Community Hospice LLC

“Upon patient record review, 6 of 27 (Patients #1,#5,#10,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained Lumigan eye drops without instructions of whether to administer in both eyes or one eye. Patient 5: The medication profile contained Pepto-Bismol with no frequency, stating as needed without parameters for how often it can be administered. During home visit medication reconciliation, the daughter confirmed there was no oxygen in the home, patient’s dose of metoprolol is 12.5 mg daily, and takes prevastatin 40 mg daily. The hospice profile contained oxygen, metoprolol 25 mg daily, and no prevastatin. Patient 10: Nursing Facility contains vit C 500mg BID, vit D3 5,000 units daily, methenam 1 gm HS, ibuprofen 400mg daily not on the hospice profile; the hospice profile has evista 60mg daily, meloxicam 15mg daily, and rasagiline 1 mg daily not on NF, NF has tylenol 325mg BID PRN and hospice has 650 mg Q6h PRN Patient 12: During home visit medication reconciliation, the son confirmed patient is taking cetirizine for allergies approximately for a month. There was no evidence of cetirizine included on the medication profile. Patient 13: The medication profile contained Voltaren topical gel with no area defined for administration. Patient 14: The medication profile contained a fluticasone inhaler with incorrect route via nasal cannula, and polyethylene glycol oral powder with no instructions to mix with a diluent.”

“Upon patient record review, 1 of 27 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: There was no evidence of a physical assessment completed by an RN between 3/5/26 and 4/3/26. All nursing visits completing in between those dates were by an LPN. Per Gentiva’s procedures an RN visit is required every 15 days.”

“Upon patient record review, 1 of 27 (Patient #17) 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 17: The plan of care included problems, goals, and interventions to be completed by the chaplain. There was no evidence of an ordered frequency for spiritual care visits.”

“Upon patient record review, 4 of 27 (Patients #1,#5,#13,#14) 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: The medical record contained an order for Lumigan eye drops without instructions of whether to administer in both eyes or one eye. Patient 5: The medical record contained an order for Pepto-Bismol with no frequency, stating as needed without parameters for how often it can be administered. During home visit medication reconciliation, the daughter confirmed patient’s dose of metoprolol is 12.5 mg daily, and takes prevastatin 40 mg daily. The medical record contained an order for metoprolol 25 mg daily, and did not have an order for prevastatin. Patient 13: The medical record contained an order for Voltaren topical gel with no area defined for administration. Patient 14: The medical record contained orders for a fluticasone inhaler with incorrect route via nasal cannula, and polyethylene glycol oral powder with no instructions to mix with a diluent.”

“Upon patient record review, 5 of 27 (Patients #3,#4,#5,#10,#14) 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 3: The medical record contained nursing documentation upon recertification assessment 2/3/26 identifying patient use of a fall pad. There was no evidence of an order for the DME included in the plan of care. Patient 4: The medical record contained nursing documentation upon recertification assessment 1/23/26 identifying patient use of a specialty mattress. There was no evidence of an order for the DME included in the plan of care. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Patient 10: The plan of care included an order for a nebulizer and there was no evidence of any orders for nebulized medication. Patient 14: The medical record contained nursing documentation upon recertification assessment identifying patient use of a hospital bed, full rails, walker, wheelchair, and nebulizer. There was no evidence of orders for the DME included in the plan of care.”

“Upon patient record review, 4 of 27 (Patients #3,#13,#15,#20) 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 3: The current plan of care contained former wound care interventions. There was no evidence the plan of care was updated to reflect the wound had been documented as healed 3/2/26. Patient 13: The medical record contained nursing documentation since recertification assessment identifying patient is a high risk for skin impairment requiring a specialty mattress. There was no evidence the plan of care was updated to include problems, goals, and interventions related to risk for skin breakdown. Patient 15: There was no evidence the plan of care was updated to omit problems, goals, and interventions to be completed by the chaplain. Spiritual care visits were ordered to be discontinued 3/5/26. Patient 20: There was no evidence the plan of care was updated to omit problems, goals, and interventions related to oxygen safety that were entered in error. The medical record did not contain an order for oxygen or documentation identifying patient use of oxygen.”

“Upon patient record review, 1 of 27 (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: There was no evidence tasks were completed as assigned on the bereavement care plan.”

“Upon personnel record review, 1 of 17 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #8: No evidence of a competency assessment completed on all tasks.”

“Upon patient client record review, 1 of 27 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The medical record contained social worker documentation 4/7/26 stating a visit was missed due to patient death. Additional visits were completed by other disciplines to show evidence the documentation of death was in error.”