Compassionate Hospice Care, Inc.

“Based on interviews and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process) of Patient was met as follows: The Hospice failed to ensure the initial bereavement assessment was conducted for a thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process for six of fourteen sampled patients (Patient 2, Patient 3, Patient 5, Patient 6, Patient 10 and Patient 12). This deficient practice has the potential to result in the patient’s family members’ social, spiritual, cultural, and emotional bereavement needs will not be evaluated before and after the patient passes away that may impact their ability to cope with the patient’s death. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patients to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the initial bereavement assessment was conducted for a thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process for six of fourteen sampled patients (Patient 2, Patient 3, Patient 5, Patient 6, Patient 10 and Patient 12). This deficient practice has the potential to result in the patient’s family members’ social, spiritual, cultural, and emotional bereavement needs will not be evaluated before and after the patient passes away that may impact their ability to cope with the patient’s death. Findings:1. FOR PATIENT 22. FOR PATIENT 33. FOR PATIENT 54. FOR PATIENT 65. During a review of Patient 10’s clinical record titled “Patient Information” (summary of patient’s basic information), the “Patient Information” indicated Patient 10 had a start of care (SOC) on 12/17/2025 with diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities)During a concurrent interview and record review on 7/27/2026 at 12:52 pm with the DPCS, Patient 10’s clinical record titled “Comprehensive Nursing Assessment”, dated 12/17/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated that Patient 10 and Patient 10’s family appeared fear, hopelessness, and/or struggling with meaning of illness. The DPCS stated that the bereavement coordinator should assess the needs and concerns of Patient 10’s family in preparation for the period following their loss.During a During a concurrent interview and record review on 7/27/2026 at 12:54 pm with the DPCS, Patient 10’s clinical record titled “History of Bereavement Assessment”, for the period of 12/17/2025 to 8/13/2026 was reviewed. The DPCS stated that “History of Bereavement Assessment” did not contain any information a bereavement assessment was completed. The DPCS stated bereavement assessment should be completed within 72 hours of Patient 10’s SOC. The DPCS stated that the inability to assess Patient 10 and Patient 10’s family’s bereavement status may result in failing to recognize and address the family’s emotional needs and support. 6. During a review of Patient 12’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 12 had a SOC on 12/17/2025 with diagnosis of diffuse large B-cell lymphoma (fast growing type of cancer in the blood).During a concurrent interview and record review on 7/27/2026 at 12:47 pm with the DPCS, Patient 12’s clinical record titled “Comprehensive Nursing Assessment”, dated 12/26/2025 was reviewed. The “Comprehensive Nursing Assessment” indicated that Patient 12 and Patient 12’s family needed bereavement coordinator to complete the initial bereavement assessment within five days of Patient 12’s SOC. The DPCS stated that the bereavement coordinator should assess the needs and concerns of Patient 12’s family in preparation for the period following their loss.During a During a concurrent interview and record review on 7/27/2026 at 12:49 pm with the DPCS, Patient 12’s clinical record titled “History of Bereavement Assessment”, for the period of 12/26/2025 to 2/18/2026 was reviewed. The DPCS stated that “History of Bereavement Assessment” did not contain any information a bereavement assessment was completed. The DPCS stated bereavement assessment should be completed within 72 hours of Patient 12’s SOC. The DPCS stated that the inability to assess Patient 12 and Patient 12’s family’s bereavement status may result in failing to recognize and address the family’s emotional needs and support. During a review of HA’s policies and procedures (P&P), titled “Bereavement Assessment”, revised on October 2019, the P&P indicated the following: - On admission, the social worker of hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. The bereavement coordinator will review the risk assessment to determine potential needs of the survivors.- bereavement coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment.During a review of HA’s P&P titled “Bereavement Services”, updated on October 2019, the P&P indicated the following:- Depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact or provide supportive counseling to the patient and family/caregiver prior to patient’s death.- A bereavement file will be maintained on each unit of care that will contain all the bereavement assessments made and clinical notes. 1.During a review of Patient 2’s clinical record titled “Patient Information” (summary of patient’s basic information), the “Patient Information” indicated Patient 2 had a start of care (SOC) on 11/28/2025 with diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), unspecified. During an interview on 7/27/2026 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that completing Patient 2’s Initial Bereavement Assessment is essential. The DPCS explained that failure to assess Patient 2 and the family’s bereavement status may result in the hospice not identifying or addressing the family’s emotional support needs related to the patient’s imminent death. During a concurrent interview and record review conducted on 7/27/2026 at 12:41 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 2’s Initial Bereavement Assessment had not been completed. The DPCS further stated that the assessment should have been completed even if the family declined bereavement services, as it helps identify what additional resources and support may be needed by Patient 2’s family. 