Interim Healthcare Hospice of Erie

“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 measures 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, interview, and observation. In 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient’s current medications. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 02/17/2026 with diagnoses of hemiplegia following cerebral infarct affecting the right side, aphasia, acquired absence of the right leg above the knee, hypertension (HTN), and vascular degeneration. The patient resided in a skilled nursing facility (SNF). During a home visit with the Chaplain (SCC) [Personnel Record 5] on 03/17/2026, a medication review revealed the following medications documented on the agency’s medication profile were not documented on the SNF medication profile: lorazepam 0.5 mg, one (1) tablet every four hours as needed for anxiety, morphine sulfate oral solution 100 mg/mL, 0.25 mL every three hours as needed for pain or dyspnea, and Senna-S 8.6–50 mg, one (1) tablet orally daily as needed for constipation. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 12/04/2024 with diagnoses of Alzheimer’s Disease, type 2 diabetes, and gastro-esophageal reflux disease. The patient resided in a SNF. During a home visit with the Hospice Aide (HA) [Personnel Record 6] on 03/17/2026, a medication review revealed the following medications documented on the agency’s medication profile were not documented on the SNF medication profile: hydrocodone-acetaminophen 5-325 mg oral tablet, one (1) tablet every 6 hours as needed for pain, and lorazepam oral concentrate 2 mg/mL, 0.5 mg sublingually every 4 hours as needed for anxiety/restlessness. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/17/2025 with diagnoses of unspecified B-Cell lymphoma, unspecified diastolic congestive heart failure (CHF), HTN, and chronic pain. The plan of care dated 10/17/2025 ordered oxygen at 2 liters per minute via nasal cannula, to be used as needed. The patient’s medication profile did not include documentation of oxygen. CLINICAL RECORD 14: The patient elected the benefit on 01/23/2026 with diagnoses of end-stage heart failure, atrial fibrillation (A-Fib), chronic obstructive pulmonary disease (COPD), and sarcoidosis of the lung. A review of the clinical record revealed that the plan of care dated 01/23/2026 ordered oxygen 1-5 liters per minute via nasal cannula to be used as needed. Oxygen was not documented on the agency’s medication profile. During interviews on 03/17/2026, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the agency’s medication profile did not align with the SNF medication profile. The Clinical Director reported that medications not administered for more than two weeks are automatically removed (“fall off”) from the facility’s medication profile. Following clarification with the Hospice Medical Director, updated medication orders were issued to the facility on 03/18/2026. Additionally, they confirmed that oxygen was not listed on the agency’s medication profile, despite being an active order on the patient’s plan of care.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that hospice care and services provided to the patient followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). CLINICAL RECORD 3: The patient elected the hospice benefit on 06/26/2025 with diagnoses of heart disease, senile degeneration of the brain, chronic kidney disease, and benign prostatic hyperplasia (BPH). The plan of care dated 06/26/2025 ordered a 16 Fr coude catheter with a 10–30 cc balloon, to be changed monthly and as needed. The Skilled Nurse (SN) visit notes documented that on 09/04/2025: Foley replaced with 16 Fr, 10 cc balloon; 10/07/2025: Foley replaced with 18 Fr, 10 cc balloon; 02/12/2026: Foley replaced with 18 Fr, 10 cc balloon; and 03/12/2026: 18 Fr, 10 cc balloon. A review of the clinical record revealed that the catheter type and size were changed multiple times without updates to the plan of care or documented physician orders. During a joint record review and interview on 03/16/2026, the Clinical Director and Administrator confirmed that the plan of care was not updated based on the patient’s assessed needs and changes.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; 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 that the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025 with diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), lupus, and type 2 diabetes mellitus. The plans of care dated 05/16/2025 through the recertification plan of care dated 03/12/2026 ordered a sliding-scale insulin regimen based on blood glucose monitoring, including Novolog FlexPen (100 units/mL), 2–9 units subcutaneously three times daily as needed for elevated blood glucose, as well as Insulin glargine (100 units/mL), 18 units subcutaneously once daily. The plans of care did not include documentation of interventions or goals addressing the patient’s identified problem of diabetes management, despite active insulin therapy and ongoing blood glucose monitoring requirements. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/11/2025 with a diagnosis of esophageal cancer. The admission comprehensive assessment dated 01/11/2025 documented that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, with nutritional status documented as “PEG Tube, Diet: formula, 2 meals a day.” Additionally, the hospice narrative dated 01/15/2025 documented that the patient “continues with tube feeding for nutrition,” confirming the ongoing use of the PEG tube. The plan of care included interventions for the patient’s identified problems with dyspnea, grief, nausea, and pain. The plan of care did not include documentation of interventions or goals addressing the patient’s PEG-related needs. During a joint record review and interview, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the patient’s plans of care did not include interventions specific to diabetes management and PEG tube care and maintenance.”

