Oak Creek Hospice, LLC

“It is required that the comprehensive assessment include 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. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the completion of the initial bereavement assessment within 5 days after the patient’s hospice admission. Agency Policy: The agency’s policy “Patient Assessments (PE.5), dated 09/01/2024, read in part that “...An initial bereavement assessment of the needs of the patient, family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient death will be part of the initial assessment...information gathered from the initial bereavement assessment will be incorporated into the plan of care (POC) and considered in the bereavement POC...” CLINICAL RECORD 3: The patient elected the hospice benefit on 01/16/2026. The initial Chaplain Assessment and bereavement risk assessment was completed on 01/31/2026 by the Chaplain, fifteen days after admission. The initial Interdisciplinary Group Meeting was documented on 01/27/2026, and no bereavement assessment or needs were addressed. A joint clinical record review and interview with the Director of Patient Care Services (DPCS) (Personnel Record 4) and Director of Patient Care Services Designee (DPCS-D) (Personnel Record 5) stated the current process was for the Chaplain to complete the initial bereavement assessment and that there was no back-up process in place to ensure the assessment was completed within the required 5 days if the patient/family declined chaplain services or the initial chaplain assessment was delayed.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and document review. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that each patient’s plan of care identified measurable goals of treatment for symptoms or problems being managed. Agency Policy: The agency’s policy “Plan of Care Process (PC.30)” dated 09/01/2024, included in part that “...The contents of the comprehensive assessment will identify...the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the Hospice patient’s well-being, comfort, and dignity...Data elements that allow for the measurement of outcomes, measuring, and documenting data in the same way for all patients. The data elements take into consideration aspects of care related to hospice and palliation...The data elements for each patient will be used in individual patient care planning... “ CLINICAL RECORD 1: The patient, who resided at home, elected the hospice benefit on 02/07/2026 with a terminal diagnosis of unspecified severe protein-calorie malnutrition, accompanied by comorbid congestive heart failure. During the Registered Nurse (RN) admission visit on 02/07/2026, the RN documented that the patient experienced mild exertional shortness of breath (SOB) and required as-needed oxygen therapy for comfort. At the Interdisciplinary Group (IDG) meeting on 02/10/2026, the RN further noted that the patient was mildly SOB at rest and that symptoms worsened with minimal activity, such as turning in bed. On 02/13/2026, the RN conducted an additional visit to evaluate pain and SOB. The RN documented that the pain reported the previous evening had improved with acetaminophen, and the patient rated pain as 0/10 during the visit. The patient’s respiratory rate was 20 at rest, with an oxygen saturation of 91% on room air, increasing to 94% with 2 LPM of oxygen via nasal cannula. The documentation also referenced a breathing treatment administered the previous night. The patient’s medication list included Acetaminophen 650mg every 6 hours as needed - PRN - for pain, Morphine Sulfate Concentrate 20mg/mL: 0.25-0.5mL every 2 hours PRN for moderate pain or SOB and 1.0mL every 2 hours for severe pain or SOB, DuoNeb 2.5mg-0.5mg/3mL every 6 hours PRN SOB or oxygen saturation readings less than 90%, Oxygen 2-5 LPM via NC for SOB or oxygen saturation readings less than 90%. The patient’s plan of care (POC) for the benefit period 02/07/2026–05/07/2026 did not identify a respiratory problem, did not include measurable respiratory goals, and did not document the patient’s stated comfort goal related to pain or dyspnea. CLINICAL RECORD 3: The patient, who resided in a Board & Care (B&C) facility, elected the hospice benefit on 01/16/2026 with a terminal diagnosis of diastolic congestive heart failure and a comorbid diagnosis of dementia with behavioral disturbances. During the Registered Nurse’s (RN) admission visit on 01/16/2026, the RN documented the patient as alert to self only, mildly short of breath (SOB) at rest, and receiving 3 liters per minute (LPM) of continuous oxygen via nasal cannula, with a respiratory rate of 20. The RN noted that the patient desaturated to 89–90% on room air and was noncompliant with prescribed oxygen therapy. The patient also reported chest pain with minimal exertion, rated 2/10. Psychosocial