Sebastian Hospice Care Inc.

“Based on observation, interview, and record review, the hospice agency (HA) failed to formulate a plan of care (POC) and obtain a physician’s order timely for pain management when pain was identified for one of 14 sampled patients (Patient 1).This failure resulted in Patient 1’s pain not being addressed and managed in timely manner. Findings:During an observation, interview and record review on 3/10/26, at 11:00 a.m. with the Licensed Vocational Nurse (LN 1), LN 1 was observed assessing Patient 1. Patient 1 verbalized having pain on the right upper thigh with pain scale of five (5) out of 10. Patient 1 further verbalized pain had been going on for a month now. LN 1 provided Patient 1 an option for pain medication and then informed Patient 1 that the physician will be notified and an order for pain medication will be obtained. LN 1 confirmed there was no medication ordered to manage Patient 1’s pain. During a review of Patient 1’s “Comprehensive Nursing Assessment (CNA),” dated 10/05/25, the CNA indicated that Patient 1 was admitted to HA due to diagnosis of Parkinson’s disease (a brain condition causing problems with movement, balance and pain). Patient 1 was identified to have sharp pain on left and right thighs, three (3) of 10 pain scale (a measurement of pain intensity from zero to 10, 0 means no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 means severe level). Further review of the CNA, the CNA indicated in part, “…A plan of care was established with the input from the patient/primary caregiver (PCG) and hospice interdisciplinary group (IDG). The patient will be provided with pain management…” Further review of Patient 1’s clinical record, a follow up visit by the registered nurse, dated 11/4/25, the RN visit notes indicated that Patient 1 complaint of sharp pain again on the left and right thigh, scale of 3 or 10. There was no documentation found if Patient 1’s pain had been communicated to the physician or to the IDG.During a review of Patient 1’s initial “POC/IDG Review (POC/IDG Review),” dated 10/22/25, the “POC Summary,” dated 1/14/26, and current Medication List, no medication for pain ordered by the physician and no documentation found addressing Patient 1’s sharp pain on the left and right thigh.During an interview on 3/16/26 at 5:05 p.m. with the Administrator (ADM), the ADM acknowledged the missing order for pain medication and that Patient 1’s POC for pain was not initiated, implemented and updated.During a review of the HA’s policy & procedure (P&P) titled, “The Plan of Care,” dated 4/2021, the P&P indicated in part, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. The plan will focus on identified problems, goals, and interventions…1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the care plan. 2. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs…4. The plan of care will identify the patient’s needs and services to meet those needs including the management of pain” and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.”During a review of the HA’s P&P titled, “Pain Management,” dated 4/2021, the P&P indicated, “The patient’s right to pain management is respected and supported. Hospice clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed. 1. The admitting registered nurse will identify patients with pain or at risk for pain during each patient assessment…Ongoing assessment will be completed for patients identifying pain or at risk for pain…3.Pain will be assessed as a part of every patient contact if the patient reports pain or is at risk for pain. 5.Patients who report pain will receive further assessment and appropriate management and changes to the plan of care will be made as part of the comprehensive assessment…””

“Based on interview and record review, the hospice agency (HA) failed to ensure that patients’ plans of care (POCs) were initiated at the start of care (SOC), updated as needed, and fully implemented for three active patients (Patient 1, Patient 2, and Patient 4) and three discharged patients (Patient 8, Patient 10, and Patient 12) when:1. Patient 4 had no plan of care (POC) initiated since admission.2. Patient 1 had no identified problems, goals, interventions, or status documented for the certification period of 10/5/25 to 1/2/26.3. Patient 8 had no identified problems, goals, interventions, or status documented for the certification period of 9/10/25 to 11/8/25.4. Patient 2 had no POC initiated since admission.5. Patient 10 had no POC initiated since admission, and subsequent assessments showed no POC addressing cardiovascular (heart) or respiratory (breathing) status, despite the registered nurse (RN) identifying low blood pressure and low oxygen saturation on 12/17/25.6. Patient 12 had no POC initiated since admission, and subsequent assessments lacked a POC addressing the Foley catheter and skin condition.These failures had the potential to create significant lapses in care by depriving staff and caregivers of essential written direction, placing patients at risk for preventable harm and diminished quality of care. 4. During a review of Patient 2’s demographics, dated 12/5/24, Patient 2’s SOC date was 12/5/24 with the primary diagnosis of Chronic Ischemic Heart disease (a condition where the heart is not receiving enough blood and oxygen).During a review of Patient 2’s “Comprehensive Nursing Assessment (CNA)”, dated 12/5/24, the CNA indicated that Patient 2 was alert and oriented to person and place, bedbound, had weight loss in the last six months of more than 10 % (percent), required assistance with Activities of Daily Living (ADL) and had a recommendation for two to five (2-5) liters of oxygen to be use as needed basis.During a review of Patient 2’s initial “Plan of Care/Interdisciplinary Review (POC/IDG Review),” dated 12/18/24, the POC/IDG Review indicated, that Patient 2, was unable to communicate, walk, or carry out by any activities of daily living (ADL) on her own, had history of stroke (a condition when part of the brain is blocked and not receiving blood flow), delusion (a belief that is clearly false), Alzheimer’s disease (a progressive, irreversible disorder that affects memory, thinking skills and ability to do simple tasks). Patient 2 was admitted to hospice care under a routine level of care with the primary diagnosis of Chronic Ischemic disease. Patient 2 had total zero (0) issues and no POC was initiated since Patient 2’s admission.Further review of the most recent “POC/IDG Review,” dated 3/11/26, the POC/IDG Review indicated that Patient 2 was bedridden, declining, depressed, hospice appropriate and requires maximum assistance with care. The POC/IDG Review had 0 issues and no POC for Patient 2’s care was found in Patient 2’s clinical record.5. During a review of Patient 10’s demographics, dated 9/24/25, the demographics indicated that Patient 10 was admitted to hospice care, with the SOC date 9/19/25, and a primary diagnosis of Vascular dementia (loss of mental abilities such as memory, thinking, and reasoning that interfere with ADLs). Patient 10 had an end of care (EOC) dated 12/18/25.During a review of Patient 10’s initial “POC/IDG Review,” dated 9/24/25, the POC/IDG Review indicated that Patient 10 had 0 issues and no POC was initiated for Patient 10 since admission.During a review of Patient 10’s “Registered Nurse Visit Notes (RVN),” dated 12/17/25, the RVN indicated that Patient 10 had a BP 97/50, and O2 saturation of 88% (percent – unit of measurement) at three liters per minute via nasal (nose) canula (a type of tube used for O2 delivery).During a review of Patient 10’s “POC/IDG Review,” dated 12/17/25, no POC was found addressing Patient 10’s cardiovascular and respiratory status.6. During a review of Patient 12’s demographics, dated 2/3/25, the demographics indicated that Patient 12 was admitted to hospice care with the SOC dated 2/3/25 and a primary diagnosis of Metabolic encephalopathy (a condition where brain function is impaired). Patient 12 had EOC dated 5/15/25.During a review of Patient 12’s “CNA,” dated 2/3/25, the CNA indicated that Patient 12 was bedbound, non-ambulatory, required maximum assistance with ADLs. Further review of the CNA indicated that “Patient 12’s POC was established with the input of patient/patient primary caregiver (PCG) and hospice IDG…”During a review of “Licensed Vocational Nurse Visit Notes (LVNVN),” dated 2/7/25, the LVNVN indicated that Patient 12 had a coccyx wound, stage 3 (wound extend to the second layer of the skin into subcutaneous fat tissue (below the skin). Further review of the LVNVN, dated 2/11/25, the LVNVN indicated in part, “…foley catheter in place and draining.”During a review of Patient 12’s initial “POC/IDG Review,” dated 2/12/25, the POC/IDG Review indicated that Patient 12 had a wound on coccyx (tailbone) measuring two to four (2-4) inches (unit of measurement) in diameter. Patient 12 was immobile, bedbound, with limited sensory perception, and had very poor nutrition. Further review of the document indicated 0 issues and no POC was initiated for Patient 12 since admission and no POC addressing Patient 12’s wound condition and foley catheter use.During an interview on 3/16/26 at 5:05 p.m. with the Administrator (ADM), the ADM acknowledged the missing POC for Patient 2, 10 & 12.During a review of the HA’s policy & procedure (P&P) titled, “The Plan of Care,” dated 4/2021, the P&P indicated in part, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. The plan will focus on identified problems, goals, and interventions…1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the care plan. 2. The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs…4. The plan of care will identify the patient’s needs and services to meet those needs including the management of pain” and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.” 1 During a review of patient 4’s clinical record on 3/11/26 at 11 am, records revealed that the start of care for the patient was on 12/17/25. No plan of care was initiated on the start of care was found. Plan of care was initiated on 12/31/25. 2. During a review of Patient 1’s clinical records on 3/11/26 at 2 pm. Plan of care dated 10/22/25 for certification period of 10/5/25 to 1/2/26 does not have any identified problems, interventions, goals and status. 3. During a review of Patient 8’s clinical record on 3/11/25 at 3 pm, plan of care dated 9/10/25 for certification period of 9/10/25 to 11/8/25 does not have any identified problems, interventions, goals and status. Interview with the administrator on 3/16/26 at 4:33 pm, the administrator acknowledged plan of care was not started on the start of care and plan of care does not have identified problems, interventions, goals and status.The facility policy and procedure titled “The Plan Of Care” dated April 2021 indicated in part “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program… This plan of care must be initiated at start of care.””

