Trucare Hospice and Palliative Services

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure documentation that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan, were reviewed and updated at least every two (2) years. The emergency preparedness plan stated the last review was on 03/20/2017. During a joint document review and interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan, were not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation consisted of Agency Emergency Preparedness Plan Evaluation forms dated 05/16/2024-05/21/2026, 07/08/2024-07/17/2024, 01/20/2025-01/22/2025, and 01/24/2026-01/26/2026 for weather-related events. These forms did not evaluate the full emergency preparedness plan. The documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan, were reviewed and updated at least every two (2) years.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. The communication plan must include all of the following: names and contact information for the following: hospice employees, entities providing services under arrangement, patients’ physicians, and other hospices. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure the agency EP communication plan included all contact information was reviewed and updated at least every two (2) years. The documentation lacked evidence of a communication plan that included names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians, and other hospices. During a joint document review and interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that the communication plan, including all contact information, was not reviewed and updated at least every two (2) years. The Director of Nursing confirmed that the documentation lacked the names and contact information required. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) communication plan, including all contact information, was reviewed and updated at least every two (2) years. The documentation lacked evidence of a communication plan that included names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians, and other hospices.”

“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, 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 2 of 14 (14%) clinical records reviewed, the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/30/2026 the diagnosis of Alzheimer’s disease with late onset. The hospice registered nurse (RN) admission note dated 07/30/2026 included documentation that the “Patient was recently hospitalized following seizure activity... New orders were initiated for Lorazepam 1 mg scheduled and Keppra for seizure management.” The medication profile was reviewed on 08/13/2026, which revealed Lorazepam 0.5 mg tablet: Give 0.5 mg/one tab orally or sublingual every 4 hours as needed for anxiety or agitation. The medication profile lacked documented evidence of “Lorazepam 1mg and Keppra” as documented in the nursing visit note. A written order for Keppra and Lorazepam was in the paper chart but not added to the electronic medical record medication profile. The record lacked evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/09/2025 with diagnosis of end-stage heart failure. The medication profile reviewed on 08/13/2026 revealed Lasix 40 mg tablet, given 1 tab PO daily, started 05/09/2025; Potassium Chloride 20 mEq tablet, given 1 tab PO daily, started 05/09/2025; Senna 8.6 mg tablet, given 1 tablet daily, started 05/09/2025; and Metoprolol Tartrate 25 mg tablet, given 1 tab PO daily at 0830 once a day, started 05/09/2025, was marked as not covered by hospice. The Director of Nursing/Alternate Administrator verified through pharmacy bills that the medications were being provided by the agency. The record lacked evidence that medication reconciliation occurred for medication-relatedness. During a joint record review and interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications.”

