Enhabit Hospice (Richmond)

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined the hospice failed to conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. Specifically, the hospice failed to ensure the comprehensive assessment included the patient/family goal for pain management, dyspnea, and other distressing symptoms and their satisfaction with the current level of symptom management (L0524); failed to maintain an accurate and current medication profile for each patient (L0530); and failed to update the patient’s comprehensive assessment as often as the patient’s condition required (L0533). Cross Reference:§418.54(c) Content of the Comprehensive Assessment§418.54(c)(6) Drug Profile§418.54(d) Update of Comprehensive Assessment”

“Based on staff (EMP) interview, document review, and review of medical records (MR), it was determined the hospice failed to organize and manage its resources to provide appropriate care and services to hospice patients, caregivers, and families. Specifically, the hospice failed to ensure its medical director appropriately supervised and was responsible for the medical component of the hospice program (L0669); failed to ensure medications were available on a 24 hour a day, 7 days a week basis (L0653); and failed to ensure appropriate care coordination with nursing facilities (L0778). Additionally, the hospice failed to develop and implement policies, procedures, and/or standard practices for patient care including but not limited to pain assessment and reassessment (L0512), conducting a comprehensive assessment to include the required content of such an assessment (L0520), obtaining medications for acute symptom management needs (L0512), establishing a consistent method for assessment and quantifiable measurement of patient symptoms such dyspnea, fatigue, nausea (etc.) leading to inconsistent practices among staff resulting in delayed and inadequate management of the patient’s terminal illnesses. Cross Reference:§418.52(c) Rights of the patient §418.54 Initial and Comprehensive assessment of the patient §418.102(d) Medical Director Responsibility §418.100(c)(2) Services418.112(e)(1)(i) Coordination of Services”