2. During a review of Patient 3’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 3 had a SOC on 3/8/2025 with diagnosis of Chronic obstructive pulmonary disease (a long-term lung problem that makes it to breathe, causes a lasting cough, and makes you feel very tired). During an interview conducted on 7/27/2026 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 3’s Initial Bereavement Assessment is essential and had not been completed. The DPCS further stated that failing to assess Patient 3 and the family’s bereavement status may result in the hospice not identifying or addressing the family’s emotional support needs related to the patient’s imminent death. During a concurrent interview and record review conducted on 7/27/2026 at 12:43 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 3’s Initial Bereavement Assessment had not been completed. The DPCS further stated that the Initial Bereavement Assessment should have been completed even if the family declined bereavement services, as the assessment helps identify what additional resources or support may be needed for Patient 3’s family. 3. During a review of Patient 5’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 5 had a SOC on 6/30/2026 with diagnosis of Liver cell carcinoma (is the most common type of primary liver cancer {a disease where abnormal cells grow out of control, ignore normal body rules, and can spread to other parts of the body} it happens when the main cells of the liver start to grow out of control and form a harmful tumor {an abnormal lump or mass of tissue in the body}). During an interview on 7/27/2026 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that completing Patient32’s Initial Bereavement Assessment is essential. The DPCS explained that failure to assess Patient 2 and the family’s bereavement status may result in the hospice not identifying or addressing the family’s emotional support needs related to the patient’s imminent death. During a concurrent interview and record review conducted on 7/27/2026 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 3’s Initial Bereavement Assessment had not been completed. The DPCS further stated that the Initial Bereavement Assessment should have been completed even if the family declined bereavement services, as the assessment helps identify what additional resources or support may be needed for Patient 5’s family. 4. During a review of Patient 6’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 6 had a SOC on 12/20/2025 with diagnosis of Malignant (the growth is cancerous {an abnormal of cells that grow out of control, can harm healthy body parts, and can spread to other areas of the body} neoplasm {a new and abnormal growth of tissue} of the stomach. During an interview on 7/27/2026 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that completing Patient32’s Initial Bereavement Assessment is essential. The DPCS explained that failure to assess Patient 2 and the family’s bereavement status may result in the hospice not identifying or addressing the family’s emotional support needs related to the patient’s imminent death. During a concurrent interview and record review conducted on 7/27/2026 at 12:39 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 3’s Initial Bereavement Assessment had not been completed. The DPCS further stated that the Initial Bereavement Assessment should have been completed even if the family declined bereavement services, as the assessment helps identify what additional resources or support may be needed for Patient 6’s family.”

“Based on concurrent interview and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure that two missed visits for one of fourteen patients (Patient 4), on 12/12/2025 and 12/19/2025, were communicated to the interdisciplinary group (IDG – the team {core group} of professionals who work together to make sure your loved one gets well‑rounded, compassionate care that meets to coordinate and update the patient’s care plan) during the 12/23/2025 IDG meeting. This failure prevented the IDG from making informed decisions, delaying symptom management, medication adjustments, caregiver support, and other interventions, and comfort measures necessary to ensure continuity and quality of hospice care, including the patient’s untimely death. During a review of Patient 4’s clinical record titled “Patient Information” (summary of patient’s basic information), the “Patient Information” indicated Patient 4 had a start of care (SOC – the date the service started with the agency) on 5/10/2025 with diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), unspecified. During a record review of Patient 4’s “Visit Note”, dated 12/12/2025, the “Visit Note” indicated, Patient 4 declined the skilled nurse (SN) visit. There was documented evidence of the patient’s reason to refuse the SN visit. During a record review of Patient 4’s “Visit Note”, dated 12/19/2025, the “Visit Note” indicated, Patient 4 declined the SN visit. There was documented evidence of the patient’s reason to refuse SN visit. During a record review of Patient 4’s “POC/IDG Review - Cert# 3”, dated 12/23/2025, the “POC/IDG Review - Cert# 3” indicated, Patient 4’s declined SN visits were not communicated to the IDG during the meeting on 12/23/2025. During the record review of Patient 4’s “POC/IDG Review – Cert #3” dated 12/23/2025, the “POC/IDG Review – Cert #3” indicated, Patient 4’s SN declined visits on 12/12/2025 and 12/19/2025 were not communicated to the IDG team. During a concurrent interview and record review on 7/27/2026 at 1:56 p.m. with the Director of Patient Care Services (DPCS - senior nurse leader in charge of making sure hospice patients get safe, effective, and well-coordinated care in their last stages of life), Patient 4’s “POC/IDG Review – Cert #3” did not reflect that the two declined visits were presented or discussed during the 12/23/2025 IDG meeting. As a result, the IDG team, including the medical doctor, remained unaware of the declined visits, no interventions were initiated, and the patient’s plan of care was not updated accordingly. During a review of the facility’s policy and procedures (P&P) titled, “Missed Visits,” dated October 2019 indicated the following:Policy: Missed visits will be communicated to the interdisciplinary Group at the IDG meeting. A missed will be rescheduled the same week if possible. Missed visits documented in the clinical record. Procedure: 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and the clinical supervisor of the missed visit and the reason for missed visit.4. The clinical supervisor will track the number and reasons for the missed visits to assess patterns and to assure that the plans of care contain the correct the correct number of planned visits.5. If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with the input from the patient and Medical Director.”

