, G-tube, J-tube, GJ-tube used for nutrition, hydration, and/or medication delivery (PEG, G-tube, J-tube, enteral tube - a tube placed surgically through the abdominal wall into the stomach or intestine for the administration of food, fluids, and medication;- To establish safe, patient-centered, comfort-focused standards for assessment, care, medication administration, feeding, troubleshooting, and documentation for patients with percutaneous endoscopic gastrostomy (PEG) or other enteral access (G-tube, J-tube, GJ-tube) receiving hospice services; and- IDG: Reviews goals, outcomes, complications, and POC at least every 15 days or with change in condition.RECORD/PATIENT #3: Review of the clinical record showed the following:- The patient was admitted to hospice services on 12/06/2023 with a terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood);- The patient had an automatic cardiac defibrillator (a battery-powered device that monitors and treats abnormal heart rhythms with electrical impulses);- Tracheostomy tube (trach, a surgical opening in the airway in the windpipe to facilitate breathing); and- The patient resided at home with his/her spouse who was the primary caregiver. The POC failed to show specific interventions for cardiac defibrillator and trach care. Review of the nurse’s note dated 05/08/2025 at 2:12 PM, showed the following:- The patient had a fall one week ago and had a skin tear on the left forearm and right eye;- The patient was complaining of chest pain in his/her back and rated the patient seven (7) on a pain scale of zero to 10 (zero representing no pain and 10 representing the worst pain possible);- The patient requested the nurse to apply Aspercreme (a topical pain reliever used for minor aches and pains in muscles and joints) patches to his/her back for relief;- The patient was hypertensive (had elevated blood pressure) 118/96 and one (1) plus edema (swelling of the tissues) in bilateral lower extremities (BLE); and- Wound care was provided to the skin tear on the right eye and left forearm.The POC failed to include the fall with injury, chest pain with interventions and edema. Review of the nurse’s note dated 05/08/2025 at 9:39 PM, showed the following:- The patient was short of air (SOA) at rest and took him three to five minutes to recover, wore oxygen as needed and mostly at night; and- The patient stated that he/she had chest pain over the weekend and had to take one nitroglycerin (used to treat certain heart conditions and to widen the opening in blood vessels) tablet. (The clinical record failed to show the physician was notified of the patient’s SOA and chest pain.)The POC failed to include the SOA and chest pain. Review of the nurse’s note dated 05/19/2025 at 2:55 PM, showed the following:- The patient’s spouse reported the patient had a varicose vein (a condition in which a vein becomes permanently enlarged, twisted, and painful) rupture a few days ago in the left leg;- The patient had a pool of blood in his/her shoe and on the deck, where he/she had been sitting when this happened; and- The patient stated his/her tube feedings came back up last night and came up into his/her throat and nose for approximately two hours after finishing the feeding.The POC failed to include interventions for the ruptured varicose vein (treatment) and revised interventions to address intolerance of the tube feeding. Review of the nurse’s note dated 05/26/2025 at 2:08 PM, showed the following:- The patient complained of nine (9)/10 pain;- He/she took a Norco (used to treat moderate to moderately severe pain) not long before this visit;- The patient stated that pain had been worse lately and was not getting much relief even with using the lidocaine patch on his/her back;- The physician was notified to switch Norco to Oxycodone (used to treat moderate to severe pain) as needed (11 days after the patient’s pain had increased); and- The patient had conversational dyspnea (shortness of breath) and dyspnea with ambulation (walking), patient had oxygen as needed at two (2) to 10 liters via trach, trach care was completed per the patient’s request.The POC failed to include specific adjustment of flow rate, and how to administer the oxygen (i.e. higher flow rate nasal cannula or mask) and if a humidifier was needed with use of a higher flow rate, and revised interventions to address the increased pain. During an interview on 10/08/2025 at 12:18 PM, registered nurse (RN)-A stated the following:- He/she was the case manager for the patient;- RN-A cleaned the trach at each visit unless the patient cleaned it;- There was a disposable inner cannula (single-use, sterile tube that fits inside a tracheostomy tube’s outer tube to keep the airway open and clean) and he/she would change this at times;- The patient’s pulmonologist (a medical doctor who specializes in treating diseases of the respiratory system) changed the whole trach every three months; and- The patient was very independent, and he/she could clean and suction his/her trach. The POC failed to include the RN cleaned the trach and specific interventions how this was done, changing the disposable inner cannula, suctioning, and the pulmonologist. During an interview on 10/08/2025 at 12:55 PM, the administrator stated that:- Active issues with the G-Tube should be on the plan of care; and- The clinician should have reached out to the physician who inserted the feeding tube with any issues (this was not on the POC). During an interview on 10/08/2025 at 2:32 PM and 2:45 PM, the registered nurse coordinator, known by the provider as the clinical director, stated that:- The patient’s chest pain was managed with nitroglycerin (used to treat certain heart conditions and to widen the opening in the blood vessels);- The patient had a cardiologist (a medical doctor who specializes in the treatment of diseases of the heart and circulatory system) who was not listed on the POC;- The patient also had a pulmonologist who was not listed on the POC; - He/she would have expected staff to notify the gastrointestinal (GI) clinic specialist with any problems/complications with the feeding tube; and- The POC did not include this information.”