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined the hospice failed to develop policies, procedures, and/or practices to comprehensively assess and reassess patient’s pain, resulting in two (2) of fourteen (14) patients in the survey sample receiving ineffective pain and symptom management. Medical Records (MR) MR9 and MR10. Findings:Review of MR9 revealed the patient was admitted to hospice on June 14, 2025, with a terminal diagnosis of neurogenerative disease. On admission, the patient reported 10/10 pain on a numeric pain scale and voiced a goal of being “pain-free.” The medical record contained no documentation that the physician was notified of the 10/10 pain or that any new medication or intervention was implemented for pain management on June 14, 2025. There was no evidence documented in the medical record that anyone reassessed the patient’s pain for two (2) days. A Registered Nurse (RN) visited the patient on June 16, 2025. The patient continued to complain of severe pain 8/10 on a numeric pain scale. There was no documented evidence that the physician was notified of the continued severe pain or that any new interventions were put in place for the patient’s pain. The physician ordered the following pain medications on June 18, 2025, four (4) days after the initial complaint of 10/10 pain: Methadone 5mg/mL three times a day; tramadol 50 mg three times a day for two days; then every six hours as needed for pain; ibuprofen 800 mg liquid three times a day as needed; discontinue Fentanyl patch once Methadone started. On June 21, 2025, the patient continued with complaints of pain; 4/10 on a numeric pain scale. Methadone that had been ordered from a mail order pharmacy on June 18, 2025, had still not arrived to the patient. The RN documented that due to shipping issues, the medication would not be received until June 23, 2025 (five (5) days after the pain medication was ordered). The hospice made no attempt to procure the Methadone from a local pharmacy after being made aware of the prolonged delay in medication delivery by mail.Review of MR10 revealed the patient was admitted to hospice services on June 24, 2025, with a terminal diagnosis of lung cancer. The RN completed an admission visit from 5:31 PM to 6:36 PM on June 24, 2025. The patient voiced concerns of “severe,” “continuous,” and 10/10 pain on a numeric scale. The physician was contacted and ordered oxycodone/acetaminophen (a pain medication) 10 mg by mouth scheduled every six (6) hours. The RN left the visit at 6:36 PM with no intervention or reassessment for the patient’s severe pain. The hospice did not order oxycodone/acetaminophen from the pharmacy or obtain the medication until the following day, June 25, 2025. The medication was ordered from the patient’s local pharmacy on June 25, 2025, and delivered at an unknown time June 25, 2025. No reassessment of the patient’s pain was conducted on June 24th or June 25th, 2025, despite the patient’s previous complaints of experiencing severe pain. MR10 called the hospice on June 26, 2025, with complaints of continued severe pain. MR10 stated they were “doing terrible.” A nurse visited the patient after the phone call but did not notify the physician of the patient’s continued pain and did not implement any new interventions or medications to manage the pain until the following day on June 27, 2025, when the patient was given morphine and pain reduced to 6/10 on a numeric pain scale. During record review on July 16, 2025 at 10:00 AM, EMP2 confirmed the pain medication was not ordered from the pharmacy until June 25, 2025. EMP2 indicated the patient was agreeable to waiting until the next day for the pain medication, but this information was not documented in the medical record. An interview was conducted with EMP2 on July 16, 2025, at 10:00 AM. EMP2 indicated that the facility did not have a specific policy related to pain assessment, management, or reassessment. The facility had no policy related to what pain scales would be appropriate for what patients or when a comprehensive pain assessment should be completed. The facility had no policy for a timeframe of when to reassess a patient who had reported severe pain or other symptoms. EMP2 indicated that pain assessment was partially addressed in the following policy, “Patient reassessment and recertification” last revised October 2023. The policy reads in part, “...The Registered Nurse, Medical Director, and other IDG (interdisciplinary Group team members regularly reevaluate the patient’s hospice needs during the certification period through...communication with staff, other team members, the physician and patient, or family and caregivers...Promptly alert the physician to any changes in the patient’s condition that suggest a need to modify the plan of care. Establish parameters such as patient response to medications, increased discomfort level, and periods of crisis...” The policy provided by the hospice did not contain guidance related to pain assessment or reassessment. EMP2 indicated that their expectation was if a patient was experiencing severe pain on admission, they should be called or visited the next day, but the nurse was permitted to leave the patient visit after ordering medications, even before the medications were received, administered, or their effectiveness assessed. During the interview with EMP2, regarding how the hospice ensures consistency in assessing and reassessing pain, EMP2 indicated that all nurses are provided education on hire. EMP2 provided the surveyor with two (2) modules required at onboarding for nurses, “How to for Hospice Assessments...” and “Pain Management at End of Life.” Both of these modules provided education on pain assessment but did not contain information on pain reassessment or frequencies at which these assessments should occur. The modules contained various pain rating scales for verbal and nonverbal patients. EMP2 indicated the hospice had no documentation that any of these scales were approved for use at the hospice or that nurses were competent in utilizing them. EMP2 indicated the hospice’s electronic medical record guides them in pain assessment and what type of pain assessment would be appropriate for the patient. An interview was conducted with EMP13 on July 21, 2025, at approximately 10:15 AM. EMP13 indicated that the hospice’s policy regarding symptom management was to assess pain on each visit. If the patient is experiencing severe pain, the physician should be contacted. If the patient receives new medication the nurse should ensure it can be ordered and obtained from a local pharmacy and make plans with the patient’s family or caregiver to obtain the medication. EMP13 indicated that the patient should be called back approximately one (1) hour after taking the pain medication to assess for effectiveness. An interview was conducted with EMP10 on July 21, 2025, at approximately 11:00 AM EMP10 indicated that if a patient was experiencing severe symptoms such as pain the nurse should not leave the visit until interventions for pain management were effective. EMP10 indicated the facility’s policy was to reassess the patient’s pain 20-30 minutes after pain medication was administered. An interview was conducted with OTHMD1 (a physician) on July 17, 2025, at approximately 2:00 PM. OTHMD1 indicated that if a patient was experiencing 10/10 pain medications should be ordered or administered and the patient’s pain should be reassessed. OTHMD1 indicated it would not be appropriate for a patient to go the entire night with unmanaged symptoms and if pain could not be managed at home, the hospice would consider a higher level of care.”

