Beloved Hospice, Inc.

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) home visits, it was revealed that the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 04/02/2026 for a diagnosis of cerebral atherosclerosis. The patient resided in an assisted living facility (ALF). During the home visit with the Music Therapist (Personnel Record 8) on 05/20/2026, the hospice medication profile (printed on 05/20/2026) was compared to the ALF medication profile (printed on 05/21/2026). The following medications were listed on the ALF medication profile and were not listed on the hospice medication profile: Nutritional supplement shake twice daily (ordered 11/14/2024), Milk of magnesia 30 ml by mouth daily as needed (ordered 04/26/2026), Tamsulosin 0.4 mg 1 capsule by mouth daily (ordered 02/22/2024), Acetaminophen 325 mg 2 tablets every 4 hours as needed (ordered 12/03/2025), Antac + Sim 200-200-20mg/5ml 10 ml by mouth 4 times daily as needed (ordered 12/08/2025), Fleet enema 1 rectally if no bowel movement on day 6 (ordered 12/03/2025), Loperamide 2 mg 1 tablet for 1st episode of diarrhea (ordered 12/03/2025), Miralax powder 17 grams every day as needed (ordered 04/16/2026) and Triple antibiotic ointment topically as needed (ordered 12/03/2025). Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 12/04/2025 for a diagnosis of heart disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (Personnel Record 4) on 05/20/2026, the hospice medication profile (printed on 05/20/2026) was compared to the SNF medication profile (printed on 05/20/2026). The following medications were listed on the hospice medication profile and were not listed on the SNF medication profile: Carbamide peroxide 65 mg/ml 4 drops twice daily (ordered 12/24/2025) and Promethazine 25 mg tablet every 6 hours as needed (ordered 12/26/2025). The following medications were listed on the SNF profile and not on the hospice medication profile: Ondansetron 4 mg every 8 hours as needed (ordered 10/25/2025), Orajel every 4 hours as needed (ordered 01/19/2026) and Levothyroxine 112 mcg 1 tablet daily (ordered 01/13/2026). An interview and joint clinical record review was conducted with the Director of Nursing on 05/21/2026 during which time she confirmed the discrepancies and advised on Home Visit 2/Clinical Record 2 the discontinue orders for all those medications had been faxed to the facility upon his admission but appeared they had not been removed from his profile at the facility. For Home Visit 3/Clinical Record 3, she stated they should have received the med reconciliation orders for most of the medications, but she didn’t see the Orajel.”

