Medi Home Hospice

“Based on staff (EMP) interview, hospice document review, and review of medical records (MR), it was determined the hospice failed to complete the comprehensive assessment no later than five (5) calendar days after the election of hospice care in five (5) of five (5) medical records of patients receiving general inpatient (GIP) level of care for at least five (5) calendar days after election reviewed in the survey sample. MR1, MR2, MR8, MR10, and MR11. Findings:MR1 was admitted to hospice services at the GIP level of care at a contracted hospital with a terminal diagnosis of acute hypoxic respiratory failure on August 9, 2025. MR1 contained the following documentation from the social worker on August 11, 2025, “MSW (Medical social work) services declined for this patient.” The medical record contained no documentation of who declined the services and/or that the patient’s psychosocial needs were assessed. The record did not contain documentation that the social worker saw or spoke to the patient and/or family within five (5) days after the election. On August 12, 2025, the chaplain documented the following: “Chaplain declined.” There was no documentation in the record of who declined chaplain services, why services were declined, or that the patient’s spiritual needs were assessed during the first five (5) days of hospice care. MR2 was admitted to hospice services on August 8, 2025, to GIP level of care at a contracted hospital. MR2 contained documentation from the hospice social worker and chaplain on August 11, 2025, and August 12, 2025, respectfully indicating social work and chaplain services were declined. There was no evidence that a comprehensive assessment was completed on the patient to include psychosocial or spiritual needs within the first five (5) days after election. MR8 was admitted to GIP level of care at a contracted hospital July 24, 2025 -July 21, 2025, with a terminal diagnosis of bowel perforation. The social worker documented the following on June 24, 2025, “MSW not needed for this GIP patient.” It was unclear from the medical record why social work services were not needed and/or if the patient refused social work services. There was no documentation in the medical record that the psychosocial component of the comprehensive assessment was completed within the first five (5) days of admission. The chaplain documented on July 25, 2025, “Chaplain services declined at this time.” It was unclear from the record who declined the chaplain services. The medical record failed to contain documentation that a spiritual assessment was included as part of the comprehensive assessment within the first five (5) days of admission.MR10 was admitted to GIP level of care at a contracted hospital from June 24, 2025 - June 29, 2025, with a terminal diagnosis of acute respiratory failure. On June 24, 2025, the chaplain documented, “Chaplain services declined at admission.” It was unclear who declined these services. On June 25, 2025, the social worker documented, “MSW not needed.” There was no documentation in the record that social work services were ever offered to the patient or that the social worker spoke to the patient or family. MR11 was admitted to GIP level of care at a contracted hospital from June 27, 2025 - July 02, 2025, with a terminal diagnosis of subdural hematoma. MR11 contained documentation on June 27, 2025, that the “patient denied MSW.” Nursing documentation indicated that on June 27, 2025, the patient was “constantly confused,” had slurred speech and spoke Tagalog. It was unclear from the record that the patient whether or not the patient had the capacity to decline social work services or that a translator had been used to facilitate the admission and assessment process. The chaplain documented on June 27, 2025, that chaplain services were declined. It was unclear from the record who declined these services. The RN documented on June 28, 2025, that the patient was Catholic and requesting a priest for last rights. The medical record contained no documentation that a priest was contacted. The patient’s plan of care contained no psychosocial or spiritual problems or goals despite the family’s request for the patient to have last rights with a Catholic priest. An interview was conducted with the social worker (EMP5) on August 20, 2025, at 3:27 PM who had been employed with the agency since 2021. EMP5 indicated that they had never visited a GIP level patient at a hospital for the entirety of their employment with the hospice. EMP5 indicated their understanding was they would only see a GIP patient if the family specifically requested a social worker. Additionally, EMP5 indicated the contracted hospital has social workers on staff if needed. EMP confirmed they had not completed the psychosocial component of the comprehensive assessment for the above noted five (5) patients. An interview was conducted with the chaplain (EMP9) at 2:58 PM on August 21, 2025. EMP9 indicated they had never seen a GIP patient while they were in the hospital. If needs arose while the patient was in the hospital, the hospital chaplain could see the patient. EMP9 indicated that if a GIP patient returned home for routine hospice care, a spiritual assessment would then be completed. The hospice’s policy, “Comprehensive Assessment” (last revised May 2025) was reviewed and reads in part, “...The initial and comprehensive assessments are foundational to hospice care and must be completed within federally mandated timeframes. These assessments are multidisciplinary, person-centered, and take into account the patient’s terminal diagnosis, care needs, support systems, and personal goals...Assessments must be updated regularly and coordinated among the entire interdisciplinary group (IDG), in collaboration with the attending physician if any...Comprehensive Assessment: Completed by the IDG, in consultation with the attending physician (if applicable), no later than five (5) calendar days of hospice election...builds on the initial assessment and ensures all care domains are evaluated including physical, emotional, psychosocial, spiritual, and bereavement needs are assessed related to the terminal illness and related conditions in order to promote the patient’s well-being, comfort, and dignity. Assessment Elements. The comprehensive assessment includes but is not limited to: evaluation of the caregivers and family’s willingness and capability to care for the patient...patient and family’s social support, cultural, and resource needs (including need for counseling and education) ...”The facility’s contracts with the GIP hospitals were reviewed and the contracts did not indicate that hospital employees would function as core members of the IDG or complete the required psychosocial and spiritual components of the comprehensive assessment.”

