Morning Star Hospice and Palliative Care Solutions, LLC

“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 4 of 14 (29%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/12/2025 with a diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the psychosocial assessment and the bereavement assessment completed as part of the comprehensive assessment were dated 05/20/2025, 8 days after the election of benefit and 3 days outstanding. The clinical record did not include documentation to explain the delay in the assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/20/2025 with a diagnosis of protein calorie malnutrition. Clinical record review revealed the psychosocial assessment and the bereavement assessment completed as part of the comprehensive assessment were dated 05/27/2025, 7 days after the election of benefit and 2 days outstanding. The clinical record did not include documentation to explain the delay in the assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/04/2025 with a diagnosis of respiratory failure. Clinical record review revealed the psychosocial assessment completed as part of the comprehensive assessment was not completed, as of the date of record review on 06/11/2025, 7 days after the election of benefit and 2 days outstanding. The Medical Social Worker had made a note in the record that stated the family had been called on 06/10/2025, the 6th day after the election of benefit, to set up a time for the assessment, however the clinical record did not include documentation to explain the delay in the assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/24/2025 with a diagnosis of Alzheimer’s disease. Clinical record review revealed the psychosocial assessment completed as part of the comprehensive assessment was dated 06/03/2025, 10 days after the election of benefit and 5 days outstanding. The clinical record did not include documentation to explain the delay in the assessments. During joint review of records and interviews on 06/10/2025 and 06/11/2025, the Clinical Manger (Personnel Record 5) confirmed the assessments were not completed within the first 5 days of the patient’s election of benefit and the records were missing a reason for the delay in completing the comprehensive assessment.”

“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 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 1 of 14 (7%) clinical records reviewed, the agency did not ensure the medication profile included the patient’s current medications. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/28/2024. Clinical record review revealed the patient was ordered Oxygen at 3 liters per minute continuously on 11/30/2024. The medication profile did not include Oxygen, as of the date of record review on 06/10/2025. During joint clinical record review and interview on 06/10/2025, the Clinical Director (Personnel Record 5) confirmed that the Oxygen should have been included on the medication profile as of 11/30/2024 when it was ordered.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviews, the agency did not ensure the interdisciplinary group (IDG) updated the comprehensive assessment, including the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/12/2025 with a diagnosis of chronic obstructive pulmonary disease. Review of the IDG update dated 05/29/2025 revealed no documented evidence that the Registered Nurse, Chaplain, and Medical Director had reviewed or revised the patient’s assessment and included information related to the patient’s progress toward outcomes and/or response to care. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/20/2025 with a diagnosis of protein calorie malnutrition. Review of the IDG update dated 05/29/2025 revealed no documented evidence that the Medical Social Worker, Chaplain, and Medical Director had reviewed or revised the patient’s assessment and included information related to the patient’s progress toward outcomes and/or response to care. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/13/2025 with a diagnosis of respiratory failure. Review of the IDG update dated 05/29/2025 revealed no documented evidence that the Medical Director had reviewed or revised the patient’s assessment and included information related to the patient’s progress toward outcomes and/or response to care. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/04/2025 with a diagnosis of Alzheimer’s disease. Review of the IDG update dated 05/29/2025 revealed no documented evidence that the Chaplain and the Medical Director had reviewed or revised the patient’s assessment and included information related to the patient’s progress toward outcomes and/or response to care. During joint clinical record reviews and interviews on 06/10/2025 and 06/11/2025, the Clinical Director (Personnel Record 5) confirmed that patient updates were not documented by various disciplines during the interdisciplinary group meeting.”

