Seva Hospice, Inc.

“Based on interview and record review the agency failed to provide services consistent with patient and family needs for one of three sampled patients (Patient 1), when Patient 1’s family was not notified of her death. This failure resulted in Patient 1’s family not being aware of her death until six hours after it occurred. A review of Patient 1’s clinical document titled, “PATIENT PROFILE,” indicated that Patient 1 was admitted to hospice services while residing in a skilled nursing facility (SNF, facility that provides 24-hour medical care). The document further indicated that Family Member (FM) 1 was Patient 1’s emergency contact.A review of an email correspondence from FM 1, dated 8/15/25 at 6:50 PM, indicated FM 1 had been present at Patient 1’s bedside until 12:30 AM on 8/15/25. The email further indicated that FM 1 left the facility and returned at 9:45 AM to discover Patient 1 had died at 3:37 AM and FM 1 had not been contacted.A review of Patient 1’s clinical document titled, “HOSPICE DEATH REPORT SUMMARY/MEDICATION DISPOSAL,” dated 8/15/25 at 4:30 AM, indicated, “…Time of Death: 3:36 AM…Family/Caregiver…Family/Caregiver’s emotional reaction to patient’s death…Family members not present, per facility staff…family members at bedside already went home…”During an interview on 1/23/26 at 10:50 AM with skilled nurse (SN) 1, SN 1 stated she did not notify the family of Patient 1’s death because the facility staff indicated the family was present at the time of death. During an interview on 1/23/26 at 11:41 AM with the Director of Patient Care Services (DPCS), the DPCS stated the agency’s protocol when a patient has died in a facility included, the SN went to the facility and ensured the family was informed of the death.The DPCS stated it was her expectation that the SN would have contacted the family to report the death and offered condolences. The DPCS stated that the family of Patient 1 was distressed when they were not notified of Patient 1’s death.A review of an agency policy titled, “DEATH AT SKILLED NURSING FACILITY,” dated 2003, indicated, “…It is anticipated that hospice patients will die in a skilled nursing facility…The family/caregiver may require skilled nursing intervention, psychosocial support, and practical assistance during the time immediately surrounding the death…Following the notification of a patient’s approaching or actual death, the nurse…will assist the family/caregiver…””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 6 of 6 (100%) home visits revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 08/27/2025 for a diagnosis of hemiplegia following cerebral infarction. The patient resided in an assisted living facility (ALF). During Home Visit 1 with the spiritual counselor (Personnel Record 6) on 09/15/2025, the hospice medication profile (printed on 09/15/2025 was compared to the ALF medication profile (printed on 09/15/2025). The following medications were listed on the hospice medication profile and were not listed on the ALF medication profile: Lorazepam 0.5 mg, give 1 tablet every 4 hours as needed (ordered 08/27/2025). The following medications were listed on the ALF medication profile and not on the hospice profile: “Aspirin 81 mg, take 1 tablet daily (ordered 02/18/2024), Potassium 10 mEq, take 1 capsule daily (ordered 08/04/2025), Docusate 100 mg, take 1 daily as needed (ordered 03/12/2024), Oxycodone 5-325 mg, take 1 tablet every 6 hours as needed (ordered 07/05/2025). The dates of the last nursing visits were on 09/10/2025 by a registered nurse (RN) and 09/16/2025 by an licensed vocational nurse (LVN). There was no documented evidence that the most recent RN or LVN visit included a medication review. Home Visit 2: The patient elected the hospice benefit on 07/23/2025 for a diagnosis of chronic obstructive pulmonary disease. The patient resided in an assisted living facility (ALF). During the home visit with the hospice aide ( Personnel Record 7) on 09/16/2025, the hospice medication profile (printed on 09/15/2025 was compared to the ALF medication profile (printed on 09/16/2025). The following medications were listed on the ALF medication profile and not on the hospice profile: “Preversion, take 1 capsule daily (ordered 09/06/2025).” The following medication discrepancies were noted: Hospice had Polyvinyl alcohol/Providine 1.4/0.6%, instill 1 drop