“Based on record review and interview, the hospice agency (HA) failed to develop an initial plan of care upon election of hospice services for three of 14 patients in the sample (Patient 13, Patient 6, and Patient 3).This failure had the potential to prevent patients from receiving the necessary care and services to meet their identified needs, increasing the risk for inadequate care and poor patient outcomes. Findings:1.During a review of the hospice agency’s policy and procedure (P&P) titled “The Plan of Care” dated 4/2021, the P&P indicated, “…The Case Manager (or admitting registered nurse)…will initiate the development of the plan of care after the consent forms are signed…” A review of Patient 13’s comprehensive nursing assessment dated 1/14/25 revealed that the admitting nurse discussed the patient’s status with the physician, who issued an order to admit this patient to hospice. Patient 13 was admitted with the primary diagnosis of heart failure. A review of Patient 13’s plan of care (POC) indicated that the initial POC was developed on 1/29/25, 15 days after the start of care. During an interview with the administrator (ADM) on 3/16/2 at 4:44 PM, the ADM acknowledged that the initial POC was not developed at the start of care and should be. 2. During a review of the hospice agency’s policy and procedure (P&P) titled “The Plan of Care” dated 4/2021, the P&P indicated, “…The Case Manager (or admitting registered nurse)…will initiate the development of the plan of care after the consent forms are signed…” A review of Patient 6’s comprehensive nursing assessment dated 12/15/25 revealed that the admitting nurse discussed the patient’s status with the physician, who issued an order to admit this patient to hospice. Patient 6 was admitted on 12/15/25 with the primary diagnosis of heart disease. A review of Patient 6’s plan of care (POC) indicated that the initial POC was developed on 12/31/25, 16 days after the start of care. During an interview with the administrator (ADM) on 3/16/2 at 5:00 PM, the ADM acknowledged that the initial POC for Patient 6 was not developed at the start of care and should be. 3. During a review of the hospice agency’s policy and procedure (P&P) titled “The Plan of Care” dated 4/2021, the P&P indicated, “…The Case Manager (or admitting registered nurse)…will initiate the development of the plan of care after the consent forms are signed…” A review of Patient 3’s plan of care (POC) indicated that the initial POC was developed on 3/11/26, 8 days after the start of care on 3/3/26. During an interview with the administrator (ADM) on 3/16/2 at 4:54 PM, the ADM acknowledged that the initial POC for Patient 3 was not developed at the start of care and should be.”

“Based on interview and record review, the hospice failed to maintain a system of communication among its interdisciplinary group (IDG) members when:Nursing staff recorded home care visits after Patient 13 had been released to another agency.IDG notes continued to be generated for Patient 14 after the patient had revoked hospice services.These failures resulted in unnecessary IDG review sessions, poor coordination of patient care, and had the potential to cause delays or gaps in communication essential to safe and appropriate service delivery. Findings:The facility policy and procedure (P&P) titled “Interdisciplinary Group Meeting,” revised 4/2021, indicated in part, “…The interdisciplinary group will meet on a regular basis to discuss patient…changes and progress and updates to the plan of care…circumstances…”During a record review and concurrent interview with the Administrator (ADM) on 3/16/26 at 4:44 p.m., Patient 13’s clinical record (CR) was discussed. The CR showed that Patient 13’s hospice services were revoked on 4/30/25; however, a licensed nurse (LN) documented a home visit on 5/3/25, and a certified hospice aide (CHA) documented a home visit on 5/4/25. The ADM acknowledged this finding.During a record review and concurrent interview with the Administrator (ADM) on 3/16/26 at 5:15 p.m., Patient 14’s clinical record (CR) was discussed. The CR showed that Patient 14’s hospice services were revoked on 3/9/26; however, an IDG review meeting for the patient was documented as having occurred on 3/11/26. The ADM acknowledged this finding.”

“Based on interview and record review, the hospice agency (HA) failed to ensure there were physician orders for nursing services provided for one of 14 patients in the sample (Patient 13). This deficient practice of providing care without a physician’s order placed the patient at increased risk for unsafe or inappropriate interventions, and had the potential to compromise the quality and safety of care delivered. A review of Patient 13’s clinical record (CR) for the certification period from 4/13/25 to 7/12/25 revealed that a skilled nurse (SN) visit occurred on 5/3/25, followed by a certified hospice aide (CHA) visit on 5/4/25, without a physician’s order.A review of the agency document titled “HIS Report‑Discharge” showed that Patient 13 was discharged from the agency on 4/30/25.During a concurrent record review and interview with the Administrator (ADM) on 3/16/25 at 4:44 p.m., Patient 13’s CR was discussed. The ADM confirmed there were no physician orders for the SN visit on 5/3/25 and the CHA visit on 5/4/25.”

“Based on record review and interview, the hospice agency failed to ensure that performance improvement projects (PIP) were developed and implemented as part of its Quality Assessment and Performance Improvement (QAPI) program, as evidenced by their inability to provide documented evidence of both a completed and on-going PIP.This failure resulted in limited information for evaluating quality trends and had the potential to affect the agency’s ability to identify areas needing improvement, increasing the chance that their QAPI program would not produce meaningful care improvements. Findings:During a review of the facility’s policy and procedures (P&P) titled “Improving Organizational Performance” dated 4/2021, the P&P indicated, “…The organization shall develop, implement, and evaluate performance improvement projects…”A review of the hospice’s QAPI records revealed no evidence of a performance improvement project.During an interview on 3/12/26 at 4:40 PM, the office manager (OM) verbalized that their hospice agency had no record of completed performance improvement projects and no on-going projects at the time. During an interview with the administrator (ADM) on 3/16/26 at 5:10 PM, the ADM acknowledged that the hospice had no information on the previous and present PIP. No other information was provided.”

