The Community Hospice, Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 3 of 30 (10%) clinical records reviewed revealed that the agency did not ensure that each patient received a spiritual assessment within 5 days of the election of the hospice benefit. CLINICAL RECORD 8: The patient was admitted to hospice on 07/10/2026 with a RN assessment on 07/10/2026. The initial psychosocial assessment was completed on 07/13/2026 by MSW (Medical Social Work). The clinical record contained no evidence of a spiritual assessment. The chaplain noted on 07/15/2026, day 5 that a call was made to the patient asking if they wanted him to come out. CLINICAL RECORD 9: The patient was admitted to hospice on 07/17/2025. The chaplain called the patient and spoke with the spouse on 07/23/2026, 6 days after admission and made an appointment to visit the patient on 07/27/2026. There was no evidence of a spiritual assessment within the first 5 days after admission. CLINICAL RECORD 12: The patient was admitted to hospice on 08/05/2026. The clinical record evidenced the first note from the chaplain was dated 08/17/2026. The note from the chaplain documented that there was prayer over the phone only. The clinical record contained no evidence of a spiritual assessment. The Administrator confirmed findings in an interview on 08/18/2026 and stated in part, “I agree with you. I think there may be more going on than is documented but I agree we need to get the assessments completed.””

“It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by document review, interview and observation. A tour of the agency’s inpatient unit (IPU) revealed that IPU staff did not have access to an eye wash station within the facility. The OSHA requirements for emergency eyewashes and showers, found at 29 CFR 1910.151(c), specify that “where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.” IPU TOUR: During a tour of the agency’s IPU, which is on the fifth floor of a hospital building, no eyewash station was found. During an interview on 08/18/2026, the hospital’s coordinator of Safety and Emergency Management, whose duties included facility maintenance for the IPU, confirmed that no eyewash station was present within the IPU work area or anywhere else on the fifth floor. A tour of the agency’s inpatient unit (IPU) revealed that the IPU did not have access to an eye wash station within the facility.”

“It is required that the hospice inpatient facility have documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that the inpatient unit (IPU) conducted and documented quarterly fire drills for each shift. A review of the IPU (inpatient unit) fire drill logs on 08/19/2026 revealed that documentation of fire drills was missing for the following quarters within the survey review period: Quarter (Q) 1 of 2024 - no drill for night shift (a 01/04/2024 day shift drill was present); Q3 of 2024 - no drill for night shift (a 09/11/2024 day shift drill was present); Q4 of 2024 - no drill for night shift (a 11/12/2024 day shift drill was present); Q1 2025 - no drill for night shift (02/06/2025 and 02/27/2025 day shift drills were present); Q3 2025 - no drill for day shift (a 09/09/2025 night shift drill was present); and Q4 2025 - no drill for night shift (a 10/17/2025 day shift drill was present). Additionally, this references K712 “Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift....” During interviews on 08/18/2026 and 08/19/2026, the Executive Director confirmed that the IPU had no documentation of additional fire drills during those quarters. A review of the fire drill logs for the agency’s inpatient unit (IPU) revealed that the agency did not ensure that fire drills were conducted once per quarter per staff shift.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: the Health Care Facilities Code NFPA 99, 2012 edition. This standard was not met as evidenced by interview and observation. A tour of the IPU (inpatient unit) on 07/06/2026 revealed that the agency had not maintained the storage area containing oxygen cylinders. Life Safety Code K923 Gas Equipment – Cylinder and Container Storage... “Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion.” IPU TOUR: During a tour of the agency’s IPU on 08/18/2026, portable oxygen storage cylinders used in the course of patient care were found stored in two racks placed immediately next to each other in an open corner of the IPU’s family lounge. One rack was marked “Full,” and the other rack was marked “Empty.” In addition, an individual cylinder was found unsecured, placed next to, but not in, the two racks. In addition, an individual cylinder was found unsecured with other equipment in a communal bathing/bathroom. During an interview on 08/18/2025. the IPU Nurse Supervisor (Personnel Record 15), who was present for the IPU tour, confirmed that the use of the two racks in the family lobby area was the current process for the storage of oxygen cylinders in the IPU. The IPU Nurse Supervisor confirmed that the two single cylinders were unsecured and misplaced. A tour of the agency’s inpatient unit (IPU) revealed that the agency did not ensure that the requirements of NFPA 99, 2012 edition, pertaining to the storage of oxygen cylinders were being observed.”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review and interview. Document review of the temperature check logs for a refrigerator-freezer used by patients and families in the agency’s inpatient unit (IPU) revealed that the agency did not ensure that all food was stored at proper temperatures. During a review of the IPU’s temperature check logs for a refrigerator-freezer unit in the IPU’s family lounge on 08/18/2026, which was available for patient and family food storage, no documented evidence of temperature checks for the unit’s freezer was found. Documented temperature checks within the unit’s refrigerator were inconsistent, with multiple days missed. During an interview on 08/18/2026, the agency’s IPU Nurse Supervisor, who was present for the IPU tour, confirmed that there was no documented evidence of additional temperature checks for the refrigerator-freezer unit. A review of the temperature check logs for a refrigerator-freezer used by patients and families in the agency’s inpatient unit (IPU) revealed that the agency did not ensure that all food was stored at proper temperatures.”

