A Better 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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the drug profile was updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication was added or changes were made to existing medication. Agency Policy Medication List and Monitoring PC.85 stated, in part: “VI. A. The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate.”. CLINICAL RECORD 1: This patient elected the hospice benefit on 12/28/2024 with a terminal diagnosis of Alzheimer’s Disease. A review of the initial registered nurse comprehensive assessment completed 12/28/2024 it was documented that patient was administered oxygen 2-4 liter per nasal cannula prn. An order was documented for oxygen 2-4 liters continuous prn dated 12/28/2024. The medication profile was reviewed for the dates of 12/28/2024-08/27/2025 and revealed that oxygen was not listed. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 12/06/2024 with a terminal diagnosis of Alzheimer’s Disease. During the home visit with the Hospice Aide (Personnel Record 2) on 08/26/2025 the medications were reviewed with the patient’s daughter who stated that she prepared the medications for the patient. A review of the agency provided medication profile dated 08/26/02025 included these medications: Apixaban 2.5 mg one tablet twice a day, acetaminophen 325 mg two tablets every six hours prn, Tizanidine 2 mg every 6 hours for muscle spasms, and Roxicodone 5 mg every six hours for pain, oxycodone acetaminophen 5-325mg every four prn. She stated, “he does not take Apixaban, Tizanidine, and the correct dosage for the oxycodone acetaminophen 5-325mg every four hours was routine not prn as stated on the drug profile”. She was administering these medications morphine liquid 20mg/5ml 1 ml twice a day, Carvedilol 6.25 mg twice a day (bottle was filled 08/21/2025), Aldactone 25 mg one tablet by mouth once a day (bottle filled 08/13/2025), Senokot, two tablets by mouth at bedtime as needed and lactulose 15-30 ml by mouth daily as needed for constipation, however these medications were not on the agency provided medication profile. CLINICAL RECORD 3: This patient elected the hospice benefit on 04/16/2024 with a terminal diagnosis of senile degeneration of the brain. A review of the initial registered nurse comprehensive assessment dated 04/16/2024 revealed that the patient was administered oxygen 2-4 liters per nasal cannula as needed. An order was documented for oxygen 2-4 liters prn dated 04/16/2024. Review of the medication profile for the dates of 04/16/2024-08/27/2025 revealed that oxygen was not included in the profile. CLINICAL RECORD 13: This patient elected the hospice benefit on 11/27/2024 with Alzheimer’s Disease. TA review of the initial registered nurse comprehensive assessment dated 11/27/2024 revealed that the patient was administered oxygen 2-4 liters per nasal cannula as needed. An order was documented for oxygen 2-4 liters prn dated 11/27/2024. Review of the medication profile for the dates of 11/27/2024-12/10/2024 revealed that oxygen was not included in the profile. During an interview and review of findings with the Administrator (Personnel Record 6) on 08/27/2025, it was stated that oxygen should be on the drug profile and that the nurses would be re-educated. It was also stated by the Alternate Administrator (Personnel Record 5) that the medication profile for clinical record 2 should have included morphine as she knew the patient took it twice a day. She stated that the changes to the medication profile would be made immediately.”

“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, interview and observation. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the written 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 1: This patient elected the hospice benefit on 12/28/2024 with a terminal diagnosis of Alzheimer’s Disease. The initial registered nurse comprehensive assessment dated 12/28/2024 documented that the patient had a history of chronic urinary tract infections. Review of the clinical record revealed that on 08/05/2025, the RN nursing note documented the patient was experiencing ongoing symptoms for a urinary tract infection, including tea color urine and increased confusion. The patient was treated for probable urinary tract infection on 08/05/2025 and 08/13/2025. Interdisciplinary group notes for 08/27/2025, revealed the physician ordered Cipro 500 mg every Monday and Wednesday for chronic UTI’s. The plan of care was reviewed for the dates of 12/06/2024-08/27/2025. There were no patient or family goals or planned interventions present in the plan of care for the frequent urinary tract infections. CLINICAL RECORD 3/ HOME VISIT 3: This patient elected the hospice benefit on 04/16/2024 with a terminal diagnosis of senile degeneration of the brain. Review of the initial Registered Nurse comprehensive assessment dated 04/16/2024 revealed the patient experienced bilateral knee pain at 7/10 which was described as aching/dull, throbbing intermittently and frequent, with a current order for Tramadol 100 mg twice a day, and dysphagia which caused patient to cough and choke and to be at risk for aspiration. Aspiration precautions were documented as reviewed with the patient’s caregiver. During a home visit that was conducted on 08/27/2025 with the LMSW (Personnel Record 3), the patient verbalized that he was experiencing pain in his left leg. The LMSW stated that she would report this concern to the patient’s nurse. The review of the Plan of Care for 04/16/2025-08/27/2025 revealed the plan of care did not include documentation of the patient/family goals or interventions for pain management or dysphagia/aspiration risk. In an interview and review of the clinical record with the Administrator (Personnel Record 6) on 08/27/2025, it was stated that the plan of care should include problems that are identified in the assessments similar to how home health develops care plans. The Alternate Administrator stated that the staff must be re-educated on writing care plans.