“Based on interview and record review, the hospice agency (HA) failed to ensure nursing services were provided as planned for ten of the 14 sampled patients (Patient 4, Patient 8, Patient 7, Patient 2, Patient 5, Patient 11, Patient 12, Patient 13, Patient 6, and Patient 3) when: Patient 4 – LVN and Registered Nurse Supervisory (RNS) visits were not provided.Patient 8 – LVN and RN visits were not provided.Patient 7 – RN visits were not provided.Patient 2 – medication reconciliation was not provided.Patient 5 – the LVN visit was not provided.Patient 11 – the RNS visit was not provided.Patient 12 – Certified Hospice Aide (CHA), LVN, and RNS visits were not provided.Patient 13 – a skilled nurse (SN) visit was not provided during the week of 3/30/25–4/5/25.Patient 6 – CHA visits were not provided from 2/24/26 to 3/14/26.Patient 3 – one of two scheduled CHA visits was not provided during the week of 3/8/26–3/14/26.This failure resulted in required nursing services not being provided and had the potential to significantly compromise the hospice’s ability to meet patients’ nursing needs and jeopardize the quality of care provided. 8.During a review of the hospice agency’s policy and procedure (P&P) titled “Missed Visits” dated 4/2021, the P&P indicated, “…Document in the patient’s clinical record the…reason for the missed visit…” During a concurrent record review and interview with the hospice agency’s (HA’s) administrator (ADM) on 3/16/26, at 4:44 PM, Patient 13’s clinical records (CR) were reviewed for the two certification period of 1/14/25 and 4/14/25. The CR revealed there was no skilled nurse (SN) visit for the week of 3/30/25 to 4/5/25. There was no documented explanation for the missed SN visit. This finding was validated by the ADM. 9.During a concurrent record review and interview with the administrator (ADM) on 3/16/25, at 5:00 PM, for the certification period from 12/15/25 to 03/14/26, the clinical record (CR) for patient 6 was reviewed. The plan of care (POC) included the frequency of the certified hospice aide (CHA) visit: twice per week (2X/WK). A review of patient 6’s visit calendar indicated that no further CHA visits occurred from 2/24/26 to 3/14/26. There was no evidence in patient 6’s CR that the appointments were rescheduled. The ADM acknowledged the findings. 10. During a concurrent record review and interview with the hospice agency’s administrator (ADM) on 3/16/26 at 5:10 PM, patient 3’s clinical record (CR) for the certification period from 3/3/26 – 5/31/26 was reviewed. Patient 3’s visit calendar revealed one of two proposed certified hospice aide (CHA) visits did not occur in week 3/8/26 – 3/14/26. This finding was validated by the ADM. 5. During a review of Patient 5’s clinical record (CR), the CR indicated that Patient 5 had a doctor’s order for the LVN visit one time a week plus one as needed for certification period 12/6/25 to 2/3/26. Further review of the CR revealed that the LVN had a missed visit the week of 2/1/26 to 2/7/26.6. During a review of Patient 11’s clinical record (CR), the CR indicated that Patient 11 had a doctor’s order for the LVN visit one time a week plus two as needed and RNS visit every 14 days for certification period 1/1/25 to 3/1/25. Further review of the CR revealed that the LVN had a missed visit the week of 2/16/25 to 2/22/25 and a missed RNS visit the week of 1/5/26 to 1/11/25 and 1/19/25 to 1/25/25.7. During a review of Patient 12’s clinical record (CR), the CR indicated that Patient 12 had a doctor’s order for HA visit two times a week, LVN visit one time a week and RNS visit initial eval then q14 days for certification period 2/3/25 to 5/3/25. Further review of the CR revealed that the HA had seen the patient one time the week of 3/9/25 to 3/15/25 and no HA visit the week of 3/30/25 – 4/5/25, 4/6/25 - 4/12/25, 4/13/25 – 4/19/25, 4/20/25 – 4/26/25, 4/27/25 – 5/3/25, 5/4/25 – 5/10/25, 5/11/25 – 5/17/25. LVN had a missed visit the week of 3/16/25 to 3/22/25, 3/23/25 to 3/29/25 and no RNS visit was found after the initial visit.No additional documentation was found related to missed visits for Patient 5, 11 & 12.During an interview on 3/16/26 at 5:05 p.m. with the Administrator (ADM), the ADM acknowledged the missed visit for Patient 5, 11 & 12 and was unable to provide additional proof of documentation as to the reason why.During a review of the HA’s policy & procedure (P&P) titled, “Missed Visits,” dated 4/2021, the P&P indicated in part, “Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting…1.If a missed visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2.If a visit is missed and not rescheduled the clinician will: A.Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient’s clinical record…3.If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take appropriate measures as stated above…” 1. Review of patient 4’s clinical records on 3/11/26 at 10:15 am, clinical records revealed the patient had an order for license vocational nurse (LVN) visits of 2 per week and 1 as necessary and a registered nurse (RN) visit of 1 per week plus 3 as necessary for the certification period of 12?17/25 to 3/16/26. The patient has multiple missed visits:Week of 12/21/26 to 12/27 – only 1 LVN visit.Week of 1/11/26 to 1/17/26 – no lvn visits.Week of 1/18/26 to 1/24/26 - only 1 lvn visitWeek of 1/25/26 to 1/31/26 – only one LVN visit.Week of 2/1/26 to 2/7/26 – no visit by LVN and RN.Week of 2/15/26 to 2/21/26 – no visits by the LVN and RN.Week 3/1/26 to 3/7/26 – no visits by LVN and RN.No documentation of missed visit found in the clinical records. 2. Review of patient 8’s clinical records on 3/1126 at 3 pm revealed Patient 8 had registered nurse (RN) visits of 1 per 2 weeks and licensed vocational nurse (LVN) visits of 1 per week plus 1 visit as necessary for certification period of 9/10/25 to 11/8/25. Visit calendar list RN visit was on 9/26/26 (week 9/21/25 to 9/27/26). The week on 10/5/25 to 10/11 revealed no RN visit for the week. No missed visits documentation found in the clinical records.3. Review of patient 7’s clinical record on 3/11/16 at 3:30 pm revealed the patient had a RN visit of 1 per week plus 1 as necessary for the certification period of 9/925 to 11/7/25. Only 1 visit was made (9/19/25) for the whole certification period. During an interview with the administrator on 3/16/26 at 4:33 pm, the administrator acknowledged missed visits for patient 4, 7 and 8. The facility policy and procedure titled “Missed Visits” dated April 2021indicates, “Missed visits will be communicated to the interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.” 4. During a home visit for Patient 2 with the registered nurse (RN) on 3/10/26 at 10 am, agency home medication list was compared with the on hand medication. A bottle of multi-vitamins was found to be not in the agency home medication list. Interview with the care giver indicated the Patient 2 is getting the multi-vitamins everyday. Interview with the RN indicated the RN does not have knowledge of the patient receiving multi-vitamins everyday.Interview with administrator on 3/16/26 at 4:33 pm, the administrator acknowledged medication was not reconciled.The policy and procedure titled “Medication Profile” dated April 2021 indicates, “Patients receiving medication administered by the hospice will have a current, accurate medication profile in the clinical records.””

“Based on record review and interview, the hospice agency (HA) failed to ensure one of 14 sampled patients (Patient 5) was evaluated by a Medical Social Worker (MSW) for psychosocial needs as directed by the physician.This failure had the potential for Patient 5’s psychosocial needs, including interaction with their social environment, not to be met, which could negatively affect their overall health and well‑being. Findings:During a review of Patient’s demographics, dated 10/12/24, the demographics indicated that Patient 5’s start of care dated 10/12/24 and was admitted to hospice care with the primary diagnosis of Alzheimer’s disease (a brain condition that affects memory, thinking skills, and ability to perform simple daily tasks).During a review of Patient 5’s “Physician’s Order (PO), dated 10/12/24, the PO indicated a physician order for Medical Social Worker (MSW) to evaluate Patient 5 and family for psychosocial support during initial and recertification assessment.Further review of Patient 5’s clinical record (CR), psychosocial evaluation was completed on 10/15/24 and 6/23/25. Further review of the CR, certification period from 12/6/25 – 2/3/26, no psychosocial assessment was found in Patient 5’s CR.During an interview on 3/16/26 at 5:05 p.m. with the Administrator (ADM), the ADM acknowledged the missing MSW evaluation.During a review of the HA’s policy & procedure (P&P) titled, “Psychosocial Assessment,” dated 4/2021, the P&P indicated in part, “…An in-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes, but not limited to: 1.Coping with and adjusting to the patient’s terminal illness. 2.Making final arrangements. 3. Reaction to the terminal illness and subsequent bereavement needs. 4.Social and financial needs….2. A psychosocial assessment will be performed at the initial meeting of patient and family/caregiver…4.The assessment will completed and placed in the patient’s clinical record…”Further review of the HA’s P&P titled, “The Plan of Care,” dated 4/2021, the P&P indicated in part, “…The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process…””

“Based on record review and interview, the hospice agency (HA) failed to ensure a certified hospice aide (CHA) assignment or written instructions prepared by a registered nurse (RN) was completed for two of 14 sampled patients (Patient 13 and Patient 6).This failure had the potential to result in the hospice aide care plan not being implemented and to not meet Patient 13’s and Patient 6’s specific care needs, placing the patients at risk for decreased quality of care and compromised safety. Findings:1.During a review of the hospice agency’s policy and procedure (P&P) titled “Hospice Aide Services,” dated 4/2021, the P&P indicated, “…Hospice aide patient care instructions will be written by the RN… Hospice aide assignments… will be documented and included in the patient’s clinical record…”During a review of the document “Hospice Aide (HA) Assignment” dated 1/14/25 for Patient 13, this document was assigned for the registered nurse (RN‑name) to complete; however, the RN did not complete or sign this document.During an interview with the Administrator (ADM) on 3/16/26 at 4:44 p.m., the ADM validated these findings.2. During a review of the hospice agency’s policy and procedure (P&P) titled “Hospice Aide Services,” dated 4/2021, the P&P indicated, “…Hospice aide patient care instructions will be written by the RN… Hospice aide assignments… will be documented and included in the patient’s clinical record…”During a review of the document “Hospice Aide (HA) Assignment” dated 12/16/25 for Patient 6, this document was assigned for the registered nurse (RN‑name) to complete; however, the RN did not sign this document.During an interview with the Administrator (ADM) on 3/16/26 at 5:00 p.m., the ADM validated this finding”

“Based on interview and record review, the facility failed to ensure the governing body employed staff who met all required qualifications for one employee, Licensed Nurse (LN). This failure had the potential to result in patients not receiving proper care and to compromise patient safety and the quality of care. Findings:During a review of the employee files on 3/12/26 at 10:00 a.m., the LN was listed as an administrator designee on the organization chart. The employee files did not contain a signed job description for the administrator designee role. No employment medical exam and no tuberculosis (TB) test (a test used to check for TB infection in the lungs) were found in the employee files.During an interview with the Administrator on 3/16/26 at 4:24 p.m., the Administrator acknowledged that the administrator designee did not have a signed job description, medical exam, or TB test.The policy and procedure titled “Governing Body,” dated April 2021, indicates, “The governing body will assume full legal authority and responsibility for the operation of Sebastian Hospice Care Inc. The governing body of Sebastian Hospice Care Inc. will serve as the governing authority for the hospice program, which will function according to Sebastian Hospice Care Inc. bylaws.””