“Based on clinical record review, the hospice failed to ensure in three of three records (Patient #1, 2, and 3) that care was provided in accordance with the individualized written Plan Of Care (POC) established by the Hospice Interdisciplinary Group (IDG). Failure to provide care in accordance with the established POC has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. Finding:Patient #1 (start of care 03/23/2026) has diagnoses of Combined Systolic and Diastolic Heart Failure and Dilated Cardio Myopathy. The record contains IDG meeting notes (dated 07/14/2026 and 07/28/2026) which identify “commode” as an ordered piece of durable medical equipment (DME). The clinical record also contains skilled nursing (SN) notes (dated 07/14/2026 and 07/28/2026) that do not identify the use or presence of a commode. The clinical record requires clarification regarding the order for a commode. Patient #2 (Start of care 06/26/2026) has diagnoses of Perinephric Abscess and Hydroureternephrosis. The clinical record contains SN notes (dated 06/26, 06/29, 07/2, 07/22 and 07/27/2026) which identify the use of a “Broda Chair.” The IDG meeting notes (dated 06/26, 07/08, 07/22/2026) lack orders for a “Broda Chair.” The clinical record lacks an order for the DME being used. Patient #3 (start of care 07/03/2026, deceased 07/27/2026) has diagnoses of Gastrointestinal Stromal Tumor of Other Sites, Anemia due to Antineoplastic Chemotherapy. The record contains a Skilled Nurse (SN) Regular Visit note conducted on 07/22/2026 stating “... Flushed irrigated great R toe with warm water and dawn dish soap per POC....Medihoney impregnated gauze placed over site wrapped with Kling....” The record contains an IDG note (dated 07/21/2026) stating; “cleanse wounds to left great toe, right great toe, and right third toe with normal saline using 4x4 gauze. Apply adhesive band aids to all wounds.” The record lacks documented evidence the wound care was provided as ordered by the IDG. The findings were confirmed on 07/28/2026 at 4:00 PM with the Director of Patient Services, Executive Director, and Director of Quality Assurance and Performance Improvement and Compliance Director; no additional evidence was provided.”

“Based on clinical record review, the hospice failed to ensure in one of three clinical records reviewed (Patient # 1) an individualized and comprehensive Plan of Care (POC) was developed to meet the specific needs of the patient. Failure to develop an individualized and comprehensive POC has the potential to result in unmet patient needs and negative patient outcomes. Finding: Patient #1 (admitted on 03/23/2026 and deceased on 03/26/2026) with diagnoses of Glioblastoma and Crohn’s Disease of the Colon without complication. The clinical record contains the following orders:-“Acetaminophen (TYLENOL) 650mg suppository; insert 650mg in to the rectum every six hours...”-“Bisacodyl (DULCOLAX) 10mg suppository; insert 10mg into the rectum one time each day...”The clinical record also contains a physicians note (dated 03/23/2026) which states the following:”...status post total colectomy for Crohn’s disease and high output ostomy...” The clinical record requires clarification regarding the route by which the Acetaminophen and Bisacodyl should be administered. The finding was confirmed on 05/28/2026 at 8:45 AM with the Director of Patient Services, Executive Director and Patient Care Supervisor; no additional evidence was provided.”