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined the hospice failed to ensure the comprehensive assessment identified the needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Specifically, the comprehensive assessment failed to include the patient/family goal for pain management, dyspnea, and other distressing symptoms and their satisfaction with the current level of symptom management in two (2) of fourteen (14) records reviewed in the survey sample. MR3 and MR13. Findings:Review of MR3 revealed the patient was admitted to hospice services on April 5, 2025, with a terminal diagnosis of heart failure. The patient was complaining of dyspnea on the initial Registered Nurse (RN) admission visit. The patient’s comprehensive assessment failed to include the patient’s goal for level of dyspnea and satisfaction of current level of management of dyspnea. The patient complained of pain during an RN visit on May 28, 2025. The comprehensive assessment was not updated to include the patient’s goal for pain management. Review of MR13 revealed a nurse practitioner saw the patient to recertify them for hospice services on May 25, 2025. The nurse practitioner’s note indicated the patient had a terminal diagnosis of Parkinson’s disease and had been experiencing worsening fatigue and shortness of breath over the past few months. The patient’s updated comprehensive assessment dated May 28, 2025, contained no documented interventions to treat fatigue and shortness of breath and contained no patient and/or caregiver goal for relief of shortness of breath and fatigue. The assessment contained no documentation that the patient and/or caregiver was satisfied with their level of symptom management. An interview was conducted with EMP2 on July 15, 2025, at approximately 2:30 PM. EMP2 indicated that the comprehensive assessment and care plan should include patient and/or caregiver stated goals for pain and symptom management. The surveyor requested the hospice’s policy for comprehensive assessment and was provided with two documents, “Clinical records” last revised May 13, 2025, that reads in part, “...Definitions...Initial and Comprehensive Assessment is the assessment, used to document the patient’s status upon admission...” The policy failed to address what components were required in the comprehensive assessment. The hospice’s policy, “Interdisciplinary group” last revised March 13, 2023, was also provided. It was reviewed and reads in part, “Definitions...Comprehensive Assessment means a thorough evaluation of the patient’s physical, psychosocial, emotional, and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver’s and family’s willingness and capability to care for the patient. The hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care...The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days...Any revised plan of care will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals as specified in the plan of care...” This policy also failed to address the specific content of the comprehensive assessment to include pain and symptom assessment.”

“Based on staff (EMP) interview, review of agency documents, and review of medical records (MR), it was determined the hospice failed to include a current drug profile in the patient’s comprehensive assessment to include a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy including but is not limited to, identification of the following: (i) Effectiveness of drug therapy (ii) Drug side effects (iii) Actual or potential drug interactions (iv) Duplicate drug therapy (v) Drug therapy currently associated with laboratory monitoring in three (3) of fourteen (14) records reviewed in the survey sample. MR2, MR9, MR13. Findings:The hospice’s policy, “Medications,” last revised March 31, 2025 was reviewed and reads in part, “...Policy...The clinical record includes appropriate physician orders for all medications prescribed by the physician included medicated dressings and for all OTC (over the counter) medications...automatic stop of medication with a discontinuation date, applicable titrating or tapering instructions...Staff assesses all medications a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication. Medications will be reviewed by a physician or pharmacist on admission and throughout the benefit period. Staff will assess every visit and document assessment on the visit note. Staff documents all medication a patient may take on the medication profile...”Review of MR2 revealed the patient was admitted to hospice services on May 30, 2025, with a terminal diagnosis of senile degeneration of the brain. The patient’s plan of care for the benefit period May 30, 2025, to August 27, 2025, was reviewed. The plan of care indicated the patient had a feeding tube. Clinical documentation revealed the patient did not eat or drink by mouth and received feedings through the feeding tube. The medication list on the plan of care contained eight (8) medications with instructions to give “by mouth” despite the patient not taking anything by mouth and being dependent on tube feeding. Lansoprazole 5mg tablet by mouth daily had instructions from the pharmacy to “not chew or crush.” There was no evidence in the medical record that the pharmacy had reviewed the medication list to ensure that these eight (8) medications could be safely crushed and administered via feeding tube.An interview was conducted with EMP2 on July 21, 2025, at 10:00 AM, who confirmed the medications on MR2’s profile had an inaccurate route documented and that all medications were given through the feeding tube and not orally as ordered on the medication profile. MR2 confirmed that a physician or pharmacist had not reviewed the medications to determine if they could be safely crushed and administered via feeding tube because of the inaccuracy on the medication profile. EMP2 indicated they were unsure if the nurse should assess the medications the patient was taking and update the medication profile at each nursing visit, despite the hospice’s policy indicating the medication profile should be assessed and updated at each visit. Review of MR9 revealed the patient was admitted to hospice on June 14, 2025, with a terminal diagnosis of neurogenerative disease. The physician ordered the following for pain on June 18, 2025: Methadone 5mg/mL three times a day...discontinue Fentanyl patch once Methadone started. Fentanyl was removed from the patient’s medication profile on June 18, 2025. An interview was conducted during record review on July 17, 2025, with EMP2 at approximately 1:00 PM. EMP2 indicated that the patient is currently using Fentanyl patches despite not having a physician order. EMP2 confirmed there was currently no Fentanyl listed on the medication profile and that the patient was currently using 25 mcg Fentanyl patches they had obtained prior to admitting to hospice. EMP2 confirmed a physician and/or pharmacist had not reviewed an accurate medication profile to include the patient’s use of the Fentanyl patch to assess contraindications and duplicate drug therapy. A home visit was conducted with MR13 on July 16, 2025, beginning at approximately 1:00 PM. MR13 resides in a skilled nursing facility. During the home visit the facility’s medication administration record (MAR) was reviewed. The medication record indicated that the patient was prescribed and being administered Omeprazole 20mg daily beginning September 21, 2024. The July 2025 MAR indicated the patient had received this medication every day from July 1, 2025 – present. The hospice’s current medication profile for the patient was reviewed. Omeprazole was not noted on the medication profile. The hospice’s medication profile contained Paxil 30 mg tablet by mouth daily for anxiety ordered by the hospice physician on May 28, 2025. The facility’s MAR was reviewed and there was no documentation that the patient ever received Paxil as ordered by the hospice. An interview was conducted with EMP2 on July 21, 2025, who confirmed there were discrepancies between the facility’s medication list and the hospice’s medication profile and they would have to speak to the IDG (interdisciplinary group) to determine what medications the patient should be on.”