“Based on record review and interview, the hospice agency (HA) failed to ensure a discharge summary was sent to the responsible health care provider for one of 14 sampled records (Patient 13).This failure had the potential to disrupt the patient’s continuity of care and place the patient at risk for delays or gaps in follow‑up care. Findings:During a review of the hospice agency’s policy and procedure (P&P) titled “Discharge Summary” dated 4/2021, the P&P indicated, “…Hospice personnel …will complete a discharge summary at the time the discipline is discontinued, which may include…A summary of care or services provided…A copy of the discharge summary will be provided to the patient’s attending physician…” During a review of the hospice agency’s policy and procedure (P&P) titled “Transfer Information” dated 4/2021, the P&P indicated, “…Completed transfer summaries will be given to the receiving organization within 72 hours of transfer…” During a review of the agency document titled “HIS Report-Discharge” indicated Patient 13 was discharged from the agency on 4/30/25. A review of Patient 13’s discharge summary revealed that the patient was transferred to another hospice agency on 04/30/25. The discharge summary was incomplete since the transfer documents, which included a POC summary with a list of medications and advance directives, were not checked to ensure that they were forwarded to the receiving agency and it did not have the clinician’s signature. During an interview with the administrator (ADM) on 3/16/2 at 4:44 PM, the ADM validated this finding.”

“Based on interview and record review, the hospice agency (HA) failed to follow its policies and procedure (P&P) for completion of discharge summaries when the discharge summary for one of the six discharged patients (Patient 11) was completed by office personnel who had not provided direct care to the patient. This failure resulted in discharge documentation being completed by personnel who were not involved in the patient’s care and had the potential to produce inaccurate, incomplete, or unreliable discharge information. Findings:During a review of Patient 11’s demographics dated 5/6/24, the record indicated that Patient 11’s start of care (SOC) began on 5/6/24, with admission to hospice services for the primary diagnosis of metabolic encephalopathy (a condition in which brain function is impaired), and that the patient was discharged from hospice care on 8/20/25.During a review of Patient 11’s “Discharge Summary (DS),” dated 8/20/25, the DS indicated, “Based on the type of Discharge provide a brief summary related to: Diagnosis, health, history, symptom and pain management, extent to which goals were and/or were not met, and if applicable, summarize post-discharge continuity of care orders…” Further review of the DS, the DS was signed by the office manager (OM) with the following documentation, “No longer eligible for hospice, patient seems to be stable and is not declined or imminently declining for his condition. Will refer patient to a home health care…”During an interview on 3/16/26 at 5:05 p.m., the Administrator (ADM) acknowledged that the Office Manager (OM) did not provide care for Patient 11 and was not qualified or permitted to do discharge summaries, as only licensed healthcare professionals are authorized to complete discharge summaries according to agency requirements.During a review of the HA’s policy and procedure (P&P) titled “Discharge Summary,” dated 4/2021, the P&P indicated, in part, “…Each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued… 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.””

“Based on interview and record review, the hospice agency (HA) failed to ensure the statuses of discharged patients were communicated and that a physician’s order was obtained and clarified for two of 14 sampled patients (Patient 10 and Patient 12) when:A durable medical equipment (DME) for an oxygen (O2 - colorless odorless gas) concentrator was ordered for Patient 10.An assessment revealed a change in skin condition for Patient 12.These failures placed current hospice patients at risk and had the potential for medication error due to the lack of clear direction on how the oxygen (O2) was to be administered, and had the potential to negatively impact the quality of care by delaying the implementation of necessary skin treatment. Findings:1.During a review of Patient 10’s “Registered Nurses Visit Notes (RVN),” dated 12/17/25, the RVN indicated that Patient 10 had an oxygen saturation (measurement of how blood carries oxygen to the body) of 88% (percent – unit of measurement) at three liters per minute via nasal (nose) canula (a type of tube used for O2 delivery).During a review of Patient 10’s “Physician’s Order (PO),” dated 12/17/25, the PO indicated a phone order for one stationary five (5) liters oxygen concentrator obtained by the registered nurse (RN) at 12:50 p.m. The document further indicated that the phone order was read back to the physician and the medication was reconciled.Further review of Patient 10’s clinical record showed no clear documentation indicating how the oxygen (O2) was to be administered, and no evidence that the order had been clarified with the physician.2. During a review of Patient 12’s demographics, dated 2/3/25, the demographics indicated that Patient 12 was admitted to hospice care with the start of care dated 2/3/25 with a primary diagnosis of Metabolic encephalopathy (a condition where brain function is impaired). Patient 12 had an end of care, dated 5/15/25.During a review of Patient 12’s “Comprehensive Nursing Assessment (CNA),” dated 2/3/25, the CNA indicated that Patient 12 was bedbound, non-ambulatory, required maximum assistance with ADLs, skin was clean and dry…The Physician has issued an order to admit this patient to hospice. His initial order on Level of Care, Frequency of Visit and any applicable Meds/DME/Treatments is entered below. This is a verbal order/ read back and verified.”During a review of “Licensed Vocational Nurse Visit Notes (LVNVN),” dated 2/7/5, the LVNVN indicated that Patient 12 had a coccyx wound, stage 3 (wound extend to the second layer of the skin into subcutaneous fat tissue (below the skin).”Further review of Patient 12’s clinical record, there was no treatment order found and no documentation if Patient 12’s skin condition had been communicated with the physician.During an interview on 3/16/26, at 4:35 p.m. with the office manager (OM), the OM verbalized remembered ordering the oxygen concentrator for Patient 10, and was aware of Patient 12’s skin condition, but OM was unable to provide additional proof of documentation on how concentrator would be used and if skin treatment had been ordered and communicated with the physician.During an interview on 3/16/26 at 5:05 p.m. with the Administrator (ADM), the ADM acknowledged that the skin treatment order for Patient 12 was missing and that the oxygen use for Patient 10 had not been clarified with the physician.During a review of the HA’s policy & procedure (P&P) titled, “Verification of Physician Orders,” dated 4/2021, the P&P indicated in part, “Orders will be obtained from a licensed physician (or authorized licensed independent practitioner) for care and services to be provided to hospice patients.””

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed that received hospice services at least five (5) days revealed the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/20/2025. On the initial nursing assessment dated 06/20/2025, the nurse documented “SC visit needed - Yes”. The record lacked evidence of a completed Spiritual counselor initial assessment. The Administrator and Director of Patient Care Services stated in an interview on 07/08/2025 that the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care.”

“It is required that the update of the comprehensive assessment is completed by the Hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes, and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires, and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed revealed the agency did not ensure the update of the comprehensive assessment was completed by the hospice Interdisciplinary Group (IDG), who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/20/2025. The IDG meeting held on 07/02/2025 lacked evidence that the registered nurse (RN), social worker, and Spiritual counselor/bereavement coordinator attended IDG. The Administrator, Hospice Medical Director, and two (2) office staff were present for the IDG meeting. The Administrator stated in an interview on 07/08/2025 that the RN, MSW, and SC did not attend because it was a holiday week.””

“It is required that each patient’s individualized written plan of care 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 2 (50%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. CLINICAL RECORD 2: The aide care plan dated 06/20/2025 stated the aide frequency was two (2) times per week. The IDG POC summary dated 07/02/2025 lacked evidence of the frequency for aide services. The Administrator and Director of Patient Care Services (DPCS) stated in an interview on 07/08/2025 that the agency did not ensure the POC included a detailed statement of the scope and frequency of services.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that elected the hospice aide revealed the agency did not ensure the aide services were provided as ordered by the interdisciplinary group (IDG). THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 2: The IDG plan of care (POC) dated 06/20/2025 ordered, “HA services - 2 times a week for assistance with ADLs and grooming”. There was evidence of aide visits completed on 06/25/2025, 06/28/2025, 07/02/2025, and 07/05/2025. The record lacked evidence aide visits for week 1 that started 06/20/2025. The Administrator and Director of Patient Care Services stated in an interview on 07/08/2025 that the agency did not ensure the aide services were provided as ordered by the IDG. CONTINUATION OF REQUIRED ACTION”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record reviews and interviews with the Administrator, which revealed the following: Failed to ensure the skills competency assessment for the aide was completed prior to providing unsupervised direct patient care in 1 of 1 (100%) personnel records reviewed [HSRM.9.I/L615/418.76(c)(1)]; Failed to ensure the registered nurse made an annual on-site visit to the location where a patient was receiving care in order to observe and assess each aide while he or she is performing care, in 1 of 1 (100%) of personnel records reviewed [HSRM.27.D/L632/418.76(h)(2)]; and Failed to ensure hospice aide services were provided as ordered by the interdisciplinary group [HCDT.16.I/L626/418.76(g)(2)(i)]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide 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, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed the agency did not ensure that the medication review process included all the medications the patient was currently taking. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated “Our electronic medical record system is down and we are unable to obtain access to it”. No further documentation was provided.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated, “Our electronic medical record system is down, and we are unable to obtain access to it”. No further documentation was provided.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed revealed the agency did not ensure the plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated “Our electronic medical record system is down and we are unable to obtain access to it”. No further documentation was provided.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed the agency did not ensure that nursing care and services were provided per the patient plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated, “Our electronic medical record system is down, and we are unable to obtain access to it”. No further documentation was provided.”

