Care 4 You Senior Services

“It is required that each patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviews of patients who elected hospice services, the agency did not ensure the patients’ individualized written plan of care included the drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 1: The plan of care dated 06/21/2026 to 08/19/2026, which has Gastrostomy tube (G-tube) site care identified as a problem. Goal: G-tube site remains clean, dry, and intact with no signs of infection. Interventions: Educate patient and/or caregiver on PEG tube use and/or maintenance and educate patient and/or caregiver on proper oral hygiene. The nursing comprehensive assessment dated 06/08/2026 stated that the patient was receiving Jevity 1.5, 240 mL every 6 hours via gravity through the G-tube. No interventions regarding feeding or flushing of the G-tube were noted in the plan of care. CLINICAL RECORD 2: The recertification plan of care dated 05/15/2026 to 07/13/2026 has the problem: Stage 2 pressure injury with Goal: Patient maintains stable skin integrity with no new pressure injuries, and the intervention: Assess for changes in skin integrity and teach and/or demonstrate good preventive skin care (e.g repositioning, keeping skin clean and dry, use of wedges, floating heels, etc) and wound care provided per the plan of care. The wound care order was documented on the order dated 05/05/2026 for wound care to be performed by an RN/trained CG. Using sterile technique, cleanse the site with NS, pat dry with gauze, paint with betadine, cover with a foam dressing, and secure with tape. Dispose of soiled dressings and used supplies using the double-bag technique; this was not included in the patient’s written plan of care. During an interview with the Administrator (personnel record 5) on 07/08/2026, she stated she is already making a list of education that she needs to provide to the clinical staff.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical record reviews of patients who were discharged from hospice services, the agency did not ensure that a copy of the hospice discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 13: The patient was discharged from hospice on 02/02/2026 due to no longer being terminally ill. There was no documented evidence in the clinical record that the attending physician was notified of the patient’s discharge or that a copy of the discharge summary was sent to the attending physician. CLINICAL RECORD 14: The patient was discharged from hospice on 09/29/2025 due to the patient moving out of the service area. There was no documented evidence in the clinical record that the attending physician was notified of the patient’s discharge or that a copy of the discharge summary was sent to the attending physician. During an interview with the Administrator (Personnel Record 5) on 07/08/2026, she stated that they left the plan of care/medication and discharge summary at the Assisted Living Facility for the rotating visiting physicians, who are the attending physicians.”

“It is required that the designated IDG member provide the SNF/NF or ICF/IID with the following information for each patient/resident: the physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 2 (100%) clinical records reviewed, with patients that resided in a skilled nursing facility, the agency did not ensure the skilled nursing facility was provided the most recent certification of terminal illness. HOME VISIT 1/CLINICAL RECORD 1: The patient was admitted to hospice on 12/23/2025 with the diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. During the home visit with the registered nurse (RN) (Personnel Record 1) on 07/07/2026, the facility’s medical record was reviewed. The facility’s medical record did not include the most recent recertification of terminal illness for the election period 06/21/2026-08/19/2026. HOME VISIT 2/ CLINICAL RECORD 2: The patient was admitted to hospice on Cerebral Palsy. During the home visit with the Licensed Master Social Worker (LMSW) (Personnel 3) on 07/07/2026, the facility’s medical record was reviewed. The facility’s medical record did not include the most recent recertification of terminal illness for the election period 05/15/2026-07/13/2026. During an interview with the Administrator (Personnel Record 5) on 07/07/2026, she stated that she was unaware that the certification or recertification of terminal illness needed to be included in the nursing home binder, but that it would be included moving forward.”