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 3 (33%) home visits observed, the agency did not ensure that accepted standards of practice to prevent the transmission of infections and communicable disease, including hand hygiene, were followed. Agency policy “Hand Hygiene” IC.15 stated, in part: “All Hospice staff providing patient care will perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.” “Hand hygiene with an alcohol based-hand rub 4. after contact with body fluids, or excretions, mucous membranes, nonintact skin...”. CLINICAL RECORD 1/ HOME VISIT 1: This patient elected the hospice benefit on 12/28/2024 with a terminal diagnosis of Alzheimer’s Disease.: During the home visit with the Registered Nurse (RN) (Personnel Record 1) on 08/26/2025 the RN washed her hands and donned gloves to provide perineal care for the patient. The RN washed the patient’s perineal area and then reached for a medication bottle without removing gloves and sanitizing hands. An interview was conducted with the Administrator (Personnel Record 6) on 08/26/2025 and it was stated that the Registered Nurse did not follow the agency policy for hand hygiene.”

“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 standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) records reviewed of patients receiving hospice aide services, the agency did not ensure that the aide care plan provided patient specific instructions. CLINICAL RECORD 1: This patient elected the hospice benefit on 12/28/2024 with a terminal diagnosis of Alzheimer’s Disease. The initial comprehensive assessment dated 12/28/2024 revealed that the patient was bedbound and required total assistance with a Hoyer lift. The hospice aide care plan was reviewed for the dates of 12/30/2024-03/27/2025 and included an order for hospice aide visits 3XW. There was no documented evidence in the clinical record or the hospice aide plan of care review that the hospice aide received specific instructions on the use of the Hoyer lift for the patient. CLINICAL RECORD 2: This patient elected the hospice benefit on 12/06/2024 with a terminal diagnosis of Alzheimer’s Disease. The CTI dated 12/06/2024 documented the patient’s transfers were via a Hoyer lift. Nursing assessments dated 12/30/2024, 01/02/2025, 06/26/2025 and 08/07/2024 documented that the patient was transferred with a Hoyer lift. The hospice aide care plan was reviewed for the dates of 12/06/2024-08/07/2025 which included an order for hospice aide visits 2XW. The hospice aide care plan instructed the hospice aide to assist with transfers at each visit. There was no documented evidence in the clinical record or the hospice aide plan of care review that the hospice aide received specific instructions on the use of the Hoyer lift for the patient. In an interview and joint record review on 08/27/2025, the Administrator (Personnel Record 6) stated that the hospice aide care plan did not include instructions for the hospice aide to use the Hoyer lift and that the Hoyer lift would be removed from the patient’s homes as these patients were no longer being transferred from the bed with a Hoyer lift.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed for live discharge, the agency did not ensure that the discharge summary included the patient’s current plan of care. CLINICAL RECORD 12: This patient elected the hospice benefit on 01/16/2025 with a terminal diagnosis of protein malnutrition. The patient revoked services to seek aggressive treatment on 04/07/2025. There was no documented evidence in the clinical record review that the discharge summary that was faxed to the physician included the patient’s current plan of care. During an interview and review of findings with the Administrator (Personnel Record 6) on 08/27/2025, there was an extensive search for documentation that the discharge summary that was sent to the physician included a current plan of care. The Administrator stated that there was no evidence that the discharge summary faxed on 04/07/2025 included a current plan of care.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed for live discharge, the agency did not ensure that the discharge summary included the patient’s latest physician orders. CLINICAL RECORD 12: This patient elected the hospice benefit on 01/16/2025 with a terminal diagnosis of protein malnutrition. The patient revoked services to seek aggressive treatment on 04/07/2025. Review of the clinical record revealed that the discharge summary did not include the patient’s latest physician orders. During an interview and review of findings with the Administrator (Personnel Record 6) on 08/27/2025, there was an extensive search for documentation that the discharge summary that was sent to the physician included the patient’s latest physician orders. The Administrator stated that there was no evidence that the discharge summary faxed on 04/07/2025 included the patient’s latest physician orders.”