“Based on staff (EMP) interview, review of agency documents, and review of medical records (MR), it was determined the hospice failed to update each patient’s comprehensive assessment no less frequently than every fifteen (15) days in one (1) of fourteen (14) records reviewed in the survey sample. MR10. Findings:The hospice’s policy, “Interdisciplinary group” last revised March 13, 2023, was reviewed and reads in part, “...The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days...”MR10 revealed the patient was admitted to hospice services on June 24, 2025, with a terminal diagnosis of lung cancer. The Registered Nurse completed an admission visit from 5:31 PM to 6:36 PM on June 24, 2025. The patient voiced concerns of “severe,” “continuous,” and 10/10 pain on a numeric scale. MR10 continued to have significant pain and symptom management needs between June 24, 2025, and July 9, 2025, necessitating multiple medication changes and changes to nurse visit frequency. Despite these needs, the first interdisciplinary group (IDG) meeting to update the patient’s comprehensive assessment was held for this patient on July 9, 2025, sixteen (16) days after the patient’s admission.An interview was conducted with EMP2 on July 21, 2025, at 10:00 AM who indicated the IDG should have met to complete a comprehensive assessment and the plan of care for MR10 should have been updated before July 9, 2025.”

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), the hospice failed to develop individualized written plans of care for each patient that reflected patient and family goals based on the problems identified in the initial and updated comprehensive assessments in four (4) of fourteen (14) records reviewed in the survey sample. MR1, MR2, MR3 and MR11. Findings:The hospice’s policy, “Interdisciplinary group” last revised March 13, 2023 was reviewed and reads in part, “...The interdisciplinary group develops an individualized written plan of care established in collaboration with the attending physician (if any), the patient representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire...The plan of care will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Interdisciplinary Group ensures each plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including, but not limited to: interventions to manage pain and symptoms...measurable outcomes anticipated from implementing and coordinating the plan of care; drugs and treatment necessary to meet the needs of the patient; medical supplies and appliances necessary to meet the needs of the patient...”Review of MR1 revealed the patient was admitted to the hospice on July 11, 2024, with a terminal diagnosis of bladder cancer. MR1 had a fall at the facility they resided in on June 10, 2025. The patient’s IDG (Interdisciplinary Group) meeting after this fall held on June 25, 2025, contained no documentation that the fall was discussed with the IDG or that any specific fall preventions were put into place. MR1 revealed the patient had another fall with major injury necessitating an emergency department visit on July 5, 2025. The record indicated a hospice nurse visited the patient on July 5, 2025, after the patient had fallen. There was no documented evidence in the medical record that the nurse updated the patient’s plan of care to include the patient being a high fall risk or added any specific interventions for fall prevention. An IDG meeting was conducted on July 9, 2025. Documentation in the IDG meeting notes read as follows, “Patient had a recent fall with upper extremity injury. Requiring daily wound care at this time.” The plan of care was not revised to add specific goals and interventions related to fall preventions. The medical record did not indicate that any fall assessment was ever completed in June or July of 2025 or that the patient had been identified as a high fall risk.Review of MR2 revealed the patient was admitted to hospice services on May 30, 2025, with a hospice diagnosis of senile degeneration of the brain and was receiving tube feeding. Nursing documentation indicated MR2 had episodes of aspiration on July 4, 2025, requiring a visit to the emergency department. The physician’s order to send the patient to the emergency room indicated the patient was experiencing “constant silent aspiration.” None of the IDG notes reviewed from the patient’s admission on May 30, 2025, to the aspiration events on July 4, 2025, contained evidence of discussion of goals of care related to enteral feeding with the patient’s family or that the tube feeding may be causing harm (constant silent aspiration) to the patient. The hospice resumed the patient’s tube feeding at a decreased rate upon return from the emergency department on July 5, 2025, despite the “constant silent aspiration.”MR2’s IDG note from June 10, 2025, revealed that patient had symptom management needs, specifically pain management. The patient’s plan of care was not modified after this meeting to include new interventions, goals, medications or treatments to facilitate pain management. MR2’s plan of care for the benefit period May 30, 2025, to August 27, 2025, was reviewed. MR2’s care plan contained no documentation of orders for the necessity or volume of tube feeding flushes, any directions for tube care, or of supplies required for tube feeding. Nursing documentation indicated the patient had an indwelling urinary catheter on admission, but the plan of care contained no orders for catheter care, size of catheter in use, or the frequency