Seasons Hospice & Palliative Care of New Jersey Ll

“It is required that the documented comprehensive assessment include 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 population 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 19 (11%) clinical records reviewed, the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. CLINICAL RECORD 9/HOME VISIT 3: The patient’s date of election was 09/02/2022. The Medication Profile printed on 07/21/2026 was reviewed on 07/22/2026. During the Home Visit on 07/22/2026 with the Hospice Aide (Personnel Record 8), the medications in the home revealed Amlodipine Besylate 2.5 mg, take one tablet by mouth daily for SBP [systolic blood pressure] greater than 160, original order date 11/11/2025, ASA [Aspirin] 81 mg, take one tablet by mouth daily, original order date 12/13/2025. Amlodipine and ASA were not listed on the agency medication profile. The daughter reported that she will give the medications “when he needs them.” The medication profile in the clinical record was reviewed on 07/23/2026 and revealed Amlodipine 5 mg tablet, one tablet orally daily, started on 09/02/2022 and stopped on 07/26/2023; and Aspirin Children’s 81 mg chewable tablet, one tablet orally daily, started on 09/02/2022 and stopped on 07/26/2023. There were no other entries for Amlodipine or Aspirin on the clinical record medication profile after 07/26/2023. The clinical record did not have documented evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. CLINICAL RECORD 8/HOME VISIT 4: The patient’s date of election was 12/11/2025. The Medication Profile printed on 07/21/2026 was reviewed on 07/22/2026. During the Home Visit on 07/22/2026 with the Registered Nurse (Personnel Record 5), the facility’s medication record revealed Atorvastatin Calcium 40 mg tablet, take 1 tab by mouth daily at 9 PM, dated 11/24/2025. Atorvastatin was not listed on the agency medication profile. The clinical record did not have documented 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 07/23/2026, the Director of Clinical Operations 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 a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 6: The patient’s date of election was 10/06/2025. The hospice aide plan of care dated 03/17/2026 stated, “Bathing - Shower Seated.” The aide visit note dated 06/04/2026, 06/08/2026, 06/09/2026, 06/11/2026, and 06/15/2026 documented, “Service: Bathing - Shower Seated, Completed: Y [yes], Note: Bed bath.” Bed bath was not listed on the aide plan of care. CLINICAL RECORD 10: The patient’s date of election was 07/09/2025. The hospice aide plan of care dated 05/15/2026 stated, “Bathing - Bed Bath every visit if cannot stand or sit in shower; and Bathing - Shower Seat weekly.” The Aide Hospice Visit notes dated 05/18/2026, 05/29/2026, and 06/05/2026 documented, “Bed bath completed: Y; and Shower seat completed N, not required this visit.” The Aide Hospice Visit notes dated 05/19/2026, 05/20/2026, 05/21/2026, 05/22/2026, 06/02/2026, and 06/03/2026 documented, “Bed bath completed: N, not required this visit; and Shower seat completed Y.” The Aide Hospice Visit notes dated 05/26/2026, 05/27/2026, 05/28/2026, 06/01/2026, and 06/04/2026 documented, “Bed bath completed: Y; and Shower seat completed Y.” The aide did not provide the type of bathing according to the plan of care. During a joint clinical record review and interview on 07/23/2026, the Executive Director stated that the hospice aide did not provide services according to the plan of care. During a joint clinical record review and interview on 07/23/2026, the Director of Clinical Operations stated that the hospice aide did not provide services according to the plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 6: The patient’s date of election was 10/06/2025. The hospice aide plan of care dated 03/17/2026 stated, “Bathing - Shower Seated.” The aide visits notes dated 06/04/2026, 06/08/2026, 06/09/2026, 06/11/2026, and 06/15/2026 documented, “Service: Bathing - Shower Seated, Completed: Y [yes], Note: Bed bath.” Bed bath was not listed on the aide plan of care. The clinical record did not have documented evidence of notifying the Registered Nurse (RN) of changes to the plan of care. CLINICAL RECORD 8: The patient’s date of election was 12/22/2025. The hospice aide plan of care was dated 05/15/2026 stated, “Bathing - Bed bath; Nail care - clean nails; perineal care; skin care; stand-by assistance with ambulation; code status DNR/DNI; fall precaution; mental status - forgetful/confused at times but able to verbalize simple needs; Date of last BM - document date of last known BM; Intake - food.” The Aide Hospice Visit note dated 06/09/2026 documented, “Bed bath completed: N, not required this visit; skin care completed: N, task already completed; clean nails completed: N, not required this visit.” The Aide Hospice Visit note dated 07/09/2026 documented, “Bed bath completed: N, task already completed; skin care completed: N, task already completed; perineal care completed: N, task already completed; clean nails completed: N, not required this visit.” The Aide