distress was documented as severe, with increased afternoon and evening anxiety/agitation, suspected to be related to sundowning. On 01/19/2026, the Social Worker (SW) documented that the patient lacked the cognitive ability to understand his illness and had a moderate psychosocial distress rating related to anxiety. At the 02/10/2026 Interdisciplinary Group (IDG) meeting, the RN reported that the patient continued to experience chest pain both with exertion and at rest, frequently refused oxygen therapy, and that Lorazepam had been effective in managing anxiety and agitation. The patient’s medication profile included Morphine Sulfate 15mg IR - give 7.5 for mild pain/sob; 15mg for severe every 4 hours as needed - PRN - for pain or SOB, DuoNeb 2.5mg-0.5mg/3mL every 6 hours PRN SOB or oxygen saturation readings less than 90%, and Lorazepam 1mg: 0.5mg for mild sob/anxiety; 1mg for moderate to severe every 4 hours PRN for SOB and/or anxiety. The plan of care (POC) for the benefit period 01/16/2026–04/15/2026 identified a respiratory problem and included goals stating the patient would “verbalize decreased episodes of SOB during activities” and that “the use of oxygen therapy would achieve and maintain the patient’s comfort and decrease episodes of SOB.” The terms “decreased” and “comfort” were not defined, not quantified, and therefore not measurable. No objective parameters (e.g., frequency of SOB episodes, oxygen saturation ranges, expected tolerance for activity, number of refusals of oxygen therapy) were included to evaluate the effectiveness of interventions. The POC identified pain as a problem with goals for the patient or family to verbalize understanding of non-verbal signs of pain, and for B&C staff to verbalize understanding and use of comfort medications. These goals addressed education, not patient-specific measurable outcomes for pain control. The POC did not include the patient’s pain goal, expected pain level, or measurable criteria for evaluating pain-related interventions. Agitation was included on the POC with the goal that the patient and/or caregiver verbalize an understanding of the medications used for anxiety/agitation. No symptom-specific, measurable goal was established for the management of the patient’s anxiety/agitation, despite recurrent documentation of severe distress, sundowning behaviors, and the use of PRN anxiolytics. CLINICAL RECORD 4: The patient, who resided at home, elected the hospice benefit on 11/20/2025 with the terminal diagnosis of malignant neoplasm of the kidney and a comorbid condition of pulmonary fibrosis. During the Registered Nurse’s (RN) visit on 01/14/2026, she documented frequent anxiety with some agitation, and the discussion of the use of comfort medications such as Lorazepam during the visit, and the first dose was administered. Crackles were noted in the patient’s left lower lobe, and the patient exhibited increased mucous production and worsening shortness of breath (SOB) and fatigue. The patient was taking Percocet three times a day with good effect. The physician’s certification of terminal illness (CTI) for the benefit period from 02/18/2026 to 05/18/2026 noted the patient’s dyspnea intermittently at rest and with mild exertion and increasing anxiety requiring treatment with medications. The patient’s medication list included Buspirone Hydrochloride 15mg three times daily for anxiety, Lorazepam: 0.5mg for mild anxiety or 1mg for severe anxiety - every 4 hours as needed - PRN - for anxiety/agitation, Percocet 5mg-325mg every 6 hours PRN pain and anxiety, and Dilaudid: 0.5mg for moderate pain/SOB or 1mg for severe pain/SOB every 2 hours PRN. A review of the patient’s plans of care (POC) for the benefit periods from 11/20/2025 to 02/17/2026 and 02/18/2026 to 05/18/2026 identified pain as a problem; however, the goals focused solely on education, stating that the patient/family would “verbalize confidence in managing the patient’s pain,” understand medication orders and side effects, and call hospice if the regimen was ineffective. The POC did not include any patient-specific, measurable symptom goals (e.g., target pain level, frequency/duration of pain episodes, response expectations to PRN medications). No parameters were identified to evaluate the effectiveness of pain interventions. Anxiety/agitation was identified as a problem, with goals for the patient/family to verbalize understanding of prescribed medications, their purpose, dosing, and side effects. The POC did not establish a measurable symptom-related goal for anxiety/agitation despite documented episodes of anxiety with agitation, PRN Lorazepam and Percocet being used for anxiety, and the CTI documentation noting increasing anxiety requiring medication. No measurable criteria (e.g., frequency of anxiety episodes, targeted reduction, effect