“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 6 of 14 (43%) clinical records reviewed, the agency did not ensure the plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/30/2026. The hospice diagnosis was Alzheimer’s disease with late onset. Comorbidities included recurrent urinary tract infections, history of fractures, diabetes mellitus, hyperlipidemia, constipation and acute kidney failure. The Hospice RN Admission note dated 07/30/2026 included documentation that the “Patient was recently hospitalized following seizure activity... New orders were initiated for Lorazepam 1 mg scheduled and Keppra for seizure management.” The Care Plan/Physician Order dated 07/30/2026 lacked problems, interventions, and goals for seizures and related safety concerns. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/09/2025. The hospice diagnosis was End-stage heart failure. The Care Plan/Physician Order dated 07/03/2026 documented medical social work problems for anxiety and agitation and mental status with interventions, however there was no documented evidence of goals for the problems identified. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/12/2024. The hospice diagnosis was Alzheimer’s disease with late onset. The Care Plan/Physician Orders dated 08/12/2024, 11/10/2024, 02/08/2025, 04/09/2025, 06/08/2025, and 08/07/2025 documented the following nursing problems and goals for Bowel Elimination: constipation/impaction - In process patient will remain free from constipation/impaction; Educational Needs - In process, patient/family will verbalize understanding of end of life signs/symptoms; Genitourinary Issues: incontinence - in process patient will be provided with frequent toileting/brief changes, patient will remain free from skin breakdown, and patient will remain free from urinary tract infections; Impaired ADL’s (activities of daily living) - In process patient will assist in self-care as capable, patient will be assisted with completion of ADL’s, and patient will remain safe during completion of ADLs; Injury/Risk For Injury - In process patient will remain safe/free from injury, patient/primary caregiver will verbalize understanding of safety needs and injury prevention; Knowledge Deficit - In process patient will have sufficient understanding of end of life processes, patient/family/caregiver will verbalize understanding of hospice care and patient rights, and patient/family/caregiver will verbalized understanding of role of hospice in patient care; Medication Management - In process patient/caregiver/family will verbalize need to follow patient orders, patient/primary caregiver will demonstrate and verbalized understanding of medication regimen, patient/primary caregiver will verbalize understanding role of comfort medications, and patient/family/caregiver will verbalized understanding of narcotic refills and policy on disappearance; and Wounds/Impaired Tissue Integrity - In process facility staff/primary caregiver will notify hospice with any new wounds or changes in existing wound, maximum effort will be made to heal or maintain status of wound without further breakdown, patient will remain comfortable, patient will report any altered sensation or pain at site of tissue impairment/wound, patient/primary caregiver will verbalize understanding of wounds in terminal patient, and wounds will be prevented. There was no documented evidence of interventions for these problems identified. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/22/2026 with diagnosis of end-stage heart disease and comorbidities seizures. The hospice RN Admission note dated 04/22/2026 included documentation that “The patient has repeat hospitalizations within weeks for repeat episodes of seizures, fatigue... and full code.” The medication profile reviewed on 08/13/2026 revealed Levetiracetam 750 mg tablet, 1 tablet PO 2x daily, started 04/22/2026. The Care Plan/Physician Orders dated 04/22/2026 and 07/21/2026 did not included documented evidence of problems, interventions, and goals for seizures and the patient’s code status. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/09/2025 with diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris and comorbidities included type 2 diabetes mellitus with ketoacidosis. The hospice RN admission note dated 10/09/2025 included documentation that the patient had frequent admissions to the intensive care unit for diabetic ketoacidosis and was a full code. There was a physician’s order on 10/14/2025 that stated, “Caregiver to perform Accu checks TID (three times daily) and record readings. If blood glucose is less than 100 or above 500, call (agency name).” The skilled nurse visit note dated 10/31/2025 documented, ‘Glucose is elevated 346, pt (patient) states he/she has been taking Insulin Glargine 20 units twice daily. Pt educated to take 30 units subcutaneously twice daily per MD order.” The medication profile revealed insulin glargine 100 units/ml, inject 30 units subcutaneously twice daily, dated 10/09/2025; insulin Glargine 100 units/ml, inject 35 units once daily, dated 10/09/2025; insulin Lispro 100 units/ml, inject 15 units subcutaneously three times a day, dated 10/09/2025. The Care Plan/Physician Order (Initial Plan of Care) dated 10/09/2025 and the Interdisciplinary Team Review dated 10/28/2025 and 11/25/2025 lacked documented evidence of problems, interventions, and goals related to hypoglycemia/hyperglycemia and the patient’s code status. CLINICAL RECORD 14: The patient elected the hospice benefit on 11/11/2025. The hospice RN admission note dated 11/11/2025 included documentation that the patient had bilateral nephrostomy tubes and was a full code. The Care Plan/Physician Order dated 11/11/2025 lacked documented evidence for problems, interventions, and goals for the patient’s code status and altered urine elimination. During a joint review of the record and an interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document review and interview which revealed the agency did not ensure to demonstrate measurable improvement among indicators related to improved palliative outcomes and hospice services. DOCUMENT 1: Agency Document: QAPI Program, not dated, stated in part, “Scope of the QAPI Program: (Agency Name) will evaluate all services, departments, and functions that directly or indirectly affect patient care, safety, and satisfaction. The scope of the QAPI Program will include, but not be limited to: clinical assessment, care planning, and interdisciplinary coordination; pain and symptom management; nursing, physician, social work, spiritual care, hospice aide, and volunteer services; infection prevention and control; medication management and safety; patient rights, dignity, and ethical care; care transitions and coordination across settings; staff competency, education and performance; contracted and outsources services; administrative and operational processes that impact care delivery; and patient, family, caregiver, and referral source satisfaction… Program Goals and Objectives: (Agency Name) will use the QAPI Program to: improve patient outcomes by ensuring timely, effective, and evidence-based hospice care; enhance patient and family experience by actively evaluating satisfaction, communication, and responsiveness; promote patient safety by identifying and reducing risks associated with care delivery; ensure ongoing compliance with CMS Conditions of Participation and applicable state regulations; support staff accountability, competency, and professional development; and identify system-level opportunities for improvement rather than focusing solely on individual performance… Data Collection and Performance Measurement: (Agency Name) will systematically collect, monitor, and analyze data to evaluate the quality and safety of care. Data sources will include but are not limited to: clinical quality indicators and outcome measures; incident reports, near misses, and adverse events; infection prevention and surveillance data; patient and family satisfaction surveys; Hospice Item Set (HIS) and other CMS-required data submissions; complaints, grievances, and service recovery outcomes; and staff competency assessments and training records. (Agency Name) will trend data over time to identify patterns, risks, and opportunities for improvement. Findings will be documented and reviewed by the QAPI Committee and Governing Board as appropriate.” During a joint document review and interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that the QAPI program lacked evidence that the agency demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services.”