of changes for the catheter. A nursing visit was conducted to MR2 on July 12, 2025, for a leaking urinary catheter. The nurse documenting changing the urinary catheter. The plan of care contained no physician order to change the catheter and no documentation of the size of the catheter, frequency of catheter changes, or catheter care. Review of MR3 revealed the patient was admitted to hospice services April 5, 2025, with a terminal diagnosis of heart failure. The nursing admission note indicated that pain was a problem for the patient. Documentation on admission indicated that pain interfered with patient’s movement “all of the time.” The patient’s initial plan of care contained no patient’s stated goal for a tolerable level of pain for the patient. No new interventions were put into place at the time of admission to manage the patient’s pain. The patient’s plan of care contained no interventions or measurable goals for pain management. A nursing visit on April 11, 2025, indicated that MR3 wished to be able to go outside every day. The nurse indicated that they had concerns about patient being in the heat and requested the patient only go outside two to three times a week to allow patient time to rest. The record contained no documentation that the hospice modified the patient’s plan of care to provide any intervention or assistance to facilitate the patient meeting their stated goal of daily trips outside.MR3 revealed the patient had complained of dyspnea from admission to present in varying degrees of severity. The patient’s plan of care contained no evidence of a care plan for the patient’s dyspnea to include interventions and goals to treat dyspnea, or a patient stated goal of a tolerable level of dyspnea for the patient. An interview was conducted with EMP2 on July 15, 2025, at approximately 2:30 PM. EMP2 indicated the hospice has no standard measurement tool to measure the severity of patient dyspnea. EMP2 acknowledged there was no documentation in the record to indicate whether the patient’s dyspnea was improving with treatment, and that nursing staff does not have a standard way to document severity of dyspnea.Review of MR11 revealed that the patient was admitted to hospice with the terminal diagnosis of cerebral vascular accident on April 4, 2025. On admission, the nurse identified the patient as a moderate fall risk but did not implement any specific interventions on the patient’s plan of care to prevent falls. On April 28, 2025, the nurse documented the patient has a history of repeated falls dating back to 2009. The patient experienced episodes of loss of consciousness and then fell. The patient’s caregiver reported the patient taking a significant time to regain consciousness after these falls. The hospice failed to update the patient care with safety interventions related to loss of consciousness and falls.The surveyor requested the agency’s fall prevention policy on July 18, 2025. On July 21, 2025, at approximately 10:30 AM, EMP2 indicated the hospice does not have a fall prevention policy but provides general fall and home safety precaution information to patients and families at admission. EMP2 indicated that patients’ plans of care should reflect the needs of the patient and be revised when changes to the patient condition occur.”

“Based on staff (EMP) interview, hospice document review, and review of medical records (MR,) it was determined the hospice failed to ensure each patient’s plan of care contained measurable outcomes anticipated from implementing and coordinating the plan in two (2) of fourteen (14) records reviewed in the survey sample. MR4 and MR11. Findings:The hospice’s policy, “Interdisciplinary group” last revised March 13, 2025, was reviewed and reads in part, “...The Interdisciplinary group ensures each plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including, but not limited to...Measurable outcomes anticipated from implementing and coordinating the plan of care...Any revised plan of care will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals as specified in the plan of care...”Review of MR4 revealed the patient was admitted to hospice services November 22, 2024, with a terminal diagnosis of Parkinson’s disease. The patient’s Interdisciplinary Group (IDG) meeting notes from June 10, 2025, and June 25, 2025, contained no documentation that measurable goals or interventions for the patient’s care were discussed. The goals for the next two weeks in the updated plans of care were documented as “monitor decline.” The goals lacked measurable outcomes or specific interventions to be used to “monitor decline.”Review of MR11 revealed the patient was admitted to hospice with the terminal diagnosis of cerebral vascular accident on April 4, 2025. An IDG meeting was held June 10, 2025, and documented the following plan for the next two weeks, “Plan to meet patient/caregiver goals for the next two weeks: Follow care plan.” The IDG did not modify the patient’s care plan to include specific goals and interventions to meet the patient’s needs for the following two weeks. On July 9, 2025, the IDG documented the following plan of care for the patient over the next two weeks, “Monitor Decline.” The IDG did not develop patient specific interventions or measurable goals to monitor the patient’s decline.An interview was conducted with EMP2 at approximately 11:00 AM who indicated that the plans of care should include individualized, measurable goals and outcomes, and the patient’s progress toward those goals.”