“Based on staff (EMP) interview, medical record (MR) review, and hospice document review, it was determined the hospice failed to maintain an accurate and current drug profile for each patient in one (1) of nineteen (19) medical records reviewed in the survey sample. MR2. Findings:Documentation revealed MR2 was receiving respite care at a contracted hospice house. A registered nurse (RN) from the contracted hospice house documented on August 16, 2025, that the patient vomited oral medications the prior evening and a Macy catheter (a rectal catheter to administer medications) was placed to administer medications. The hospice’s medication profile for MR2 was reviewed on August 19, 2025, during a home visit. None of the medications on the profile had been ordered to be administered rectally. An interview was conducted with EMP1 on August 20, 2025, at approximately 3:00 PM. EMP1 confirmed the patient’s medications were not ordered to be given rectally. On August 21, 2025, EMP1 confirmed that all medications have been given rectally from August 16, 2025 - August 21, 2025, and the medication profile has been updated the morning of August 21, 2025, to include the correct route of administration, but was previously incorrect. The medication profile from MR2 was reviewed on August 19, 2025, and contained the following medications:”Start: 08/08/2025: HYDROmorphone HCl Injection Solution 1 MG/ML Dose: 1 mlFrequency: Q3Indication: PainInstructions: Administer 1 ML every 3 hours” (Discontinued 08/15/25).The hydromorphone had no route of administration listed.”Start 8/8/25 diazePAM Injection Solution 5 MG/ML (N)Dose: 2 mlFrequency: prnIndication: Anxiety agitationInstructions: Administer 2ml every 30 minutes as needed” (Discontinued 08/15/25). The diazepam had no route of administration listed. “Start 08/15/2025 Morphine Sulfate Oral Solution 10 MG/5ML (N)Dose: 0.5 mlFrequency: Q6Indication: Pain air hungerInstructions: Administer 0.5 ml every 6 hours” (Discontinued 08/20/25). The Morphine did not have a route of administration listed. The contracted hospice house’s medication list for the patient was reviewed and contained” “Morphine Sulfate Oral Solution 20mg/1mL. Dose 0.25 mL every six hours for pain.” It was unclear from review of the record if the patient was receiving morphine in a 20mg/1mL solution as listed in the hospice house medication list or the 10mg/5mL solution as listed in the hospice’s medication list. The hospice’s policy, “Comprehensive Assessment” last revised May 2025, was reviewed and reads in part, “...The comprehensive assessment includes, but is not limited to: Prescribed medications, over the counter drugs, herbal remedies, and alternative treatments that could affect drug therapy...”The hospice’s policy, Medication Management” last revised September 2024 was reviewed and reads in part, “...A medication profile is completed and maintained for every patient. The Medication profile includes, but is not limited to the following: prescription medications, controlled substances, over the counter medication, alternative/complementary/herbal preparations; cannabis and cannabinoids use...name of medication; dose/route; frequency, purpose...The medications are reviewed and assessed at every comprehensive visit...””