on breathing, expected response time to medication) were included. CLINICAL RECORD 5: The patient, residing in a nursing facility (NF), elected the hospice benefit on 10/30/2025 with a terminal diagnosis of end-stage heart failure and a comorbid condition of schizophrenia. On 12/08/2025, the Registered Nurse (RN) documented that the NF reported an unwitnessed fall. During the 12/16/2025 Interdisciplinary Group (IDG) meeting, the RN noted that the patient had an ejection fraction of 17%, exhibited dyspnea on exertion and at rest, and required 3–5 liters per minute (LPM) of continuous oxygen via nasal cannula. The RN further documented that the patient became anxious when experiencing SOB and was using Lorazepam and Dilaudid for management of pain, anxiety, and SOB. At the 12/30/2025 IDG, it was reported that the patient had experienced three unwitnessed falls since the previous IDG, along with episodic anxiety and complaints of pain. On 01/13/2026, the RN documented in IDG that the patient was dependent in four of six activities of daily living (ADLs), reported consistent pain at 6/10, experienced increasing dyspnea at rest despite continuous oxygen, and had sustained four unwitnessed falls. During the RN visit on 01/31/2026, the patient was alert and oriented, reporting generalized pain at 6/10, constant chest pain, and SOB on exertion. The patient’s medication list included Gabapentin 600mg twice daily for neuropathy, Cyclobenzaprine Hydrochloride 10mg three times daily for muscle spasms, Methadone Hydrochloride 5mg twice daily for pain and Dilaudid 1mg/mL: 6mg every 4 hours as needed - PRN - for pain or SOB, DuoNeb every 6 hours PRN SOB, Duloxetine 60mg daily for depression, and Eliquis 5mg daily. No PRN medications were ordered for the patient’s anxiety symptoms; several had been placed on hold or discontinued. The patient’s plans of care for the benefit periods from 10/30/2025 to 12/28/2025 and 12/29/2025 to 02/26/2026 were reviewed. The POC identified a cardiovascular problem related to intermittent chest pain, with goals for the patient to “verbalize a decrease in episodes of SOB” and for the patient/caregiver to verbalize understanding of medications and treatment orders. Another stated goal was “patient has intermittent chest pain managed with Dilaudid as needed.” These goals were not measurable, lacked defined parameters, and did not include: baseline chest pain frequency or severity, expected reduction in symptoms, or measurable indicators of treatment effectiveness. The POC identified a respiratory problem related to heart failure, with goals for the patient to “verbalize decreased episodes of SOB” and for oxygen therapy to “achieve and maintain comfort.” Neither the patient’s baseline respiratory status nor the targeted goals for SOB management were defined. The POC did not include objective measures such as frequency or duration of SOB episodes, oxygen saturation thresholds, or expected change with treatment. Anxiety was identified as a problem related to SOB and terminal prognosis, with goals for the patient’s needs “to be met on a day-to-day basis, as communicated,” and for the patient/caregiver to verbalize understanding of medication orders and side effects. These goals addressed education, not clinical symptom management. The POC identified a safety problem related to the patient’s history of multiple unwitnessed falls, oxygen tubing, weakness, poor coordination, and SOB. Goals were limited to the patient verbalizing understanding of fall risk and use of safety interventions. The patient was taking Eliquis, increasing the risk of serious bleeding, yet no measurable fall prevention goals were included (e.g., frequency monitoring, evaluations after falls, environmental modifications). Despite documented pain at 6/10 on multiple occasions, no pain-related problem was identified on the POCs. No patient-specific pain goals (e.g., target pain score, functional impact, response to PRN medications) were included. CLINICAL RECORD 7: The patient, who resided at home, elected the hospice benefit on 03/22/2025 with a terminal diagnosis of respiratory failure with hypoxia and a secondary diagnosis of degenerative disc disease of the lumbar region with chronic lower back pain. During the Registered Nurse (RN) visit on 03/22/2025, the RN documented that the patient was uncomfortable due to pain, but no pain score was obtained, and the patient’s acceptable pain goal was not documented. The patient was also mildly dyspneic with exertion while receiving 2 liters per minute (LPM) of continuous oxygen via nasal cannula. At the 03/31/2025 Interdisciplinary Group (IDG) meeting, no information was documented or discussed regarding the patient’s pain or shortness of breath (SOB), despite these symptoms being noted during the admission visit. During the RN visit