Unicare Hospice Inc.

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records and interviews with the Director of Patient Care Services which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the individualized written plan of care included the scope and frequency of services necessary to meet specific patient and family needs (HCPC.21.I/L547/418.56(c)(2)); Failure to ensure the individualized written plan of care included drugs and treatments necessary to meet the needs of the patient (HCPC.21.I/L549/418.56(c)(4)); and Failure to ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments (HCPC.21.I/L545/418.56(c)). The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the 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, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice population are anticipated, and as appropriate, preventive measures 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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 06/18/2026 with a diagnosis of atherosclerotic heart disease. The patient resided at an assisted living facility (ALF). During the home visit observation on 08/12/2026 with the Chaplain (Personnel Record 4), a box of Lidocaine patches was observed on the side table near the patient’s reclining chair. The patient stated, “I apply one each day to my abdomen.” In addition, a bottle of Lactulose 30 milligrams suspension was observed in the facility’s medication room. A review of the hospice’s medication profile revealed that it did not include Lidocaine patches or Lactulose. A review of the facility’s medication profile revealed that it included Oxygen 2-4 liters via nasal cannula as needed. The hospice medication profile did not include Oxygen. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “We were not aware the patient was using Lidocaine patches and Lactulose. A Medication reconciliation has been performed, and the medication profile was updated.””

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/18/2026 with a diagnosis of atherosclerotic heart disease. The Registered Nurse documented in the nursing visit note dated 08/03/2026 that the patient had a fall and sustained a skin tear. The plan of care did not include documented evidence of an update on 08/03/2026 that included goals and interventions for the care of the skin tear or fall precautions. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility. The Registered Nurse documented in the initial nursing assessment dated 08/01/2026 that the patient required wound care to the coccyx as follows: “Twice daily, wound care, sacrum, clean with normal saline, apply 1/4 strength Dakins soaked gauze, and cover with dry dressing every shift and as needed.” The initial plan of care did not include skin integrity interventions or wound-management goals. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/02/2026 with a diagnosis of atherosclerotic heart disease. The Registered Nurse documented in the initial comprehensive assessment dated 04/2/2026 that the patient had pain when swallowing, dysphagia (difficulty swallowing), and required aspiration (when substances that are meant to be swallowed enter the trachea/windpipe and lungs) precautions. The initial plan of care dated 04/02/2026 did not include interventions and goals for aspiration precautions or dietary needs related to dysphagia. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/06/2026 with a diagnosis of Alzheimer’s Disease. The Registered Nurse documented in the initial comprehensive nursing assessment that the patient had Oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. The initial plan of care dated 04/06/2026 did not include respiratory interventions or goals and specific instructions for oxygen use, liter flow, frequency, or method of delivery for shortness of breath or instructions for safe storage. CLINICAL RECORD 16: The patient elected the hospice benefit on 08/04/2026 with a diagnosis of malignant neoplasm of unspecified part of bronchus or lung. A review of the clinical record revealed that a physician’s order dated 08/23/2026 ordered respite care. There was no documented evidence that the plan of care was updated on 08/23/2026 to include interventions and goals for respite care. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “I reviewed the records for Clinical Record 1, Clinical Record 4, Clinical Record 5, Clinical Record 10, and Clinical Record 16. Clinical Record 1 was missing fall precautions, Clinical Record 5 was missing aspiration precautions, and Clinical Record 16 was missing respite goals and interventions. I did not find specific goals and inventions for wound care for Clinical Record 4 and for Clinical Record 10 I did not find goals and interventions for Oxygen. The plans of care have been updated. I will instruct the nurses to include interventions and goals for all identified problems.””

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized written plan of care included the scope and frequency of services necessary to meet specific patient and family needs. CLINICAL RECORD 16: The patient elected the hospice benefit on 08/04/2025 with a diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. A review of the clinical record revealed that the initial plan of care dated 08/04/2025 and the updated plan of care dated 08/19/2025 did not include a frequency for skilled nurse and hospice aide services. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) reviewed the record and stated, “We always review the frequency in the Interdisciplinary Group (IDG) meeting. This must have been an oversight.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized written plan of care included drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/06/2026 with a diagnosis of Alzheimer’s Disease. The Registered Nurse documented in the initial comprehensive nursing assessment that the patient had Oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. The initial plan of care dated 04/06/2026 did not include specific instructions for oxygen use including liter flow, frequency, or method of delivery for shortness of breath. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “ I reviewed the record and did not find specific instructions for Oxygen. The plan of care has been updated.””