“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 5 of 5 (100%) clinical records reviewed the agency did not ensure that bereavement services were provided. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated “Our electronic medical record system is down and we are unable to access it”. No further documentation was provided.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of a hospice aide, hired within the last three years, it was revealed that the agency did not ensure that a competency evaluation was completed by an RN prior to providing unsupervised direct patient care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. PERSONNEL RECORD 2: The hospice aide’s date of hire was 12/11/2024. The record lacked documentation of a skills and competency assessment, either on a pseudo patient or actual patient, prior to being assigned unsupervised patient care. During a joint record review on 05/20/2025, the Administrator confirmed the above finding that a competency assessment was not completed prior to the hospice aide providing unsupervised direct patient care.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed with hospice aide services provided the agency did not ensure that hospice aide services were provided as included in the plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated, “Our electronic medical record system is down, and we are unable to obtain access to it”. No further documentation was provided.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed the agency did not ensure that all physician orders were included in the patient’s clinical record. THIS IS A CONTINUING PRIOR REQUIRED ACTION. CLINICAL RECORD 1: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 2: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 3: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 4: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. CLINICAL RECORD 5: The record was unable to be reviewed due to the agency’s electronic medical record being down during the survey. During an interview on 05/20/2025, the Administrator stated “Our electronic medical record system is down and we are unable to obtain access to it”. No further documentation was provided.”

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interviews with the Administrator, which revealed that the governing body failed to ensure the agency implemented the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failed to ensure emergency preparedness plan was reviewed and updated every two years [HSEP.2.D/E4/418.113(a)]; Failed to ensure the emergency plan was based on a documented, facility-based and community-based risk assessment [HSEP.2.D/E6/418.113(a)(1)]; Failed to ensure emergency preparedness policies and procedures were reviewed and updated at least every two years [HSEP.3.D/E13/418.113(b)]; Failed to ensure emergency preparedness communication plan was reviewed and updated at least every two years [HSEP.4.D/E29/418.113(c)]; Failed to ensure the emergency preparedness training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and that the communication plan and was reviewed and updated at least every two years [HSEP.5.D/E36/418.113(d)]; Failed to ensure emergency preparedness training was provided at least every 2 years [HSEP.5.D/E36/418.113(d)(1)(iii)]; and Failed to ensure the emergency preparedness plan was tested annually [HSEP.6.I/E39/418.113(d)(2)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by Quality Assessment and Performance Improvement (QAPI) documents, and interviews which revealed issues with the organization’s QAPI program in the following areas: Failed to ensure that the governing body evaluated the QAPI program annually [HQPI.1.D/L574/418.58(e)(1)]; Failed to ensure the hospice tracked, measured and analyzed quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events [HQPI.4.I/L562/418.58(a)(2)]; Failed to ensure the hospice used quality indicator data, including patient care data, in the QAPI program [HQPI.5.I/L563/418.58(b)(1)]; Failed to ensure that hospice performance improvement (PI) activities focused on high-risk, high volume, or problem prone areas [HQPI.6.I/L566/418.58(c)(1)(i)]; Failed to ensure that hospice performance improvement (PI) activities include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program [HQPI 6.I/L580/418.60(b)(1)]; and Failed to ensure that performance improvement activities analyzed the causes, implemented preventive action and mechanisms that included feedback and learning throughout the hospice [HQPI.7.I/L569/418.58(c)(2)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.58: Quality assessment and performance improvement. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record reviews and interviews with the Administrator, which revealed the following: Failed to ensure the skills competency assessment for the aide was completed prior to providing unsupervised direct patient care in 1 of 1 (100%) personnel records reviewed [HSRM.9.I/L615/418.76(c)(1)]; Failed to ensure the registered nurse made an annual on-site visit to the location where a patient was receiving care in order to observe and assess each aide while he or she is performing care, in 1 of 1 (100%) of personnel records reviewed [HSRM.27.D/L632/418.76(h)(2)]; and Failed to ensure hospice aide services were provided as ordered by the interdisciplinary group [HCDT.16.I/L626/418.76(g)(2)(i)]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered in accordance with local, state, and federal law and regulation, act only within the scope of their state license or state certification or registration and keep their qualifications current at all times. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by personnel record review, document review, and interviews with the Administrator, which revealed that the agency failed to ensure the hospice professionals met the personnel qualification requirements in the following areas: Failed to ensure the Registered Nurse/Clinical Supervisor (Personnel Record 11) maintained a current nursing license [HSRM.5.I/L793/418.114(c)(1)]; and Failed to ensure the hospice obtained criminal checks on hospice employees who have direct patient contact or access to patient records in 4 of 12 (33%) of the personnel records reviewed [HSRM.16.I/L796/418.114(d)(2)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.114: Personnel Qualifications. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the emergency preparedness plan was reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency plan reviewed in 2024. The last documented review of the plan was in 2022. During an interview on 04/10/2025, the Administrator confirmed that the emergency preparedness (EP) plan was not reviewed and updated in 2024. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2024. The previous emergency plan review was in 2022.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. The document review revealed the agency did not ensure the emergency preparedness plan was based on a reviewed and updated “all-hazards” approach specific to the hospice’s geography and population served. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the hazard vulnerability risk assessment had been reviewed and updated at least every two years. The last documented risk assessment was in 2022, and the agency was unable to present evidence that a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served was completed for 2024. During an interview on 04/10/2025, the Administrator confirmed that a hazard vulnerability risk assessment was not completed for 2024. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2024.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the emergency preparedness policies and procedures were reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were reviewed and updated at least every two (2) years. The previous emergency plan review was in 2022. During an interview on 04/10/2025, the Administrator confirmed that the hazard vulnerability risk assessment was not completed and that the emergency preparedness (EP) policies and procedures were not reviewed in 2024. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were reviewed and updated at least every two (2) years. The previous emergency plan review was in 2022.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the communication plan was reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) communication plan, including all contact information, was reviewed and updated at least every two (2) years. The previous emergency preparedness communication plan, including contact information was last reviewed in 2022. During an interview on 04/10/2025, the Administrator confirmed that the communication plan, including all contact information, was not reviewed and updated in 2024. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) communication plan, including all contact information, was reviewed and updated at least every two (2) years. The previous emergency preparedness communication plan review was in 2022.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the emergency preparedness training program was reviewed and updated at least every two years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on an emergency preparedness plan, risk assessment, policies and procedures, and a communication plan that were reviewed and updated at least every two years. The last documented review for these items was in 2022, the agency was unable to present evidence that the training program was reviewed and updated in 2024. During an interview on 04/10/2025, the Administrator confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated in 2024. The last review was in 2022. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for 2024. The documentation lacked evidence that the training program was updated for 2024. The previous emergency plan review was in 2022.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following for all new hospice employees and those providing services under arrangement: initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, personnel record review, and interview. In 6 of 12 (50%) personnel records reviewed revealed that the agency did not ensure that the employees received emergency preparedness training, based on a training program that was reviewed and updated, at least every two years. Document review of the emergency preparedness training program revealed that the last documented review occurred in 2022. PERSONNEL RECORD 1: The Administrator’s date of hire was 05/21/2021. The record lacked evidence of emergency preparedness training for 2024. PERSONNEL RECORD 2: The Director of Patient Services Designee/Registered Nurse’s date of hire was 06/23/2021. The record lacked evidence of emergency preparedness training for 2024. PERSONNEL RECORD 5: The Licensed Vocational Nurse’s date of hire was 05/09/2022. The record lacked evidence of emergency preparedness training for 2024. PERSONNEL RECORD 7: The Certified Home Health Aide’s date of hire was 09/20/2021. The record lacked evidence of emergency preparedness training for 2024. PERSONNEL RECORD 9: The Volunteer Coordinator/Volunteer’s date of hire was 09/16/2021. The record lacked evidence of emergency preparedness training for 2024. PERSONNEL RECORD 12: The Master Medical Social Worker’s date of hire was 05/05/2022. The record lacked evidence of emergency preparedness training for 2024. During an interview on 04/10/2025, the Administrator confirmed that a documented emergency preparedness training program was not based on a recent emergency preparedness plan, risk assessment, policies and procedures, and communication plan for 2024. The last review was in 2022. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for 2024. The documentation lacked evidence that the training program was updated for 2024. The previous emergency plan review was in 2022.”