“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. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of agency documentation revealed that no volunteer service percentage was calculated for 01/01/2024 through 12/31/2024. The agency reported a total volunteer service contribution of 4.8% for 01/01/2025 through 12/31/2025, which did not meet the required 5% threshold. During an interview on 03/18/2026, the Administrator stated that the program was almost “nonexistent” when they started in January of 2025. The agency has a current PIP in place related to the volunteer program. It was reported during the interview that the current Volunteer Coordinator assumed their role in February 2025. Based on interview and document review with the Volunteer Coordinator and the Administrator on 03/18/2026, it was determined that the agency failed to ensure that volunteer services met the regulatory requirement that volunteers provide at least 5% of the total patient care hours furnished by hospice employees and contract staff. Review of agency documentation revealed that no volunteer service percentage was calculated for calendar year 2024, and the agency reported a total volunteer service contribution of 4.8% for 2025, which did not meet the required 5% threshold. It was noted during the interview that the current Volunteer Coordinator assumed her role in February 2025.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that orders were obtained for all necessary services. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/26/2025 with diagnoses of heart disease, senile degeneration of the brain, chronic kidney disease, and benign prostatic hyperplasia (BPH). The plan of care dated 06/26/2025 included documentation of a Foley catheter and documented the goal: “Patient will experience no discomfort or signs/symptoms of urinary tract infection (UTI) with urinary catheter.” The POC ordered placement of a 16 French (Fr) coude catheter with a 10–30 cc balloon, to be changed monthly and as needed. A review of the clinical record revealed the Skilled Nurse (SN) visit notes documented on: 09/04/2025: Foley replaced with 16 Fr, 10 cc balloon; 10/07/2025: Foley replaced with 18 Fr, 10 cc balloon; 02/12/2026: Foley replaced with 18 Fr, 10 cc balloon; and 03/12/2026: 18 Fr, 10 cc balloon. A review of the clinical record revealed no evidence of communication with the physician or of a physician order changing the catheter type, size, or maintenance. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/16/2025 with diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), lupus, and type 2 diabetes mellitus. The plans of care dated 05/16/2025 through the recertification plan of care dated 03/12/2026 ordered a sliding-scale insulin regimen based on blood glucose monitoring, including Novolog FlexPen (100 units/mL), 2–9 units subcutaneously three times daily as needed for elevated blood glucose, as well as Insulin glargine (100 units/mL), 18 units subcutaneously once daily. The plan of care did not include documentation of the blood glucose parameters corresponding to each sliding scale insulin dose. CLINICAL RECORD 15: The patient elected the hospice benefit on 01/11/2025 with a diagnosis of esophageal cancer. The admission comprehensive assessment dated 01/11/2025 documented that the patient had a percutaneous endoscopic gastrostomy (PEG) tube, with nutritional status documented as “PEG Tube, Diet: formula, 2 meals a day.” The hospice narrative dated 01/15/2025 documented that the patient “continues with tube feeding for nutrition,” confirming the ongoing use of the PEG tube. The plan of care did not include documentation of orders, including the specific formula, tube feeding regimen, or PEG tube maintenance. During a joint record review and interview, the Clinical Director, Administrator, and Patient Care Coordinator (PCC), confirmed that the patient’s plans of care did not include orders specific to diabetes management, catheter management, or PEG tube care and maintenance.”

“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. In 1 of 5 (20%) of the clinical records reviewed, the agency did not ensure that each patient received a comprehensive assessment within 5 days of electing hospice. Clinical Record 3: Patient elected hospice on 10/4/2023. The clinical record contained a communication note on 10/6/2023 that read, “5-day SC assessment incomplete due to staffing.” Spiritual counseling assessment and social work assessment were on 10/13/2023. There was no documentation in the record to identify why the social work assessment was not completed within 5 days. In an interview on 11/13/2023, the Director of Clinical Services confirmed finding. 1 of 5 (20%) of the clinical records reviewed revealed that the agency did not ensure that each patient received a comprehensive assessment within 5 days of electing hospice.”

“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, and supplements. 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 IS A CONTINUED PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visit observed, the agency did not ensure that the medication profile was updated when changes were made to patient medication orders. Home Visit 1: During a home visit on 11/13/2023, observed all patient medications and reviewed the current medication regime with the caregiver. The clinical record revealed that the medication list was developed on 9/14/2023. The clinical record does not have any medication reconciliations documented. The medication list included a Fiber oral capsule, one capsule oral, two times per day. The patient’s caregiver reported that the Fiber capsule was discontinued upon admission to hospice, and the patient is no longer taking that medication. The caregiver reported Senna-S oral tablet 8.6-50mg, one tablet daily listed on the med profile as of 9/14/2023, was changed on 11/11/23 to 2 tablets twice a day after calling the nurse for constipation. The medication profile was not updated. In an interview on 11/13/2023, the Director of Clinical Services reported that she was on call and confirmed the caregiver’s comments. A verbal order for Senna S Oral tablet 8.6.-50mg, two tablets every 12 hours, effective 11/11/2023, was documented in the clinical record. The medication profile contained Trazadone HCL oral tablet every night at bedtime, effective 10/11/2023. The caregiver reported that the Trazadone was discontinued after the first dose and should only be used PRN because the patient was knocked out. The medication profile was not updated. The medication profile included Vitamin D3 125mcg 1 capsule daily effective 9/14/2023. The caregiver reported that Vitamin D3 was discontinued weeks ago. The medication profile was not updated. In an interview on 11/13/2023, the Director of Clinical Services confirmed the finding. THIS IS A CONTINUED REQUIRED ACTION. 1 of 1 (100%) home visits observed revealed that the agency did not ensure that the medication profile was updated when changes were made to patient medication orders.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUED PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the care plan was specific enough to provide clear direction to the Hospice Aide. Clinical Record 3: Skilled Nurse assessment on 10/4/2023 identified a pressure ulcer on the patient’s coccyx with an order to cover it with foam border gauze. The Home Health Aide care plan created on 10/4/2023 by the Registered Nurse did not include any instruction for the Hospice Aide while performing personnel care related to the coccyx wound or dressing. In an interview on 11/13/2023, the Director of Clinical Services confirmed the finding. THIS IS A CONTINUED REQUIRED ACTION 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the care plan was specific enough to provide clear direction.”