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined the hospice failed to ensure drugs and biologicals were routinely available on 24-hour basis 7 days a week in two (2) of fourteen (14) medical records reviewed in the survey sample. MR9 and MR10. Findings:The hospice’s policy, “Scope of Services” last revised March 6, 2025, reads in part, “...The agency will have an IDG (Interdisciplinary Group) that works in conjunction with the patient and family. The IGD will:...Ensure access to additional services as needed which may include, but are not limited to: Pharmacy services 24 hours a day/7 day a week through a written agreement with the hospice to provide appropriate drugs and biologicals related to the terminal illness and in the plan of care...”Review of MR9 revealed the patient was admitted to hospice on June 14, 2025, with a terminal diagnosis of neurogenerative disease. MR9 was experiencing severe pain on admission and the physician ordered the following pain medications on June 18, 2025: Methadone 5mg/mL three times a day; tramadol 50 mg three times a day for two days; then every six hours as needed for pain; ibuprofen 800 mg liquid three times a day as needed. The methadone was ordered from the hospice’s mail order pharmacy despite the medication being ordered to urgently control pain. Nursing documentation revealed that due to shipping issues, the medication would not arrive to the patient until June 23, 2025 (five (5) days after the pain medication was ordered). The record contained no documentation that hospice staff tried to obtain the medication from a local pharmacy and documented no efforts to obtain the medication more expeditiously. Review of MR10 revealed the patient was admitted to hospice services on June 24, 2025, with a terminal diagnosis of lung cancer. On June 24, 2025, MR10 voiced concerns of “severe,” “continuous,” and 10/10 pain on a numeric scale. The physician was contacted the evening of June 24, 2025, and ordered oxycodone/acetaminophen (a pain medication) 10 mg by mouth scheduled every six (6) hours. The RN did not order or obtain the medication until the following day, June 25, 2025. The medication was delivered from the patient’s local pharmacy at an unknown time June 25, 2025. An interview was conducted with EMP2 on July 17, 2025, at approximately 2:30 PM. EMP2 indicated that the hospice uses their mail order pharmacy for routine medications, refills, comfort kits, and medications that are not needed for urgent symptom management. If a medication is needed more quickly the medication could be obtained from a patient’s local pharmacy. There are several pharmacies in the area that are open 24 hours a day, 7 days a week. The hospice maintains a list of these pharmacies to use in the event a medication is needed at night, on weekends, or in an urgent situation. An interview was conducted with EMP13 on July 21, 2025, at approximately 10:15 AM. EMP13 indicated that the hospice could obtain medications needed urgently from a local pharmacy and obtained quickly or routine medications could be obtained from the mail order pharmacy. An interview was conducted with EMP10 on July 21, 2025, at approximately 11:00 AM EMP10 indicated that EMP2 maintains a list of pharmacies open 24 hours a day, 7 days a week in the event medications were needed on an urgent basis or on nights and weekends. During record review on July 16, 2025, at 10:00 AM, EMP2 confirmed the pain medication for MR10 was not ordered until the following day despite the patient’s complaints of severe pain. EMP2 indicated the patient was agreeable to waiting until the next day for the pain medication, but this information was not documented in the medical record.”

