Magnolia 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. 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, document review and interview. In 1 of 19 (5%) clinical record, and interview, the agency did not ensure that the drug profile contained the patient’s current prescription and over the counter supplements. Agency policy: Medication Management stated in part “ Medication records are established at time of admission and update, as needed. The medical record will contain a current medication list.” CLINICAL RECORD 3/HOME Visit 3: A visit was conducted with the Registered Nurse (RN) (PERSONNEL RECORD 2) on 09/15/2026 at a Skilled Nursing Facility (SNF) with a hospice benefit election date of 4/11/2026. The Executive Director of Nursing (ED) was also present during the home visit. The SNF medication profile contained an order for Aspirin 81mg po daily (written on 04/12/2026). The hospice agency’s medication profile did not contain documentation of the medication Aspirin 81mg po daily. A joint medication record review and interview with the Compliance Support Specialist confirmed the hospice medication profile was not updated to contain documentation of all the medications currently being taken by the patient. Agency policy: Medication Management stated in part “ Medication records are established at time of admission and update, as needed. The medical record will contain a current medication list”.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed with aide services provided, the agency did not ensure that the aide provided services as ordered on the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/23/2026. The aide care plan created by the Registered Nurse (RN) dated 07/23/2026 assigned the tasks shampoo weekly, assist with dressing, provide oral care, skin care, nail care, and hair care every visit. on 08/03/2026 the aide documented that no tasks were completed. The aide did not follow the aide care plan assignment. During an interview on 09/16/2026, the Compliance Support Specialist during a joint review of clinical records stated the aide care plan had not been followed and education would be provided.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) Clinical records reviewed with aide services provided, the agency did not ensure that the aide informed the RN of changes related to the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/23/2026. The aide care plan created by the Registered Nurse (RN) dated 07/23/2026 assigned the tasks shampoo weekly, assist with dressing, provide oral care, skin care, nail care, and hair care every visit. on 08/03/2026 the aide documented that no tasks were completed. There was no documented evidence that the RN was notified that the tasks were not completed. During an interview on 09/16/2026, the Compliance Support Specialist during a joint review of clinical records she confirmed that the aide did not inform the RN that tasks were not completed and education would be provided.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records of patients that transferred to a Medicare certified facility, the agency did not ensure that a discharge summary was sent to the receiving facility. CLINICAL RECORD 16: The patient elected the hospice benefit on 12/31/2025. The patient was transferred on 02/04/2026. A discharge summary was completed on 02/04/2026. There was no documented evidence that a discharge summary was forwarded to the receiving facility. During an interview and joint record review on 09/16/2026, the Compliance Support Specialist confirmed that the discharge summary was not forwarded to the receiving hospital.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: 1. The most recent hospice plan of care; 2. Hospice election form and any advance directives; 3. Physician certification and recertification of the terminal illness; 4. Names and contact information for hospice staff involved in the patient’s care; 5. Instructions on how to access the hospice’s 24-hour on-call system; 6. Hospice medication information; 7. Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) clinical records reviewed of patients residing in a Skilled Nursing Facility revealed that the agency did not ensure that a copy of the recertification of terminal illness was present at the Skilled Nursing Facility. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/03/2025. During the observation visit on 09/15/2026, the facility binder was reviewed with the Executive Director of Hospice. The Face to Face and recertification documentation for the 3rd benefit period (06/01/2026 to 07/30/2026) was completed by the hospice agency but was not forwarded to the Skilled Nursing Facility. During a SNF visit with the Executive Director on 09/15/2026, she agreed that the documentation of the patient’s Face to Face and recertification of the terminal illness by the Physician was not present at the Skilled Nursing Facility. She stated “The agency’s process is to send the latest recertification to the Skilled Nursing Facility after the IDG meeting by the RN Case Manager in charge of that Facility. The RN was no longer working at the hospice agency.””

“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; 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. CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient’s current prescription and over the counter supplements. Clinical Record 1: The patient elected the hospice benefit on 06/14/2024, with a terminal diagnosis of hypertensive chronic kidney disease stage 5. The Registered Nurse assessment dated 06/14/2024 documented pain as an active problem, and Tylenol for pain relief. During the home visit with the Registered Nurse (RN) (Personnel Record 3) and Director of Clinical Services(Personnel Record 1) on 10/21/2024, the family provided a bag of the patient’s medications. The bag included Morphine 100mg/5ml, 0.25-1ml by mouth every 2 hours as needed for pain or shortness of breath dated 06/15/2024. The medication bag also included Tylenol tablets. The hospice medication profile did not include the Morphine or Tylenol. The Registered Nurse (Personnel Record 3) was interviewed and stated, “Things get missed between admissions and I just need to remember to look at them during my visit.””

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 06/14/2024, with a terminal diagnosis of hypertensive chronic kidney disease stage 5. The Registered Nurse (RN) assessment dated 06/14/2024 documented pain as an active problem, Tylenol for pain relief, and bilateral 3+ edema. The plan of care reviewed 06/14/2024-10/21/2024 did not include interventions related to the patient’s pain and edema. Clinical Record 2: The patient elected the hospice benefit on 04/05/2023, with a terminal diagnosis of senile degeneration of brain. The plan of care dated 07/28/2024 ordered chaplain visits 1wk1, 1every4wk. The Chaplain visit dated 07/30/2024 and 08/13/2024 documented provided prayer and companionship. The plan of care dated 07/28/2024 did not include interventions for the Chaplain. During a joint record review and interview on 10/21/2024, the Director of Clinical Services agreed the interventions were not identified in the plan of care. The Director of Clinical Services also stated, “ We have some new staff that need more education on documenting the plan of care properly in the EMR.”