“It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure exercises were conducted to test the emergency plan at least annually. The last documented testing of the emergency plan was in 2022. There was no documentation that the agency had activated the plan in response to any natural or man-made emergencies in 2023 or 2024. During a document review and interview on 04/10/2025, the Administrator confirmed that the emergency preparedness plan was not tested annually and stated that actual emergencies for {city} were not documented for 2023 or 2024. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. The last testing of the EP was in 2022.”

“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, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure the medication review process included all the medications the patient was currently taking. HOME VISIT 2/Clinical Record 4: The patient’s date of election was 04/27/2024. The medication profile printed on 04/08/2025 included Gabapentin 100 mg capsule, one capsule three times a day, and Losartan Potassium 50 mg tablet, one tablet daily. During the Home Visit on 04/09/2025 with the Home Health Aide (Personnel Record 8), the medication bottles in the home revealed Losartan Potassium 100 mg tablet, one tablet daily, Venlafaxine HCl ER 75 mg tablet, one tablet daily, and Citalopram 10 mg tablet, one tablet daily. The group home caregiver reported that these medications were being administered as per the medication bottles. The group home caregiver stated that the Gabapentin was being given as needed. The Group Home did not have a paper medication record but followed the instructions on the bottles. The medications the patient was currently taking were not part of the medication review process. During a joint record review and interview on 04/10/2025, the Director of Patient Services/Registered Nurse confirmed that the medications were not reconciled and updated to the drug profile.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 2: The patient’s date of election was 02/03/2025. The record lacked evidence of an initial bereavement assessment. CLINICAL RECORD 3: The patient’s date of election was 01/14/2025. The record lacked evidence of an initial bereavement assessment. CLINICAL RECORD 4: The patient’s date of election was 01/13/2025. The record lacked evidence of an initial bereavement assessment. During a joint clinical record review and interview on 04/10/2025, the Director of Clinical Services Designee/ Registered Nurse confirmed the initial bereavement assessments were not completed.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient’s date of election was 03/17/2025. The primary hospice diagnosis was vascular dementia, moderate, without behavioral/psychiatric/mood/anxiety. The initial nursing assessment on 03/17/2025 documented that the patient had a pain rating of 5/10 with a threshold of 3, aspiration precautions, a fall risk of 7 (moderate risk), and was confined to bed or chair-w/c [wheelchair]. The nursing assessment on 03/26/2025 documented that the patient had a pain rating of 4/10 with a threshold of 2, aspiration precautions, and was confined to bed or chair-w/c. The POC/IDG [plan of care/interdisciplinary group] Review dated 03/26/2025 lacked problems, interventions, and goals for pain, aspiration precautions, and at risk for falls. CLINICAL RECORD 2: The patient’s date of election was 02/03/2025. The primary hospice diagnosis was metabolic encephalopathy. The initial nursing assessment on 02/03/2025 documented that the patient had a pain rating of 5/10 with a threshold of 6, was bed-bound, a Braden Risk of 6 (high risk), a fall risk score of 6 (moderate risk), was incontinent of bowel and bladder, and had weakness and fatigue. The POC/IDG Review dated 02/12/2025 and 03/26/2025 lacked problems, interventions, and goals for pain, risk for altered skin integrity, and at risk for falls. CLINICAL RECORD 4: The patient’s date of election was 01/13/2025. The primary hospice diagnosis was metabolic encephalopathy. The initial nursing assessment on 01/13/2025 documented that the patient had shortness of breath with mild exertion, was incontinent of bowel and bladder and had weakness and fatigue. The POC/IDG Review dated 02/12/2025 and 03/26/2025 lacked problems, interventions, and goals for altered respiratory function and the risk of altered skin integrity. During a joint review of the record and an interview on 04/10/2025, the Director of Patient Services Designee/Registered Nurse confirmed that the plans of care did not include the problems, goals, and interventions for the problems identified.”

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that the hospice measured, analyzed and tracked quality indicators. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events for 2023 and 2024. During a document review and interview on 04/10/2025, the Administrator confirmed that the QAPI program lacked evidence of data tracking and analysis for 2023 and 2024. The electronic medical record can track the quality indicators through reports, but this data was not being processed. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events for 2023 and 2024.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that the hospice included patient care data in the QAPI program. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence of monitoring or analysis of patient care, or other relevant, quality indicators for 2023 and 2024. There was no evidence of any monitoring or audits being completed and reported through QAPI. During a document review and interview on 04/10/2025, the Administrator confirmed that the QAPI program lacked evidence that the agency used quality indicator data, including patient care, and other relevant data, in the design of the program for 2023 and 2024. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency used quality indicator data, including patient care, and other relevant data, in the design of the program for 2023 and 2024.”

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that the hospice developed performance improvement activities. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence of any documented performance improvement activities for 2023 and 2024. The last performance improvement activities were from 2022. During a document review and interview on 04/10/2025, the Administrator confirmed that the QAPI program had no hospice performance improvement activities focused on high-risk, high-volume, or problem-prone areas for 2023 and 2024. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities focused on high-risk, high-volume, or problem-prone areas for 2023 and 2024.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that the hospice tracked and analyzed adverse patient events. Upon reviewing the quality assessment and performance improvement (QAPI) program lacked documented evidence of performance improvement activities, including adverse events. The last performance improvement activities were from 2022. During a document review and interview on 04/10/2025, the Administrator confirmed that the QAPI program had no performance improvement activities that tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms, including feedback and learning throughout the hospice. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms that included feedback and learning throughout the hospice for 2023 and 2024.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the hospice developed, implemented, and maintained an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI) that was evaluated by the governing body annually. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the hospice governing body evaluated the program annually for 2022, 2023, and 2024. During a document review and interview on 04/10/2025, the Administrator confirmed that the QAPI program lacked evidence that the hospice governing body evaluated the program annually. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the hospice governing body evaluated the program annually for 2022, 2023, and 2024.”

“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. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. Agency Policy No. 9-009, Hand Hygiene, (revised April 2021), stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient), after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated...after removing gloves.” HOME VISIT 1: During the home visit, on 04/09/2025, with the Licensed Vocational Nurse (LVN) (Personnel Record 5), the LVN was observed to remove the dressing to the coccyx/sacral wound and change the gloves. The LVN performed wound care with wound cleanser, dried and packed the wound, removed gloves and donned a new pair. The LVN did not disinfect the hands between glove changes. HOME VISIT 3: During the home visit, on 04/09/2025, with the Registered Nurse (RN) (Personnel Record 2), the RN was observed to remove the dressing to the right ankle wound, clean the wound with wound cleanser, removed gloves and donned a new pair. The RN dressed the wound and changed the gloves. The RN did not disinfect the hands between glove changes. During an interview on 04/10/2025, the Director of Patient Services Designee/Registered Nurse agreed the staff did not follow the hand hygiene policy.”

“It is required that hospice performance improvement (PI) activities include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the hospice included the infection control program in the performance improvement activities. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities included the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases as included in the infection control program for 2023 and 2024. The last performance improvement activities were from 2022. During a document review and interview on 04/10/2024, the Administrator confirmed that the QAPI program had no current performance improvement activities. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities included the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases as included in the infection control program for 2023 and 2024.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 9 of 12 (75%) personnel records reviewed, it was revealed that the agency did not ensure the staff received infection control education in accordance with agency policy. Agency Policy No. 9-001, Infection Control Plan (revised April 2021), stated in part, “Infection control in-services will be scheduled no less than annually. Attendance will be mandatory and will be documented. Records of in-service attendance will be maintained in the personnel file.” PERSONNEL RECORD 1: The Administrator’s date of hire was 11/04/2021. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 2: The Director of Patient Services/Registered Nurse’s date of hire was 06/23/2021. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 3: The Medical Director’s date of hire was 12/01/2022. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 4: The Medical Director Designee’s date of hire was 05/01/2022. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 5: The Licensed Vocational Nurse’s date of hire was 05/09/2022. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 6: The Bachelor Medical Social Worker’s date of hire was 08/21/2023. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 7: The Certified Home Health Aide’s date of hire was 09/20/2021. The record lacked evidence of infection control training annually for 2024. PERSONNEL RECORD 9: The Volunteer Coordinator/Volunteer’s date of hire was 09/16/2021. The record lacked evidence of annual infection control training for 2024. PERSONNEL RECORD 12: The Master Medical Social Worker’s date of hire was 05/05/2022. The record lacked evidence of annual infection control training for 2024. During a joint record review and interview on 04/10/2025, the Administrator confirmed that the records lacked evidence of infection control education for 2024.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that nursing care and services were provided per the patient plan of care. CLINICAL RECORD 2: The patient’s date of election was 02/03/2025. The Initial Plan of Care dated 02/03/2025 documented, “RN (registered nurse) visit initial evaluation, then every 14 days thereafter for supervisory visit and plan of care update and may extend up to 21 days for ongoing comprehensive assessment and recertification assessment per schedule for skilled assessment intervention; LVN (licensed vocational nurse) one visit per week and prn (as needed).” There was no documented evidence the RN or LVN made nursing visits for the weeks of 03/09/2025-03/15/2025 and 03/16/2025-03/22/2025 (greater than 14 days). The record lacked missed or declined visit notes for this timeframe. CLINICAL RECORD 5: The patient’s date of election was 12/05/2024. The Initial Plan of Care dated 12/05/2024 documented, “RN visit initial evaluation then every 14 days thereafter for supervisory visit and plan of care update and may extend up to 21 days for ongoing comprehensive assessment and recertification assessment per schedule for skilled assessment intervention; LVN one visit per week and PRN.” There was no documented evidence the RN or LVN made nursing visits for the week here was no documented evidence of a skilled nurse visit for the weeks of 12/29/2024-01/04/2025 and 01/05/2025-01/11/2025 (greater than 14 days). The record lacked missed or declined visit notes for this timeframe. During a joint record review and interview on 04/10/2025, the Director of Patient Services/Registered Nurse confirmed that nursing visits were missing for the above timeframes.”