“It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 10: The hospice aide care plan dated 04/08/2026 included the following relevant tasks: Assist to dress; shower; shampoo; style; inspect skin, pressure areas; call nurse if new pressure areas noted; shave; clean finger and toe nails; peri care; turn and position; bathe/inspect feet; inspect mouth; assist with brushing teeth; provide social and emotional support; incontinent care, change bed linen; clean patient’s room/area; clean filter on oxygen concentrator; gentle range of motion.” All tasks were to be completed every visit with an aide frequency of twice weekly unless otherwise noted. A physician’s order dated 03/02/2026 noted the following: “Cleanse the wound and surrounding area. Apply liberal amount of calazinc to the right posterior thigh above the knee and then apply foam dressing. Repeat this process daily for stage 2 pressure ulcer.” The aide care plan did not notify the aide(s) of the wounds nor provide specific instructions for the dressings or wounds during care or to notify the nurse if the dressing became soiled, dislodged or wet. CLINICAL RECORD 11: The hospice aide care plan dated 03/23/2026 included the following relevant tasks: Shower-as requested by patient; Comb/brush hair-as requested by patient; Shampoo/style-as requested by patient; Inspect skin, check pressure areas-as tolerated by patient; Call nurse if new pressure areas noted; Trim nails, fingers and toes-as requested by patient; Clean nails/toes-as requested by patient; Perineal care-as requested by patient; Bathe/inspect feet-as requested by patient; Inspect mouth-as requested by patient; Swab/Clean mouth-as requested by patient; Assist with brushing teeth, as requested by patient; Offer food/fluids, every visit; Provide social and emotional support, every visit; Incontinent care, as requested by patient; Bed linen change, as requested by patient; Clean room, as requested by patient; Clean filter on oxygen, weekly; Gentle range of motion, as tolerated by patient. Aide frequency of twice weekly. A physician’s order dated 05/04/2026 noted the following: “Apply new non adherent dressing to wound on left breast.” The aide care plan did not notify the aide(s) of the wounds nor provide specific instructions for the dressings or wounds during care or to notify the nurse if the dressing became soiled, dislodged or wet. An interview and joint clinical record review was conducted with the Director of Nursing on 05/22/2026 during which time it was agreed the wounds should have been noted on the aide care plans and the aides need more specific instructions “on several of the tasks.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 19 (21%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services ordered by the Interdisciplinary Group. Clinical Record 1/Home Visit 1: The hospice aide care plan dated 05/17/2026 included the following relevant tasks: Bed bath, assist to dress, comb/brush hair, shampoo/style hair, inspect skin/check pressure areas, trim and clean toe and finger nails, bathe/inspect feet, swab/clean mouth, assist with brushing teeth, offer food/fluids, provide social/emotional support, empty foley, incontinent care, and clean room. All tasks were to be completed every visit with a frequency of three times weekly. During the home visit with the hospice aide Personnel Record 7 on 05/22/2026, the aide was observed to remove the patient’s oxygen nasal cannula and place it on her bedside table during her tasks. There was no written instruction to remove the oxygen during personal care. CLINICAL RECORD 11: The hospice aide care plan dated 03/23/2026 included the following relevant tasks: Shower-as requested by patient, comb/brush hair-as requested by patient, shampoo/style-as requested by patient, inspect skin, check pressure areas-as tolerated by patient, call nurse if new pressure areas noted, trim nails, fingers and toes-as requested by patient, clean nails/toes-as requested by patient, perineal care-as requested by patient, bathe/inspect feet-as requested by patient, inspect mouth-as requested by patient, swab/clean mouth-as requested by patient, assist with brushing teeth- as requested by patient, offer food/fluids every visit, provide social and emotional support every visit, Incontinent care as requested by patient, bed linen change as requested by patient, clean room as requested by patient, clean filter on oxygen, weekly, and gentle range of motion as tolerated by patient. The hospice aide visit dated 04/30/2026 noted the aide documented: “Companionship only. Left wound under breast.” CLINICAL RECORD 13: The hospice aide care plan dated 04/09/2026 included the following relevant tasks: Shower two times weekly Tuesday and Saturday, comb/brush hair every visit, shampoo/style Tuesday and Saturday, inspect skin, check pressure area, every visit, message nurse in Teams if new pressure areas noted every visit, trim nails, fingers and toes Tuesdays and Saturdays, clean nails/toes, every visit, bathe/inspect feet every visit, assist with brushing teeth every visit, offer food/fluids every visit, provide social and emotional support every visit, incontinent care every visit, bed linen change Tuesday and Saturday and notify housekeeping when changed, clean room every visit, weigh patient monthly. The hospice aide visit dated 04/25/2026 (Saturday) noted the aide documented: “Offered food fluids, emotional support, changed bed linens, cleaned room.” CLINICAL RECORD 14: The hospice aide care plan dated 03/14/2026 included the following relevant tasks: Shower two times weekly, Sunday and Thursday; Comb/brush hair, every visit, shampoo/style Sunday and Thursday, inspect skin, check pressure areas every visit, call nurse if new pressure areas noted every visit, trim nails, fingers and toes weekly, clean nails/toes Sundays, bathe/inspect feet Sundays, assist with brushing teeth, every visit, offer food/fluids every visit, provide social and emotional support every visit, incontinent care every visit, bed linen change Sundays, clean room every visit, and clean filter on oxygen Sundays. The hospice aide visit dated 04/09/2026 (Thursday) noted the following tasks as completed: “peri care hair care, offer food fluids, provided emotional support.” The aide documented: “All applicable care provided.” The hospice aide visit dated 04/26/2026 (Sunday) the aide documented “No shower.” The hospice aide visit dated 05/17/2026 (Sunday) noted the aide documented: “Shower not completed. Med tech said shower already completed.” An interview and joint clinical record review was conducted with the Director of Nursing on 05/22/2026. She stated the aides “should be following the plan of care as written by the nurses.””

“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 was conducted with the Quality Nurse and Human Resources/Volunteer Coordinator on 05/21/2026, during which time the volunteer percentage for the last twelve (12) months (May 2025 to April 2026) averaged to 1.56%. During the program review, it was noted that the agency had a newer Volunteer Coordinator in place. They discussed the agency having “great growth in the past several years and hiring volunteers to keep up with the growth. There was also discussion of new music therapy volunteers/interns onboarding and “vigil” volunteers onboarding in the very near future. A performance improvement plan has been implemented to increase the number of patient volunteers and hours. They stated they are “hopeful the numbers will improve soon.” A review of the volunteer program was conducted with the Quality Nurse and Human Resources/Volunteer Coordinator on 05/21/2026, during which time the volunteer percentage for the last twelve (12) months (May 2025 to April 2026) averaged to 1.56%. They had a newer Volunteer Coordinator in place however she was unavailable to be at the interview but they discussed the Agency having “great growth in the past several years and having volunteers trying to keep up with the growth.” There was also discussion of new music therapy volunteers/interns onboarding and “vigil” volunteers onboarding in the very near future. A performance improvement plan has been in place to increase the number of patient volunteers and hours and they are “hopeful the numbers will improve soon.””