“Based on concurrent interview and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the patients’ health record included completed post-death bereavement assessments for two of fourteen patients (Patient 6 and Patient 7). This gap in documentation will result in the lack of coordination among the hospice care teams to meet the social, cultural, or spiritual needs among the surviving family members, leading to prolonged or complicated grief and negatively impacting their overall emotional well‑being. 1. During a review of Patient 6’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 6 had a Start of Care (SOC – the date service started with the agency) on 12/20/2025 with diagnosis of Malignant (the growth is cancerous {an abnormal of cells that grow out of control, can harm healthy body parts, and can spread to other areas of the body} neoplasm {a new and abnormal growth of tissue} of the stomach, unspecified. During a review of Patient 6’s “Post-Death Bereavement Assessment”, the “Post-Death Bereavement Assessment” was not completed following patient’s death on 12/31/2025. During a concurrent interview and record review on 7/27/2026 at 12:54 p.m. with the Director of Patient Care Services (DPCS - senior nurse leader in charge of making sure hospice patients get safe, effective, and well-coordinated care in their last stages of life), Patient 6’s clinical record titled “Post‑Death Bereavement Assessment” was reviewed following the patient’s death on 12/31/2025. The DPCS stated the assessment was not completed and explained it should have been finalized within 72 hours of the patient’s death. The DPCS further stated that failing to assess the family’s bereavement needs may prevent the agency from identifying appropriate resources and support, regardless of whether the family declined bereavement services. 2. During a review of Patient 7’s clinical record titled “Patient Information”, the “Patient Information” indicated Patient 7 had a SOC on 7/2/2025 with diagnosis of Unspecified (the reason is not clear) cirrhosis (damaged for a long time, and as it tries to heal, it forms scar tissue, scarred poorly) of the liver. During a review of Patient 7’s “Post-Death Bereavement Assessment”, the “Post-Death Bereavement Assessment” was not completed following Patient 7’s death on 8/2/2025. During a concurrent interview and record review on 7/27/2026 at 12:54 p.m., with the DPCS, Patient 7’s clinical record titled “Post‑Death Bereavement Assessment” was reviewed following the patient’s death on 8/2/2025. The DPCS stated the assessment was not completed and explained it should have been finalized within 72 hours of the patient’s death. The DPCS further stated that failing to assess the family’s bereavement needs may prevent the agency from identifying appropriate resources and support, regardless of whether the family declined bereavement services. During an interview on 7/27/2026 at 1:04 p.m. with the Administrator (ADM - team leader, organizer of a hospice program, and ensures the hospice agency operates well, follows the rules, and delivers caring, coordinated end-of-life support to patients and their families), the ADM stated that the agency is required to complete a post‑death bereavement assessment for every patient who dies under the agency’s care to ensure continuity of support and appropriate interventions throughout the family’s grieving process. During a review of HA’s policies and procedures (P&P), titled “Bereavement Assessment”, revised on October 2019, the P&P indicated the following:After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment.The Bereavement Coordinator will document the interventions on the bereavement services checklist. All bereavement documentation will be submitted for filling in the patient’s permanent clinical record. During a review of HA’s P&P titled “Bereavement Services”, updated on October 2019, the P&P indicated the following:After death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the interdisciplinary group meeting. The bereavement interventions will reflect the family/caregiver’s choices to participate in the bereavement program. Bereavement assessment and clinical notes will be submitted to the patient’s permanent clinical records.”