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined the hospice’s medical director failed to assume overall responsibility of the medical component of the hospice program. Specifically, the medical director failed to ensure the hospice developed and implemented policies and procedures related to pain management resulting in patients with uncontrolled pain (L0512), failed to ensure all patients’ plans of care were accurate and individualized (0L545), failed to ensure appropriate drugs and biologicals were available on a 24 hour a day/7 days a week basis (L0653), and failed to ensure care coordination with nursing facilities (L0778).Cross Reference:§418.52(c) Rights of the patient §418.56(c) Content of Plan of Care§418.100(c)(2) Services §418.112(e)(1)(i) Coordination of Services Findings:An interview was conducted with facility’s Medical Director on July 17, 2025. The Medical Director indicated that they provided pain and symptom management for hospice patients, participated in the Interdisciplinary Group (IDG) meetings, and contributed to patient’s care planning. Regarding pain management, the medical director indicated it would be unacceptable to leave a patient “overnight” or for a prolonged period of time with uncontrolled symptoms. The Medical Director indicated that they prescribe medication for pain, but once the order is sent to a pharmacy, it is, “out of my hands.” The Medical Director indicated that the hospice had no control over what pharmacies did once they received a prescription or how long it took to fill a prescription and for the patient to receive it, despite the requirement that hospices provide medications on a 24 hour a day, 7 day a week basis. The surveyor requested the Medical Director’s contract from EMP2 on July 17, 2025, July 18, 2025, and July 21, 2025. The contract was not received prior to the end of the survey. The hospice provided the surveyor a document, “Physician’s Role” last reviewed November 26, 2024. document did not describe the role of the Hospice Medical Director. The hospice’s policy, “Scope of Services” last revised March 6, 2025. was reviewed and reads in part, “...The agency provides physician services and will employ or contract a Medical Director who is a Doctor of Medicine or osteopathy and holds a current license in the state. The Medical Director, on the basis of training, experience or interest is knowledgeable in both the psychosocial and medical aspects of hospice care...The Hospice Medical Director is responsible for:...assuring appropriate measures to control patient symptoms; the palliation and management of the terminal illness and conditions related to the terminal illness...The agency will have an IDG group that working in conjunction with the patient and family the IDG will: ...ensure access to additional services as needed which may include, but not not limited to: Pharmacy services 24 hours a day/7 days a week through a written agreement with the hospice to provide appropriate drugs and biologicals related to the terminal illness and in the plan of care...””

“Based on staff (EMP) interview, agency document review, and review of medical records (MR), it was determined that the hospice failed to ensure coordination of hospice care with skilled nursing facilities in one (1) of one (1) home visits conducted of patients living in a nursing facility. Specifically, the hospice failed to maintain an accurate medication profile and failed to conduct routine medication reconciliation with the nursing facility. MR13. Findings:A home visit was conducted with MR13 on July 16, 2025, beginning at approximately 12:00 PM. MR13 resides in a skilled nursing facility. During the home visit the facility’s medication administration record (MAR) was reviewed. The medication record indicated that the patient was prescribed and being administered Omeprazole 20mg daily beginning September 21, 2024. The July 2025 MAR indicated the patient had received this medication every day from July 1, 2025 – present. The hospice’s current medication profile for the patient was reviewed. Omeprazole was not noted on the medication profile. The hospice’s medication profile contained Paxil 30 mg tablet by mouth daily by mouth for anxiety ordered on May 28, 2025. The facility’s MAR was reviewed and there was no documentation that the patient ever received Paxil as ordered by the hospice. The medical record contained no documentation that the medications had been reconciled with the facility medication profile. Review of MR13 revealed that a hospice nurse had visited the patient seven (7) times between June 01, 2025, and July 17, 2025. There was no documentation in any of the seven (7) most recent nursing visits that a medication reconciliation had been performed, that the nurse viewed the nursing facility’s medication administration record, or that the hospice nurse discussed the patient’s medication regimen with facility staff. An interview was conducted with EMP2 on July 21, 2025, at approximately 10:00 AM, who confirmed there were discrepancies between the facility’s medication list and the hospice’s medication profile. EMP2 acknowledged that the nurse should be performing routine medication reconciliation and coordination of medication administration with the skilled nursing facility. The hospice provided the surveyor with two policies, “Care Coordination” and “Coordination of Services.” Neither policy addressed care coordination with skilled nursing facility. The hospice’s policy, “Medications,” last revised March 31, 2025 was reviewed and reads in part, “...Policy...Staff will assess every visit and document assessment on the visit note. Staff documents all medication a patient may take on the medication profile...””

“Based on a review of the agencys complaint log and staff interview it was determined the agency failed to ensure to protect the patient and patient caregivers right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant for one (1) of one (1) clinical record in the survey sample (Clinical record for Patient #2). Findings: A review of the complaint log in the agency on May 06, 2024 revealed no complaints documented on Patient #2 in the survey sample. The log failed to contain evidence this complaint was investigated, and the complaint was resolved. An interview with Staff Member #1 on May 06, 2024 at 3 pm revealed that Patient #2s family member made a complaint to this staff member regarding an on-call nurse who did not visit the patient. Staff Member #1 also provided the MFI (Medical Facilities Inspector) emails from the family member dated August 14, 2024 with concerns of patients vaginal bleeding and an on-call nurse to visit. The above noted findings regarding the agency’s staff failed to file a complaint to the agency was acknowledged by the Administrator during the exit conference of May 07, 2024.”