Hospice Visit note dated 07/08/2026 documented, “Bed bath completed: N, task already completed; skin care completed: N, task already completed; perineal care completed: N, task already completed; clean nails completed: N, task already completed.” The Aide Hospice Visit notes dated 06/10/2026, 06/11/2026, and 07/10/2026 documented, “Bed bath completed: N, not required this visit; skin care completed: N, not required this visit; perineal care completed: N, task already completed; clean nails completed: N, not required this visit.” The clinical record did not have documented evidence of notifying the RN of changes to the plan of care. CLINICAL RECORD 10: The patient’s date of election was 07/09/2025. The hospice aide plan of care was dated 05/15/2026 stated, “Bathing - Bed Bath every visit if cannot stand or sit in shower; Bathing - Shower Seat weekly; deodorant; dressing; hair care; oral care; shampoo/style; skin care; transfer client from bed/chair; clean multi-use patient items after each use; fall precautions; living arrangements lives with [spouse]; maintain isolation precautions - universal precautions; change linens 3 times weekly; empty trash; please apply compression stockings to bilateral lower legs daily; pain; weight weekly.” The Aide Hospice Visit notes dated 05/18/2026, 05/29/2026, and 06/05/2026 documented, “Bed bath completed: Y; and Shower seat completed N, not required this visit.” The Aide Hospice Visit notes dated 05/19/2026, 05/20/2026, 05/21/2026, 05/22/2026, 06/02/2026, and 06/03/2026 documented, “Bed bath completed: N, not required this visit; and Shower seat completed Y.” The Aide Hospice Visit notes dated 05/26/2026, 05/27/2026, 05/28/2026, 06/01/2026, and 06/04/2026 documented, “Bed bath completed: Y; and Shower seat completed Y.” The clinical record did not have documented evidence of notifying the RN of changes to the plan of care. During a joint clinical record review and interview on 07/23/2026, the Executive Director confirmed that the hospice aide documentation did not notify the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 07/23/2026, the Director of Clinical Operations confirmed that the hospice aide did not notify the RN of the changes in the plan of care.”

“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. This standard was not met as evidenced by document review and interview. A review of the volunteer program, it was revealed that the agency did not ensure that volunteers provided 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. For the calendar year 2025, the volunteer hours were 1.56% of the total patient care hours. Beginning in May 2025, the volunteer hours showed a steady increase. January through June 2026, the volunteer hours were 3.04% of the total patient care hours. The current Volunteer Coordinator began in February 2025 and has grown the program from no volunteers to a current number of ten volunteers. During a joint review of the volunteer program records and interview on 07/21/2026, the Executive Director confirmed that the agency did not meet the minimum of 5% volunteer hours for all patient care hours of paid hospice employees and contract staff for 2025 and 2026 to date. During a joint review of the volunteer program records and interview on 07/21/2026, the Volunteer Coordinator confirmed that the agency did not meet the minimum of 5% volunteer hours for all patient care hours of paid hospice employees and contract staff for 2025 and 2026 to date. Upon reviewing the volunteer program, the documentation lacked evidence that the volunteer hours equalled, at a minimum of, 5% of the total patient care hours of all paid hospice employees and contract staff for 2025 and 2026 to date. For the calendar year 2025, the patient care hours were 7637.32 and volunteer hours were 119.08 resulting in 1.56%. February, March, and April all had zero volunteer hours. Beginning in May 2025, the volunteer hours have shown a steady increase starting at 0.58 hours and reaching up to 30.3 hours in April 2026, which was also the highest patient care hours for 2025 and 2026 in one month. January through June 2026, the direct patient care hours were 4371.45 and volunteer hours were 133.03 resulting in 3.04%. During a discussion with the Volunteer Coordinator and the Executive DIrector, the volunteer program had been up at 12% until the Volunteer Coordinator was moved to another position due to restructuring. A Music Therapist stepped into the position without success and resigned. Next, a Chaplain attempted and soon took a leave of absence. After that, an employee was with the agency for two days. During this time, the program decreased down to 0%. The current Volunteer Coordinator began in February 2025 and has grown the program from no volunteer to a current number of ten volunteers. A performance improvement project, undated, was started for volunteer hours less than 5%. The initial due dates for action steps was 02/03/2026. There were weekly entries from 02/02/2026 through 07/21/2026 that documented efforts for recruitment, retention, onboarding new volunteers, and increase volunteer needs by patients”