“Based on staff (EMP) interview, medical record (MR) review, and hospice document review, it was determined the hospice failed to ensure the update to each patient’s comprehensive assessment considered changes that have taken place since the initial assessment in one (1) of nineteen (19) medical records reviewed in the survey sample. MR12. Findings:MR12 was admitted to the hospice on June 20, 2025, with a terminal diagnosis of senile degeneration of the brain. The patient had a history of multiple falls with injury prior to hospice admission. The patient’s initial care plan dated June 20, 2025, contained the problem of frequent falls and a goal indicating the patient would be free of injury from falls. Nursing interventions included identifying safety issues and educating on safety precautions. It was unclear from the record who would be educated on safety precautions. The patient lived in a facility and was not oriented to place or situation with poor safety awareness. Nursing documentation indicated MR12 fell at the facility on June 23, 2025, and June 24, 2025, resulting in bruising to hips and arm. An Interdisciplinary Group (IDG) meeting was conducted June 26, 2025. MR12’s falls were discussed and a hospital bed with bolsters was ordered.MR12 had another fall on July 13, 2025, resulting in a skin tear to the face. An IDG meeting was held July 17, 2025. Documentation indicated that the patient’s problem of falls was “improving,” despite having three (3) falls resulting in injury in approximately three (3) weeks. No new interventions for protecting the patient from injury from falls were implemented at this IDG meeting and review of the comprehensive assessment. An interview was conducted with EMP2 on August 21, 2025, at approximately 2:00 PM who indicated the nurse practitioner reviewed and changed the patient’s medication in June 2025, but no additional fall precaution measures were implemented after the MR12’s July fall. The hospice’s policy, “Comprehensive Assessment” last revised May 2025 was reviewed and reads in part, “...The comprehensive assessment is reviewed and updated by the hospice IDG, in collaboration with the patient’s attending physician, if any, at least every (15) days or more frequently as needed, in response to changes in the patient’s condition...””

“Based on staff (EMP) interviews and hospice document review, it was determined the hospice staff failed to ensure volunteers provided day-to-day administrative and/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 for the last twelve (12) months. Findings:The following information was found as part of the agency’s policy and procedure document titled “Volunteer Services HC.13” (with a last revised date of 9/2024):- “MSA (initials of the hospice company) Hospices ensure qualified volunteers are available to assist with the provision of hospice services to patients and their caregivers. Hospice volunteers provide day-to-day administrative or direct patient care services.”- “Annual compilation of the Volunteer Coordinator monthly data shows volunteer services meets or exceeds five percent (5%) of total patient care hours of all hospice employees and contract staff.” Hospice documents related to volunteer hours were reviewed and revealed the following percentage of hours provided by volunteers during the previous 12 months:- For 5/23/25 – 8/21/25, zero (0) volunteer hours were documented which was 0% of the total patient care hours.- For 2/22/25 – 5/22/25, 3.23 volunteer hours were documented which was 0.09% of the total patient care hours.- For 11/23/24 – 2/21/25, 21.77 volunteer hours were documented which was 0.53% of the total patient care hours.- For 8/24/24 – 11/22/24, 26.20 volunteer hours were documented which was 0.60% of the total patient care hours. On 8/21/25 at 10:50AM, Employee (EMP) 8 reported currently attempting to recruit volunteers using an internet application. EMP8 also reported recently having potential volunteers being recruited by agency employees. On 8/21/25 at approximately 11:00AM, EMP7 confirmed the agency did not have volunteers providing five percent (5%) of total patient care hours during the last 12-month period.”