“Based on review of medical records (MR), policies/procedures and an interview with the Agency Administrator and Director of Nursing, the agency failed to ensure the plan of care was followed in three (3) of fifteen (15) records reviewed. (MR #1- # 3) Review of Morning Star Hospice and Palliative Care Solutions, Llc, Physician orders policy on 1/28/24 at 7:05 PM revealed: Policy: “;Physician orders are obtained as needed. Verbal orders are received, processed, confirmed in writing and countersigned by the physician in accordance with state/federal laws and regulations.”; “;Some of the reasons orders are obtained from physicians include, but are not limited to: b. Change in visit frequency if not within the range specified in the patients plan of care.” Review of Morning Star Hospice and Palliative Care Solutions, Llc, Plan of care policy on 1/28/24 at 7:05 PM revealed: Policy:” The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions.”; Procedure: “;3. Care provided to an individual patient is in accordance with the plan of care.” “;6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: l. Detail of the scope and frequency of services needed to meet the patient/family needs.” Review of Morning Star Hospice and Palliative Care Solutions, Llc, spiritual care services policy on 1/28/24 at 7:20 PM revealed: Policy:” Morning Star Hospice and Palliative Care Solutions, LLC provides counseling or arranges for counseling to meet the spiritual needs of patients/caregivers in a manner consistent with their beliefs and desires and in accordance with the patients plan of care.” Procedure: “;3. Spiritual counseling services are provided in accordance with the plan of care.” Review of medical records (MR) on 1/17/24 between 2:30 PM-3:30 PM and 1/18/24 between 11:50 AM-1:00 PM revealed: Medical record (MR) #1: Start of care (SOC): 5/4/23; certification period: 11/20/23-1/18/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December. MR # 2: SOC: 10/31/23; certification period: 10/31/23-1/28/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December. Plan of care order for home health aide (HHA): 11/19/23: decrease visits to three (3) times per week. Record review revealed only one (1) HHA visit was conducted during the week of 11/26/23-12/2/23. MR # 3: SOC: 11/13/23; certification period: 11/13/23-2/10/24; plan of care order: Chaplain: once monthly and three (3) visits as needed; record noted that the chaplain visit was missed on 12/25/23 due to the holiday but no other visit was conducted by the chaplain in the month of December. An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.”

“Based on review of personnel files (PF) and interview with the agency administrator and director of nursing, it was determined the agency failed to ensure staff were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with clients in eight (8) of nine (9) files reviewed. (PFs #1-# 4, #6-# 9) Findings include: The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17)http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf. Review of Morning Star Hospice and Palliative Care Solutions, Llc, Tuberculosis (TB) infectious control policy on 1/28/24 at 6:45 PM revealed: Policy: “;It shall be the policy of this agency to adhere to the OSHA standards related to respiratory protection and the current CDC guidelines for tuberculosis infection control. “;; Purpose: “;This plan is designed to prescribe practices relating to the management of Mycobacterium Tuberculosis in an effort to minimize the risk of exposure and transmission of this disease to home care staff, patients and others.”; Procedures and Responsibilities: “;The Agency will follow current CDC guidelines for TB monitoring and testing. The two step Mantoux PPD test or FDA approved IGRA testing shall be required for all Agency field staff with patient contact upon hire.” Review of personnel files (PF) conducted on 1/17/24 from 12:05 PM-12:35 PM and 1:00 PM-2:00 PM revealed the following: PF 1, Date of hire (DOH): 4/17/23; had no documentation of TB testing upon hire. PF 2, Date of hire (DOH): 11/16/23; had no documentation of tuberculosis testing upon hire. File contained a chest x-ray dated 11/17/15 (eight (8) years prior to hire) and a Quantiferon test dated 10/20/20 (three (3) years prior to hire). PF 3, Date of hire (DOH): 2/13/23; had no documentation of tuberculosis testing upon hire.PF 4, Date of hire (DOH):9/11/23; had no documentation of tuberculosis testing upon hire. PF 6, Date of hire (DOH): 1/15/24; had no documentation of two-step tuberculosis testing upon hire. File contained a one-step test dated 1/5/24.PF 7, Date of hire (DOH): 10/12/23; had no documentation of tuberculosis testing upon hire.PF 8, Date of hire (DOH): 3/21/22; had no documentation of tuberculosis testing upon hire.PF 9, Date of hire (DOH): 7/24/23; had no documentation of tuberculosis testing upon hire. An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.”

“Based on review of medical records (MR), policies/procedures and an interview with the Agency Administrator and Director of Nursing, the agency failed to ensure revocation procedure was followed in one (1) of fifteen (15) records reviewed. (MR #13) Review of Morning Star Hospice and Palliative Care Solutions, Llc, revocation of the Medicare hospice benefit policy on 1/28/24 at 7:30 PM revealed: Policy: “;A patient or his/her representative may revoke election of the Medicare hospice benefit at any time and for any reason during an election period. “;4. To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information:a. A signed statement that the individual or representative revokes the individual’s election for Medicare coverage of hospice care for the remainder of that election period; and b. The date that the revocation is to be effective. (An individual or representative may not designate an effective date earlier than the date that the revocation is made).” Review of medical records (MR) on 1/17/24 between 2:30 PM-3:30 PM and 1/18/24 between 11:50 AM-1:00 PM revealed: Medical record (MR) # 13: Start of Care (SOC): 6/16/23; live discharge revocation date: 9/8/23; review revealed no revocation paperwork signed by patient or patients family. The physician was notified, and the discharge summary was sent. An interview with the agency administrator and director of nursing conducted on January 18, 2024, at approximately 3:15 PM confirmed the above findings.”