“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; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy 7-009 Hand Hygiene, dated April 2020, required in part, “Hand decontamination with alcohol-based hand rub which conforms to CDC (Centers for Disease Control) guidelines... 3. Hand decontamination using alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly contaminated. E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects in the immediate vicinity of the patient.” HOME VISIT 2: During the home visit observation with the hospice aide (HA) (Personnel Record 6), the hospice aide was observed providing a bed bath to the patient. The aide did not change gloves when moving from a contaminated area to a clean area. The HA washed the patient’s perineal area, then continued to bathe the patient’s anterior legs without changing gloves. The aide then turned the patient to the side and washed the patient’s buttocks and rectal area. The aide then washed the patient’s upper back and posterior legs without changing gloves. The aide applied barrier cream to the buttocks and rectal areas and did not change gloves before placing clean bed linens on the bed. The aide started the bed bath by washing the patient’s hair using a basin of water, washing the patient’s hair, and then rinsing the hair into the basin. She did not change gloves or the water after rinsing the patient’s hair and proceeded to wash the patient. While providing care, the aide left the bedside several times to obtain supplies and did not replace gloves before resuming bathing. During an interview on 08/13/2026, the Director of Patient Care Services (Personnel Record 2) stated, “We have reviewed hand hygiene several times with the staff. I will review this specifically with the aide.””

“It is required that the hospice provide nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed of patients receiving licensed practical nurse services, the agency did not ensure that the hospice provided nursing care under the supervision of a registered nurse. Agency policy 1-031 Responsibilities/Supervision of Clinical Services, April 2020, required in part, Nursing and hospice aide services will be under supervision of a registered nurse who has at least 2 years of hospice or community health experience. 7. B. A monthly patient visit will be completed by a registered nurse to supervise licensed practical /vocational nursing services.” CLINICAL RECORD 11: The patient elected the hospice benefit on 07/01/2026 with a diagnosis of chronic obstructive pulmonary disease. A review of the clinical record revealed that the Licensed Practical Nurse (LPN) provided visits on 07/07/2026 and 07/31/2026. There was no documented evidence that the registered nurse conducted a monthly supervisory visit as of 08/13/2026. During an interview on 08/13/2026, the Director of Patient Care Services (Personnel Record 2) stated, “The nurses are really good about completing supervisory visits in a timely manner. This must have been an oversight.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of deceased patients, the agency did not ensure bereavement services were available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. CLINICAL RECORD 17: The patient elected the hospice benefit on 06/17/2025 with a diagnosis of malignant neoplasm of the colon. The patient died on 08/22/2025. A review of the clinical record revealed that the bereavement plan of care included mailings that were to be sent at 3, 6, 9, and 12 months after the patient’s death. A mailing was provided in November 2025, however there was no documented evidence that additional mailings were provided after the November 2025 mailing and no documented evidence that the family declined further services. During an interview on 08/14/2026, the Administrator Designee (Personnel Record 11) stated, “The Bereavement Coordinator should have documented why no further mailings were sent.””

“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 8 of 17 (47%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nuse (RN) provided patient specific care instructions for a hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/18/2026 with a diagnosis of atherosclerotic heart disease. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive nursing assessment on 06/18/2026 that the patient was a high fall risk. The hospice aide care plan dated 06/18/2026 did not include written instructions for fall precautions. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. A review of the clinical record revealed that the registered nurse documented in the initial comprehensive nursing assessment that the patient had a stage 4 wound on the coccyx and a stage 2 wound on the right heel that required wound care. The hospice aide care plan dated 08/01/2026 did not include written instructions regarding how to care for the dressing during bathing or what to do if the dressing is soiled or dislodged. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/02/206 with a diagnosis of atherosclerotic heart disease. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment dated 04/02/2026 that the patient was a high risk for falls. The hospice aide care plan dated 04/02/2026 did not include written instructions for fall precautions. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/19/2026 with a diagnosis of dysphagia following a cerebral infarction. A review of the clinical record revealed that the Registered Nurse documented in the initial nursing assessment on 03/19/2026 that the patient was at risk for aspiration due to dysphagia. The hospice aide care plan did not include written instructions for aspiration precautions. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/11/2026 with a diagnosis of chronic combined systolic and diastolic congestive heart failure. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment dated 06/11/2026 and a subsequent visit dated 06/26/2026 that the patient did not have a Foley catheter. The hospice aide care plan dated 06/11/2026 assigned the aide the task for a Foley catheter. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/08/2026 with a diagnosis of sepsis. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment dated 08/08/2026 that the patient was using oxygen at 2-4 liters via nasal cannula as needed for shortness of breath. The hospice aide care plan dated 08/08/2026 did not include written instructions for oxygen precautions. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/06/2026 with a diagnosis of Alzheimer’s Disease. A review of the clinical record revealed that the Registered Nurse documented in the initial comprehensive assessment on 04/06/2026 that the patient was a high risk for falls. The hospice aide care plan dated 04/06 2026 and the updated hospice aide care plan dated 08/12/2026 did not include written instructions for fall precautions. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/22/2026 with a diagnosis of chronic systolic congestive heart failure. The Registered Nurse documented in the initial comprehensive assessment dated 05/22/2026 that the patient was at high risk for falls. The hospice aide care plan dated 05/22/2026 did not include written instructions for fall precautions. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “I have reviewed the aide care plans, and they are lacking written instructions for precautions. The nurses have been instructed to review all the aide care plans to be sure the appropriate precautions are listed.””