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. This standard was not met as evidenced by document review and interview which revealed that the agency did not ensure to measure, analyze, and track quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. DOCUMENT 1: Agency Document: QAPI Program, not dated, stated in part, “Scope of the QAPI Program: (Agency Name) will evaluate all services, departments, and functions that directly or indirectly affect patient care, safety, and satisfaction. The scope of the QAPI Program will include, but not be limited to: clinical assessment, care planning, and interdisciplinary coordination; pain and symptom management; nursing, physician, social work, spiritual care, hospice aide, and volunteer services; infection prevention and control; medication management and safety; patient rights, dignity, and ethical care; care transitions and coordination across settings; staff competency, education and performance; contracted and outsources services; administrative and operational processes that impact care delivery; and patient, family, caregiver, and referral source satisfaction… Program Goals and Objectives: (Agency Name) will use the QAPI Program to: improve patient outcomes by ensuring timely, effective, and evidence-based hospice care; enhance patient and family experience by actively evaluating satisfaction, communication, and responsiveness; promote patient safety by identifying and reducing risks associated with care delivery; ensure ongoing compliance with CMS Conditions of Participation and applicable state regulations; support staff accountability, competency, and professional development; and identify system-level opportunities for improvement rather than focusing solely on individual performance… Data Collection and Performance Measurement: (Agency Name) will systematically collect, monitor, and analyze data to evaluate the quality and safety of care. Data sources will include but are not limited to: clinical quality indicators and outcome measures; incident reports, near misses, and adverse events; infection prevention and surveillance data; patient and family satisfaction surveys; Hospice Item Set (HIS) and other CMS-required data submissions; complaints, grievances, and service recovery outcomes; and staff competency assessments and training records. (Agency Name) will trend data over time to identify patterns, risks, and opportunities for improvement. Findings will be documented and reviewed by the QAPI Committee and Governing Board as appropriate.” During an interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that the QAPI program lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events.”

“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 1 of 14 (7%) clinical records reviewed for patients receiving hospice aide services, the hospice did not ensure the registered nurse developed patient specific care instructions for the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/30/2026. The hospice RN (Registered Nurse) admission note dated 07/30/2026 included documentation that the “Patient was recently hospitalized following seizure activity... New orders were initiated for Lorazepam 1 mg scheduled and Keppra for seizure management.” The hospice aide care plan dated 07/30/2026 did not include instructions to the aide related to seizure precautions. During a joint clinical record review and interview on 08/13/2026, the Director of Nursing/Alternate Administrator confirmed that the aide plan of care lacked instructions for seizure precautions.”