Riverside Hospice

“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 1 of 14 (7%) clinical records reviewed, the agency did not ensure that an initial comprehensive assessment was completed by the Interdisciplinary Group no later than five (5) calendar days after the patient’s election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/30/2026 with a diagnosis of cardiovascular accident (CVA). A clinical record review revealed that the initial psychosocial assessment was completed on 05/11/2026, 11 days after the patient’s election of hospice care. There was no documented explanation for the delay in completion of the psychosocial assessment. During a joint clinical review and interview on 06/04/2026, the Agency Manager stated that there was no documentation for a psychosocial assessment before 05/11/2026.”

“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, interview, and observation. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained all of the patient’s current medications to identify any potential adverse effects and drug reactions. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 04/30/2026 with a diagnosis of CVA. During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 06/02/2026, a medication review was completed comparing the hospice medication profile, dated 06/02/2026, to the patient’s medications. A prescription bottle filled 05/01/2026 for haloperidol 2 mg twice a day as needed for agitation and vomiting was present in the home. The caregiver stated they administered the medication routinely twice a day, once in the morning and once at bedtime. The review of the clinical record revealed that an order had been written for haloperidol 2 mg 1 tablet by mouth twice a day as needed for agitation or vomiting on 05/01/2026. This medication was not documented on the medication profile. In an interview on 06/02/2026, the Agency Manager stated that the order was present in the record, but it was not added to the medication profile. HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 02/23/2026 with a terminal diagnosis of chronic cerebral ischemia. The patient resided in an assisted living facility (ALF). During the home visit with the Chaplain (CH) [Personnel Record 3] on 06/02/2026, a joint medication review was completed comparing the hospice medication profile, dated 06/02/2026, to the ALF medication profile. The following medications were documented on the hospice medication profile but not on the ALF medication profile dated 06/02/2026: amlodipine 10 mg by mouth daily, calcium carbonate cholecalciferol, two tablets daily by mouth, Namenda 10 mg, two times a day by mouth. The following medications were documented on the ALF medication profile but not on the hospice medication profile: Nystatin powder 1000000 unit/GM, apply topically to affected area twice a day for skin infection, and Lantus 6 units SQ at bedtime. During a joint clinical review and interview on 06/04/2026, the Agency Manager stated that the medication profiles were not accurate and that the nurse case managers would be re-educated to ensure accuracy.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; and includes all services necessary for the palliation and management of the terminal illness. 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 patient’s plan of care reflected patient and family goals and identifies planned interventions based on problems identified the comprehensive assessments. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/24/2025 with a diagnosis of Parkinson’s Disease. The initial comprehensive assessment dated 08/24/2025 documented the presence of the colostomy. The Registered Nurse (RN) visit note dated 06/02/2026 documented that the patient had a colostomy. The hospice plans of care for the dates 08/24/2025 through 06/04/2026 documented no problems, goals, or interventions related to the management of the colostomy. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/23/2026 with a terminal diagnosis of chronic cerebral ischemia. The Volunteer Coordinator’s visit note dated 03/10/2026 documented that a pet therapy visit was provided and that the patient looked forward to future visits. A visit note dated 05/26/2026 documented that the Volunteer Coordinator would follow for volunteer visit needs. The review of the hospice plans of care dated 02/23/2026 to 06/04/2026 revealed no problems, goals, or interventions related to volunteer services. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/05/2025 with a terminal diagnosis of renal carcinoma. The hospice plan of care dated 10/08/2025 through 01/06/2026 ordered Chaplain visits three times as needed (PRN). A Chaplain’s visit note dated 04/28/2026 documented, “will continue to provide Chaplain services throughout hospice care until the time of death or discharge.” The plans of care dated 01/07/2026 through 06/05/2026 documented no problems, goals, or interventions related to Chaplain visits. No further Chaplain visits were provided during this period. During a joint clinical review and interview on 06/04/2026, the Agency Manager. stated that the plans of care were not complete and acknowledged that the plans of care should address the identified needs of the patient.”

“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 and use of gloves. This standard was not met as evidenced by clinical record review, interview, document review, and observation. In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated by the agency’s policy. Agency policy #DIV-916 titled, Hand Hygiene Policy and Procedure, stated in part, “Hand Hygiene....All Staff... After contact with the patient’s immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after removing gloves.” HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 04/30/2026 with a diagnosis of cardiovascular accident (CVA). During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 06/02/2026, the HA washed their hands, donned gloves, cleansed the patient’s face, trunk, and legs, then cleansed the perineal area and changed the patient’s linens. The HA then cleansed the patient’s rectal area and then washed the patient’s back and lower legs. The HA used the same gloves, washcloth, and water basin for the complete bath. The HA doffed the gloves after completing the patient’s bath and linen change, and did not perform hand hygiene per the agency’s policy. In an interview on 06/02/2026, the Agency Manager stated that the Hospice Aide did not follow the agency policy and would be provided with education.”

“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%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the needs of the patient.. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/30/2026 with a terminal diagnosis of cerebrovascular accident (CVA). The hospice plan of care dated 04/30/2026 through 07/28/2026, ordered Hospice Aide (HA) visits two times a week, and wound care with dressing changes to the right lateral ankle pressure ulcer twice weekly: “caregiver or skilled nurse (SN) to apply bacitracin and secure the dressing with a foam patch twice weekly.” The HA care plan for the period 04/30/2026 through 06/01/2026 did not include instructions related to the wound and foam patch dressing for the right lateral ankle pressure ulcer, should it become soiled, wet, or dislodged during personal care. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/23/2026, with a terminal diagnosis of Alzheimer’s Disease. The patient resided in an assisted living facility (ALF). The hospice plan of care dated 04/23/2026 through 07/21/2026, ordered HA visits twice a week. The initial Registered Nurse (RN) comprehensive assessment dated 04/23/2026 documented that the patient was unable to assist with or bear weight during transfers from the wheelchair to the bed. The HA care plan dated 04/23/2026 through 07/21/2026 assigned the HA the task: a complete shower. The HA care plan did not provide the HA with specific instructions to safely accomplish this task based on the patient’s assessed functional limitations. Additionally, the HA care plan did not include instructions regarding the need for assistance to move the patient into and out of the shower given the patient’s non-weight-bearing status. During the joint clinical review and interview on 06/04/2026, the Agency Manager stated that the HA care plans were not specific enough and did not include clear and complete instructions for the HA.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day to day administrative or direct patient care services that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and a joint review of the cost savings and volunteer utilization reports on 06/03/2026 with the Agency Manager and Volunteer Coordinator (VC) revealed that, for 2024 (01/01/2024 through 12/31/2024) and 2025 (01/01/2025 through 12/31/2025), volunteer utilization was 2.54% and 1.18%, respectively. 2024 and 2025 did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator stated that an action plan was in place to recruit additional volunteers. An interview was conducted with the Agency Manager and Volunteer Coordinator (VC) on 06/03/2026 and reviewed the cost savings report for 2024 and 2025 which revealed that the volunteer utilization for the year of 2024 was 2.54% and for the year of 2025 was 1.18%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator stated that there was an action plan in place to recruit additional volunteers.”