“Based on staff (EMP) interview, medical record (MR) review, and review of hospice documents, it was determined the hospice failed to ensure medications were routinely made available on a 24-hour basis, 7 days a week in one (1) of nineteen (19) medical records reviewed in the survey sample. MR2. Findings:MR2 contained documentation that the patient was receiving GIP (general inpatient) level of care at a contracted hospital from August 8, 2025-August 13, 2025. The patient received IV (intravenous) hydromorphone (an opioid pain medication) every three (3) hours scheduled, and every 15 minutes as needed. The patient was transferred to home with routine level of care and ordered a Fentanyl patch (25 mcg) and Morphine 10mg/5mL (0.5mL every four hours as needed) on August 14, 2025. The Registered Nurse (RN) visited the patient at 6:50 PM on August 14, 2025, upon their return home. The patient reported 6/10 pain on a numeric pain scale. The RN documented that the morphine and fentanyl were not yet available from the pharmacy and advised the patient to take Tylenol. The medication profile was reviewed, and Tylenol was ordered as needed for fever (no physician’s orders to administer Tylenol for pain). The medical record contained no documentation that the RN attempted to order the morphine and fentanyl from another pharmacy or to procure the medications for the patient. The patient was transferred to a contracted hospice house the following day for respite care, August 15, 2025. The hospice RN visited the patient at approximately 10:30 AM on August 15, 2025, and documented the morphine and Fentanyl were still not available from the patient’s pharmacy. The RN then reordered them from a different pharmacy. The RN visited the patient again on August 16, 2025, and indicated the Fentanyl patch was administered the morning of August 16, 2025, two (2) days after it was initially ordered.During a home visit on August 19, 2025, an interview was conducted with MR2’s family member who confirmed the patient’s pain medications were not available due to pharmacy not having them when the patient arrived home August 14, 2025, and the patient was complaining of pain. The hospice’s policy, “Medication Management” last revised September 2024 was reviewed and reads in part, “...Medications are provided on a timely basis and are available twenty-four (24) hours a day, seven (7) days a week as needed...””

“Based on staff (EMP) interviews, hospice document review, and clinical record review, it was determined the hospice staff failed to ensure a patient’s clinical notes were maintained in a manner that showed: (a) when a clinical note was altered and (b) what information was added to and/or changed in the clinical note for one (1) of 19 sampled patients (MR6). Findings: The following information was found as part of the agency’s document titled “Patient Clinical Records HC.39” (with a last revised date of 10/2024): “The MSA (initials of the hospice company) Hospice Clinical Record is developed and maintained for every patient. The clinical record is completed promptly, documented accurately, accessible and organized systematically. All health information is protected against loss, damage, unauthorized alteration, unintentional change and accidental destruction.” The following information was found as part of the agency’s document titled “Correction to Patient Medical Record” (with an approved date of 9/2024):- “Purpose: - To preserve integrity of patient information documented and assessed by the visiting clinician.”- “Auditing employees review the documentation for errors, accuracy, and coding. The auditing employee will make recommendations and suggestions to the clinician. The clinician will review the recommendations and agree/disagree with the recommendations. The clinician will sign/approve the document if in agreement with any noted changes within the note.” On 8/21/25 at 4:20PM, EMP7 reported the agency did not have a policy and procedure to specifically address addendums to patient’s clinical notes. EMP7 provided the survey team with a reference book titled “Lippincott Nursing Procedures (Seventh Edition).” The following guidance about documentation was found on page 246 of this reference book: “Never tamper with documentation of any part of the clinical record; tampering includes adding to a clinical note at a later date without indicating that it’s a late entry…” MR6 was admitted to hospice services on 5/2/25 with a diagnosis of high blood pressure/heart disease. On 8/20/25, MR6’s clinical record was noted to include nursing documentation for a 5/2/25 visit; the documentation was not marked as being completed. The 5/2/25 visit note had been reviewed and returned to the employee (EMP1), who had written the note, for revisions. On 8/20/25 at 2:50PM, the revised 5/2/25 visit note was reviewed with EMP1. EMP1 identified four (4) of MR6’s diagnoses which had been revised, on 8/20/25, to indicate they were related to the patient’s terminal diagnosis. EMP1 also reported the following information was added, on 8/20/25, to the “Summary/Comments” section of the 5/2/25 visit note: “Given his [sic] that he is status post code sepsis requiring fluid resuscitation, per vascular, CTA shows probable left popliteal occlusion and right popliteal sever [sic] stenosis, MRI showed right foot Osteomyelitis with soft tissue necrosis, and the above mention co-morbid conditions, patient and daughter, (name omitted), have decided to for go [sic] any aggressive treatment at this time.” The sections of this note which were revised/updated, on 8/20/25, did not include a date and time to indicate they were late entries. On 8/21/25, the survey team was provided with evidence that metadata maintained by the agency’s electronic health record would provide a report of what information was added to and/or change in a note but that the note itself would not be documented in a manner to indicate what information was added/changed and when the additions and/or changes were made to the clinical note.”