“It is required that each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient record included updated comprehensive assessments and clinical notes including the care and services provided. Agency policy 7-011 Wound Care Management and Coordination of Care, dated April 2020, required in part, “Wound Assessment - the registered nurse shall assess identified wounds and reassess them as clinically appropriate. The assessment shall include: 1. Location and type of wound, 2. Length, width, and depth when clinically appropriate, 3. Wound bed and surrounding skin condition, 4. Drainage, odor, bleeding, and signs and symptoms of infection, 5. Pain associated with the wound or dressing change, 6. Presence of tunneling, undermining, slough, eschar, or necrotic tissue when applicable. 7. Factors contributing to skin breakdown, including immobility” CLINICAL RECORD 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. The Registered Nurse documented wound measurements and a description of the stage 4 coccyx wound in the initial comprehensive nursing assessment dated 08/01/2026. The nursing visit notes dated 08/06/2026 and 08/12/2026 did not include a complete assessment of the stage 4 coccyx wound, that included measurements and condition of the wound. There was no further documented evidence of a wound assessment as of the date of record review on 08/14/2026. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “I have reviewed the record. The nurse documented a comprehensive wound assessment of the coccyx wound when the patient was admitted. There is no further documentation of a coccyx wound assessment. The expectation is that the wound is assessed weekly.””

“It is required that the facility offering respite care provides 24-hour nursing services that meet the needs of the patients and each patient’s plan of care (POC). Each patient receives all nursing services as prescribed in the plan of care, is kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) clinical records reviewed of patients that received respite care, the agency did not ensure the facility offering respite care provided 24-hour nursing services. CLINICAL RECORD 16: The patient elected the hospice benefit on 08/04/2025 with a diagnosis of malignant neoplasm of unspecified part of unspecified right bronchus or lung. A physician’s order dated 08/23/2026 ordered respite care. The nurse assessment dated 08/23/2026 documented that the patient was transferred to a skilled nursing facility (SNF) to receive respite care. There was no documented evidence that the facility provided 24-hour nursing services that meet the needs of the patient and the patient’s plan of care while receiving respite care. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “I did not receive documentation from the skilled nursing facility to show the nursing care that was provided.””

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 1 of 3 (33%) clinical records reviewed of patients that reside in a skilled nursing facility (SNF), the agency did not ensure that the hospice plan of care identified the care and services that are needed and specified which provider is responsible for performing the functions that are agreed upon and included in the plan of care. Agency policy 7-011 Wound Care Management and Coordination of Care, dated April 2020, required in parts, “The Hospice Agency shall coordinate wound care with physicians, facility staff, caregivers, outside providers, and all members of the hospice interdisciplinary group (IDG) to prevent conflicting treatments, duplication of services, and gaps in care” CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. The patient resided in a SNF. The Registered Nurse documented in the initial nursing assessment dated 08/01/2026 that the patient required wound care to a coccyx wound as follows: “Twice daily, wound care, sacrum, clean with normal saline, apply 1/4 strength Dakins soaked gauze, and cover with dry dressing every shift and as needed.” The hospice plan of care dated 08/01/2026 did not specify when the hospice nurse or the facility nurse would administer the wound care. During the home visit observation with the Registered Nurse (Personnel Record 5), a review of the facility record revealed that the plan of care did not specify when the facility nurse would provide wound care and when the hospice nurse would provide wound care. During an interview on 08/13/2026, the Director of Patient Care Services (Personnel Record 2) stated, “The nurse always calls the facility when she is going to do a visit, so they know she is doing the wound care. The facility wound nurse and the facility staff provide the wound care when the hospice nurse does not visit.””

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care; Hospice election form and any advance directives; Physician certification and recertification of the terminal illness; Names and contact information for hospice staff involved in the patient’s care; Instructions on how to access the hospice’s 24-hour on-call system; Hospice medication information; Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) home visits observations for patients that reside in a SNF/NF, the agency did not ensure the SNF/NF was provided with the patient’s the hospice election form. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the Registered Nurse (RN) (Personnel Record 5), a review of the facility’s clinical record revealed that the SNF medical record was missing a copy of the hospice election form. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “The forms were faxed to the facility’s medical records department. It is the case manager’s responsibility to ensure they are placed into the patient’s medical record.””

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care; Hospice election form and any advance directives; Physician certification and recertification of the terminal illness; Names and contact information for hospice staff involved in the patient’s care; Instructions on how to access the hospice’s 24-hour on-call system; Hospice medication information; and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) home visit observation of a patient that resided in a skilled nursing facility/nursing facility (SNF/NF), the agency did not ensure the SNF/NF was provided with a copy of the physician certification of the terminal illness. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 08/01/2026 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit 4 observation with the Registered Nurse (Personnel Record 5), a review of the facility’s clinical record revealed that the SNF medical record was missing a copy of the physician’s certification of terminal illness. During an interview on 08/14/2026, the Director of Patient Care Services (Personnel Record 2) stated, “The forms were faxed to the facility’s medical records department. It is the case manager’s responsibility to ensure they are placed into the patient’s medical record.””