“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. 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, the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) records reviewed with a discharge due to death, the hospice did not ensure that bereavement services were provided to the bereaved. Agency Policy No. 2-010, Bereavement Services (revised April 2021), stated in part, “The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care... A bereavement risk assessment will be completed by the hospice social worker at the time of admission to the hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.” CLINICAL RECORD 13: The patient’s date of election was 07/08/2024. The patient died on 09/02/2024. There was no documented evidence of a bereavement POC [plan of care], declination of bereavement, or that bereavement services were provided. CLINICAL RECORD 14: The patient’s date of election was 10/12/2024. The patient died on 10/14/2024. There was no documented evidence of a bereavement POC [plan of care], declination of bereavement, or that bereavement services were provided. During a joint clinical record review and interview on 04/10/2025, the Administrator confirmed that there was no documented evidence that bereavement services were provided. The Administrator could not offer any information regarding the bereavement activities.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of a hospice aide, hired within the last three years, it was revealed that the agency did not ensure that a competency evaluation was completed by an RN prior to providing unsupervised direct patient care. PERSONNEL RECORD 8: The Home Health Aide’s date of hire was 12/11/2024. The record lacked documented evidence of a skills and competency assessment, either on a pseudo patient or actual patient, prior to being assigned unsupervised patient care. The site visitor conducted a home visit with this aide on 04/09/2025. During a joint record review and interview on 04/09/2025, the Administrator confirmed that the records did not include evidence that the employee was assessed for skills and competencies. The competency had been sent to the aide, but it had not been returned to the office.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group. CLINICAL RECORD 2: The hospice aide frequency was twice a week, starting on 02/12/2025. The record lacked evidence of aide visits for the week of 03/30/2025 to 04/05/2025. There was no documentation of the reason for missed visits or that visits were declined for this timeframe. During a joint record review and interview on 04/10/20254, the Director of Patient Services Designee/Registered Nurse confirmed that the records lacked evidence the hospice aide followed the visit frequency as ordered.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of hospice aides employed over one year, it was revealed that the agency did not ensure that the registered nurse made an annual on-site visit to observe and assess the hospice aide. PERSONNEL RECORD 7: The Hospice Aide’s date of employment was 09/20/2021. The record lacked evidence that the registered nurse made an annual on-site visit to observe and assess the hospice aide for 2022, 2023, and 2024 During a joint personnel record review and interview on 04/09/2025, the Administrator confirmed that the record lacked evidence of an annual on-site visit for 2022, 2023, and 2024. The administrator was not aware of the annual requirement.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. The document review revealed the agency did not ensure that the hospice documented the percent of the volunteer services or the cost savings achieved through volunteers. Documentation of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through March 2025 was requested by the site visitor daily. There was documentation that a volunteer was providing direct patient care, but the agency was unable to quantify the hours provided. At the time of the exit conference the agency was unable to provide documented evidence of the percent of volunteer hours or the cost savings report. During a document review and interview on 04/10/2025, the Administrator confirmed that the agency did not document the direct care staff hours, the volunteer percentage, and the cost savings from April 2024 and March 2025. The Administrator stated that the Volunteer Coordinator has a job outside of hospice and could not be interviewed. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through March 2025.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the clinical record included signed copies of the notice of patient rights and the hospice election statement. CLINICAL RECORD 14: Per the initial comprehensive assessment and documentation in the record the patient was admitted on 10/12/2024. The record lacked evidence that the patient/representative signed the notice of patient rights or the hospice election statement. The patient expired on 10/14/2024. During a joint record review and interview on 04/09/2025, the Administrator confirmed that the records lacked signed admission documents and stated that the forms were left at the patient’s location of care.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. In 6 of 14 (43%) clinical record review revealed the agency did not ensure physician orders for wound care and volunteer services. CLINICAL RECORD 1: The Nursing Update Assessment dated 03/26/2025 documented, “Patient received a visit from a wound care specialist with the following instructions: 1. Cleanse with wound cleanser; 2. Pat dry with gauze. 3. Apply Santyl on Calcium Alginate then wound bed (Santyl towards wound) 4. Cover with Silicon bordered dressing. 5. Change every day / PRN [as needed] for loss of integrity/soiling. (Q [every] Thursday).” There were no physician’s orders for the wound care. CLINICAL RECORD 2: The record contained volunteer visits on 02/24/2025 and 03/17/2025. The record lacked evidence of volunteer frequency orders. CLINICAL RECORD 3: The record contained volunteer visits on 01/23/2025, 02/11/2025, and 03/20/2025. The record lacked evidence of physician orders for volunteer services. CLINICAL RECORD 4: The record contained volunteer visits on 01/23/2025, 02/14/2025, and 03/19/2025. The record lacked evidence of physician orders for volunteer services. CLINICAL RECORD 5/Home Visit 3: During the with the Registered Nurse (RN) (Personnel Record 2) on 04/09/2025, the RN was observed to complete wound care to the right outer ankle: washed with wound cleanser, applied calcium alginate, wrapped with gauze, and secured with tape. The record lacked evidence of the wound care orders that had been performed. CLINICAL RECORD 6: The record contained volunteer visits on 01/23/2025, 02/14/2025, and 03/19/202511/18/2024, 12/11/2024, 01/14/2025, 02/18/2025, and 03/12/2025. The record lacked evidence of physician orders for volunteer services. During a joint clinical record review and interview on 04/09/2025, the Director of Patient Services Designee/Registered Nurse confirmed that the records lacked evidence of physician’s orders for wound care and volunteer services.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, in which a patient was transferred, it was revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 12: The patient’s care was transferred to another Hospice provider on 08/09/2024. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 04/10/2025, the Director of Patient Services Designee/Registered Nurse confirmed that the record lacked evidence that the discharge summary was sent to the receiving hospice.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, for discharged patients, it was revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 10: The discharge summary dated 06/24/2024 lacked documentation that the discharge summary was sent to the patient’s attending physician. During a joint record review and interview on 04/10/2025, the Administrator stated that the patient had “moved from the location but thought the patient had been readmitted the following day.” CLINICAL RECORD 11: The discharge summary dated 10/04/2024 lacked documentation that the discharge summary was sent to the patient’s attending physician. The agency was unable to present evidence that the discharge summary was sent to the physician. During a joint record review and interview on 04/10/2025, the Director of Patient Services Designee/Registered Nurse agreed that the records lacked documented evidence that the discharge summary was sent to an attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure the discharge summary included at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. CLINICAL RECORD 10: The date of the revocation was 10/04/2024. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 11: The date of the discharge was 06/24/2024. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 12: The date of the transfer was 08/09/2024. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 04/10/2025, the Director of Patient Services Designee/Registered Nurse agreed that the documentation on the discharge summary lacked a summary of the patient’s hospice stay, including treatments.”