“Based on clinical record review and staff interview, it was determined the agency failed to ensure their staff documented providing care according to the patient’s plan of care for two (2) of four (4) clinical records in the survey sample (Clinical records for Patients #3 and #4). Findings: 1. The clinical record for Patient #3 was reviewed for the timeframe of March 06, 2024 to April 4, 2024. The plan of care contained orders for a Chaplain evaluation visit to assess spiritual needs. The clinical record failed to contain documentation of any Chaplain visits. The clinical record failed to contain documented evidence of notification to the patient’s physician of the missed visits on the above noted dates upon time of review. 2 2. The clinical record of Patient #4 was reviewed for the timeframe of November 01, 2023 to December 13, 2023. The plan of care contained for a Medical Social Work evaluation visit to assess psychosocial needs. The clinical record failed to contain documentation of any Medical Social Work visits. The clinical record failed to contain documented evidence of notification to the patient’s physician of the missed visits on the above noted dates upon time of review. During the survey, the Administrator (Staff Member #1) revealed having issues with the staff scheduling and was working on the current issue. The Administrator acknowledged the above noted findings related to staff not providing care according to the patient’s plan of care again during the exit conference conducted in the agency on May 07, 2024.”

“Based on review of clinical records and staff interview the agency failed to provide medical supplies and appliances necessary to meet the needs of the patient for one (1) of four (4) clinical records in the survey sample (Clinical record for Patient #2). Findings: The clinical record for Patient #2 was reviewed for the period of August 10, 2023 to August 18, 2023. The plan of care contained DME (Durable Medical Equipment) and supplies of the following: Incontinence briefs/pull ups, under pads, wipes, skin prep/protectant; skin and body care/cleansing/protection. Staff Member #1 provided the MFI (Medical Facilities Inspector) the medical supply invoice for all the medical supplies needed for incontinence regarding Patient #2. The medical supplies were delivered on August 18, 2023 the same day Patient #2 expired. On May 07, 2024 at 12:42 pm the MFI called the hospice aide (Staff Member #9) who visited the patient the last four (4) days before expired. Staff Member #9 revealed the patient did not have any supplies for incontinence or skin care. Staff Member #9 revealed that he/she borrowed supplies from their car and bought supplies as well. The above noted findings regarding the agency staff failed to provide medical supplies to meet the needs of the patients incontinence and skin care was acknowledged by the Administrator during the exit conference on May 07, 2024.”

“Based on a review of clinical records and agency policy review it was determined the agency failed to make all reasonable efforts to facilitate the patients spiritual needs for one (1) of four (4) clinical records in the survey sample (Clinical record for Patient #2). Findings: On May 06, 2024, Staff Member #1 provided the MFI (Medical Facilities Inspector) with the agency policy regarding spiritual counseling. The procedure was titled, “;Scope of Services” and read in part as follows: Spiritual counseling is services that meet the needs of the patients or families in a manner consistent with the patient and family beliefs and desires. The agency provides spiritual care/counseling/chaplain services in accordance with the patients belief system and the IDG (Interdisciplinary Group) plan of care. Participate in IDG meetings and implementation of the patients plan of care every 2 weeks. The clinical record for Patient #2 was reviewed for the period of August 10, 2023 to August 18, 2023. The clinical record contained documentation from the skilled nurse dated August 11, 2023 of the patients religious denomination with wishes to have last rites. On August 14, 2023 the chaplain documented the patients religion with no interventions in place to implement a visit from a priest of the denomination. A IDG meeting was held August 16, 2023 with no documentation of the patients wishes regarding the religious last rites. On August 18, 2024 at 8:04 am, the coordination notes documented symptoms of end of life with changes of unresponsive, breathing changes and no relief from medications given. According to the MSW note of August 18, 2023, the patients family member called to request a priest visit for last rights. On August 18, 2023 the patient expired without receiving a visit from a priest to deliver the last rights. The hospice agency failed to provide the patients wishes of their last rites. The above noted findings regarding the agency staff failed to facilitate the patients spiritual needs was acknowledged by the Administrator during the exit conference on May 07, 2024.”