on 04/24/2025, the patient reported 7/10 back pain, and the RN noted that PRN pain medications were in place for management and effective; no objective pain goal was identified. At the 06/02/2025 IDG meeting, the RN documented that the patient remained dependent on 2–4 LPM continuous oxygen, experienced significant SOB with minimal exertion, and continued to have back pain managed with Norco PRN. No measurable goals or evaluation of symptom progression were documented. The patient’s plan of care (POC) for the benefit period from 03/22/2025 to 06/20/2025 was reviewed, and the POC identified pain as a problem, with the goal of reducing pain to below the patient’s “acceptable level” within 4 hours of admission. The patient’s acceptable pain goal was not documented, making the goal non-measurable. No baseline pain assessment (e.g., location, frequency, severity) was included. No measurable indicators were established to evaluate the effectiveness of pain interventions. Additionally, the POC identified a respiratory problem, with goals stating: the patient would have “fewer episodes of SOB,” oxygen treatment would “achieve and maintain the patient’s comfort,” and the patient would “not develop any respiratory crises.” These goals lacked measurable components: No baseline frequency or severity of SOB episodes was documented. The patient’s stated comfort goal was not documented. Terms such as “fewer episodes,” “comfort,” and “respiratory crises” were not defined, leaving no objective criteria to evaluate progress. During a joint clinical record review and interviews conducted on 02/19/2026 with the Director of Patient Care Services (DPCS) (Personnel Record 4) and the DPCS-Designee (DPCS-D) (Personnel Record 5), both leaders confirmed that there were no patient-specific, measurable goals within the reviewed plans of care. The DPCS and DPCS-D acknowledged that the agency lacks a consistent, clearly defined process for objectively measuring symptoms and documenting patient-specific, measurable goals. Both interviewees agreed that current documentation practices do not support objective measurement of progress or allow staff to determine whether the treatment plan is effectively addressing the patient’s identified needs.”

“It is required that hospice physician services are made routinely available on a 24-hour basis, seven (7) days per week. This standard was not met as evidenced by document review and interview. In 1 of 5 (20%) contracts reviewed revealed that the agency did not ensure that all contracts included contract language and that ensured the availability of all core hospice services 24 hours a day, seven days a week. CONTRACT 3: The Medical Director’s contract, effective 09/01/2021, did not include the provision requiring him to be available 24 hours a day, seven days a week. During a joint contract review and interview with the Director of Patient Care Services-Designee (DPCS-D)(Personnel Record 5) on 02/19/2026, it was revealed that the wording was not present in the agreement, and it was noted that the contract template used was in place by the previous hospice leadership and not the current template in use.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 2 (50%) home visits in facilities requiring hospice documentation revealed that the agency did not ensure that the physician’s certification and recertification of terminal illness were present in the hospice’s facility documentation or scanned into the facility’s medical record. Agency Policy: Hospice Care in a NF/SNF or ICF/IID (PC.125) 11/22/2024 The Hospice will provide the facility with the following hospice information/documentation on admission and on-going...The physician certification and recertification of the terminal illness specific to each patient. HOME VISIT 1: During the home visit on 02/19/2026, a review of the hospice patient’s facility chart revealed that the initial physician Certification of Terminal Illness (CTI) for the benefit period 10/30/2025–12/28/2025 and the physician recertification CTI for the benefit period 12/29/2025–02/26/2026 were absent from the facility’s hospice documentation. The Social Worker (Personnel Record 6) was asked to locate the documents and confirmed that neither certification nor recertification was present in the facility’s hospice binder. The nursing facility’s Social Worker then accessed the patient’s electronic medical record within the facility system, and a review of all scanned documents again confirmed that the CTIs were not uploaded or available in the facility records. Following this review, the hospice faxed the physician recertification CTI (12/29/2025–02/26/2026) to the facility, and it was subsequently placed in the hospice binder; however, the initial CTI for 10/30/2025–12/28/2025 remained missing from all facility-held documentation.”