“It is required that if no State licensing laws, certification or registration requirements exist for the profession, the following personnel qualification requirements must be met. A registered nurse (RN) is a graduate of a school of professional nursing and is currently licensed, certified, or registered in the state(s) in which they practice. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) personnel records reviewed for registered nurses revealed that the agency did not ensure that the registered nurse had a current license. PERSONNEL RECORD 11: The Registered Nurse’s license expired on 12/31/2024. On 04/08/2025, the {State} Board of Registered Nursing stated that the nursing license was delinquent. The Registered Nurse (RN) had been attending IDT [Interdisciplinary Team] meetings on 01/29/2025, 02/12/2025, 02/26/2025, 03/12/2025, and 03/26/2025. The Registered Nurse had completed an initial nursing assessment on 01/14/2025. During a joint personnel record review and interview on 04/10/2025, the Administrator confirmed that the record lacked a valid license for the RN. The Administrator stated that there was a mistake in the license for the Registered Nurse and that the {State} Board of Registered Nursing had not corrected the status. The personnel record lacked evidence of the corrective action for the license.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by interview and personnel record review. In 4 of 12 (33%) personnel records reviewed, it was revealed that the agency did not ensure that the criminal background checks were obtained within three months of the date of employment. PERSONNEL RECORD 6: The Medical Social Worker’s date of hire was 08/21/2023. The record lacked evidence of a criminal background check. PERSONNEL RECORD 8: The Home Health Aide’s date of hire was 12/11/2024. The record lacked evidence of a criminal background check. PERSONNEL RECORD 10: The Chaplain/Bereavement Coordinator’s date of hire was 09/22/2024. The record lacked evidence of a criminal background check. PERSONNEL RECORD 11: The Clinical Supervisor/Registered Nurse’s date of hire was 09/01/2024. The record lacked evidence of a criminal background check. During a joint personnel record review and interview on 04/09/2025, the Administrator confirmed that the records lacked a criminal background check within three (3) months of the date of employment. The Administrator was unsure why the background checks were not completed.”

“Based on record review and interview, the hospice agency failed to ensure correct and accurate information were maintained in the medical record of one of three sampled patients (Patient 1) when: 1. The hospice agency unethically designated a signatory for the patients admission forms. 2. The Physician Order for Life-Sustaining Treatment (POLST – a process and a form that communicates your wishes for health care treatments during a medical emergency) was not accuratey documented in the patients medical record. The cumulative effects of these failures had to the potential to compromise Patient 1s protected health information, safety, and self-determination affecting quality of life. 1) During a review of Patient 1s “;Face Sheet (FS),” dated 2/15/23, the FS indicated Patient 1 was a 78-year-old female who was admitted to the agency on 2/16/23 with a primary diagnosis of chronic systolic congestive heart failure (a condition characterized by the hearts inability to pump sufficient blood to meet the bodys needs). The FS failed to indicate the patients authorized representative or emergency contact. During a review of Patient 1s “;Admission Agreement (a legally binding contract that creates obligations for the patient, the responsible party, the sponsor and the facility),” dated 2/16/23, the patient/representative signature lines were left blank. The agreement indicated further, “;Beneficiary is unable to sign... Reason: Beneficiary is blind.” During a review of Patient 1s, “;Comprehensive Nursing Assessment,” dated 2/16/23, the “;Body System (Head-to-Toe)” section of the assessment indicated in part, “;Sensory Deficits... BLIND.” During a concurrent interview and record review, on 3/6/25 at 4:30 p.m., with the agency’s office manager (OM), a follow-up review of Patient 1s “;Admission Agreement,” dated 2/16/23 was done. A new copy of the agreement was provided by OM for further review when the representative signature line was found to have been signed. OM stated, “;I signed the patient’s caregivers name... I was told it will not look good for the agency if it (referring to the admission agreement) were left blank.” During a review of the agencys policy and procedures (P&P) titled, “;Contents of the Clinical Record,” dated 4/2021, the P&P indicated in part, “;POLICY... The clinical record will contain sufficient information to identify the patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.” 2) During a review of Patient 1s, “;POLST,” dated 2/16/23, the POLST indicated “;Do Not Attempt Resuscitation/DNR (Allow Natural Death).” During a review of Patient 1s, “;Comprehensive Nursing Assessment (CNA),” dated 2/16/23, Patient 1s “;Code Status,” indicated, “;ATTEMPT CPR/Full Code.” Further review of subsequent nursing assessments indicated the same code status. During a review of Patient 1s, “;Visit Note,” dated 2/20/23, Patient 1s “;Code Status,” indicated, “;ATTEMPT CPR/Full Code.” Further review of subsequent visit notes indicated the same code status. During a concurrent interview and record review on 3/6/25 at 5:10 p.m., with the agency Administrator (ADM), Patient 1s medical records were reviewed. ADM was informed that Patient 1s, “;POLST,” dated 2/16/23, indicated “DNR” however the rest of the patients medical records indicated “;Code Status: Attempt CPR/Full Code.” ADM acknowledged that Patient 1 was supposed be a “;DNR” but was unaware that the medical records indicated otherwise. During a review of the agencys P&P titled, “;Advance Directives,” dated 4/2021, the P&P indicated in part, “;POLICY... Valid advance directives, such as living wills, durable powers of attorney for health care, and DNR orders will be followed to the extent permitted and required by law.” The P&P indicated further, “;... 9) All clinicians providing care for the patient will: a) Review the advance directive and report any discrepancies between the directive and current treatment plan to the attending physician, clinical supervisor/nursing supervisor, and the patient.””

“Based on observation and interview, the hospice agency failed to maintain its accreditation status current and valid when it did not complete the accreditation renewal process after it expired. This failure had the potential to result in the delivery of poor standards of care to its patients due to lack of regulatory oversight. During an observation on 3/6/25 at 4:45 p.m., the agencys consumer board postings was inspected. The hospice agency was awarded accreditation (the objective evaluation process that can help health care organizations measure, assess, and improve performance in order to provide safe, high quality care for their patients) by “The Joint Commission” (a non-profit organization designated by the Centers for Medicare and Medicaid Services [CMS] to accredit health care organizations to be able to participate in the federal reimbursement program) under its “Home Care Accreditation Program.” The agencys accreditation was awarded in 9/21/18, with a notation indicating “;Accreditation is customarily valid for up to 36 months.” During an interview on 3/6/25 at 5 p.m., with the agency Administrator (ADM), ADM was asked if the agencys accreditation under The Joint Commission was renewed. ADM acknowledged that the agency’s current accreditation with The Joint Commission had expired and verbalized that it was not renewed. ADM further verbalized that there was a plan to apply for accreditation with another CMS-designated accreditation organization (AO) but has not submitted the application yet.”

“Based on record review and interview, the hospice agency failed to ensure care and services were accurately documented and implemented according to the plan of care for one of three sampled patients (Patients 1) when -Hospice Aid (HA) home visits made were not started timely as ordered in the plan of care and the reason not documented in the medical record -Registered Nurse (RN) supervisory visits were not completed. These failures had the potential to result in the inefficient delivery of care and services to Patient 1 affecting quality of life. During a review of Patient 1s “;Face Sheet (FS),” dated 2/15/23, the FS indicated Patient 1 was a 78-year-old female who was admitted to the agency on 2/16/23 with a primary diagnosis of chronic systolic congestive heart failure (a condition characterized by the hearts inability to pump sufficient blood to meet the bodys needs). The FS failed to indicate the patients authorized representative or emergency contact. During a review of Patient 1s, “;Plan of Care (POC),” dated 3/1/23, for the recertification period 2/16/23 – 5/16/23, the “;POC” indicated the home visit order, “;HA services – 2 times (2x) per week for assistance with ADLs (activities of daily living), grooming, dated 2/16/23. During a review of Patient 1s, “;All Visit Report,” dated 2/1/23 – 9/1/24 the report column labeled “;Module – HEALTH AIDE” indicated HA visits to Patient 1 were started on 8/14/23. During a review of Patient 1s “;All Visit Report,” dated 2/1/23 – 9/1/24 under the report column labeled “;Module – NURSING” indicated there were no RN supervisory visit made between 10/6/23 until the patients discharge on 8/8/24. During a concurrent interview and record review, on 3/6/25 at 12 p.m. with the agency Administrator (ADM), Patient 1s medical records were reviewed. ADM acknowledged that Patient 1s HA visits were not started until 8/14/23 which did not follow the POC order. ADM verbalized that Patient 1 declined HA services initially, but the reason was not documented in the medical record. During a review of the agencys policy and procedures (P&P) titled, “;Entries into the Clinical Record,” dated 4/2021, the P&P indicated in part, “;PROCEDURE... d) Initial plan of care, updated plans of care, initial, comprehensive and updated comprehensive assessments and clinical notes... j) Reasons for interruptions in the provision of care and services.” During a review of the agencys P&P titled, “;Plan of Care,” dated 4/2021, the P&P indicated in part, “;POLICY... The care provided to the patient must be in accordance with the plan of care. The plan of care will meet with the documentation requirements of the physician-directed medical orders and the care planning process.” During a review of the facilitys P&P titled, “;Admission Criteria and Process,” dated 4/2021, the P&P indicated in part, “;... 11) Refusal of services will be documented in the clinical record. Notification of the clinical supervisor/nursing supervisor, attending physician, and referral source will be completed and documented in the clinical record.””