in eyes daily as needed (ordered 07/24/2025) and the ALF had Polyvinyl alcohol/Providine 1.4/0.6%, instill 1 drop in eyes every 2 hours as needed (ordered 07/31/2025); Hospice had Bisacodyl 10 mg suppository, insert 1 every 72 hours as needed (ordered 07/23/2025) and the ALF had Bisacodyl 10 mg suppository, insert 1 daily as needed (ordered 05/31/2024). The date of the last nursing visit was on 09/11/2025 by an RN. There was no documented evidence that the most recent RN visit included a medication review. Home Visit 3: The patient elected the hospice benefit on 06/10/2025 for a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). During the home visit with the licensed vocational nurse (LVN)(Personnel Record 4) on 09/16/2025, the hospice medication profile (printed on 09/15/2025) was compared to the SNF medication profile (printed on 09/16/2025). The following medications were listed on the hospice medication profile and were not listed on the SNF medication profile: Lorazepam 0.5 mg, give 1 tablet every 4 hours as needed (ordered 07/23/2025). The following medications were listed on the SNF medication profile and were not listed on the hospice medication profile: The following discrepancies were noted: Hospice had Acetaminophen 325 mg tablets, take 2 tablets every 6 hours as needed (ordered 07/23/2025) and SNF had Acetaminophen 325 mg tablets, take 2 tablets every 4 hours as needed (ordered 07/23/2025). “ The date of the last nursing visits were 09/11/2025 by RN and 09/15/2025 by LVN. There was no documented evidence that the most recent RN or LVN visit included a medication review. Home Visit 4: The patient elected the hospice benefit on 04/11/2025 for a diagnosis of squamous cell carcinoma of the skin. The patient resided in a board and care. During the home visit with the RN (Personnel Record 8) on 09/16/2025, the hospice medication profile (printed on 09/15/2025) was compared to the board and care medication profile (printed on 09/16/2025). The following medications were listed on the hospice medication profile and were not listed on the board and care medication profile: “Voltaren 1%, apply three times daily as needed (ordered 05/13/2025); Omeprazole 20 mg, take 1 daily (ordered 08/05/2025); Morphine 15 mg, take 1/2 tablet twice daily (ordered 08/21/2025).” The board and care medication profile listed the following medications not listed on the hospice profile: “Aspirin 81 mg, 1 tablet daily (ordered 06/13/2025); Famotidine 10 mg, 1 tablet twice a day (ordered 06/06/2025); Metformin 500 mg, 1 tablet twice daily (ordered 06/04/2025); Vitamin C 500 mg, 1 tablet daily (ordered 06/13/2025). The following discrepancies were noted: Hospice had Escitalopram 20 mg, 1 tablet daily (ordered 08/21/2025) and the board and care had Escitalopram 10 mg, 1 tablet daily (ordered 06/13/2025). The last nursing visit was 09/11/2025 by RN. There was no documented evidence that the most recent RN visit included a medication review. Home Visit 5: The patient elected the hospice benefit on 07/02/2024 for a diagnosis of chronic obstructive pulmonary disease. The patient resided in an assisted living facility (ALF). During the home visit the social worker (SW)(Personnel Record 5) on 09/16/2025, the hospice medication profile (printed on 09/15/2025 was compared to the ALF medication profile (printed on 09/16/2025). The following medications were listed on the hospice medication profile and were not listed on the ALF medication profile: Milk of Magnesia 400mg/5ml, give 30 ml daily as needed (ordered 08/30/2025), Lorazepam 0.5 mg, give 1 tablet every 4 hours as needed (ordered 07/02/2024) The last nursing visits were 09/09/2025 by an RN and 09/14/2025 by LVN. There was no documented evidence that the most recent RN or LVN visit included a medication review. Home Visit 6: The patient elected the hospice benefit on 06/23/2025 for a diagnosis of hypertensive heart disease. The patient resided in a skilled nursing facility. During the home visit with the aide (Personnel Record 9) on 09/17/2025, the hospice medication profile (printed on 09/15/2025) was compared to the SNF medication profile (printed on 09/17/2025). The following medications were listed on the hospice medication profile and were not listed on the SNF medication profile: “Prochlorperazine, 1 tablet as needed (ordered 07/06/2025); Nystatin powder, apply every shift (ordered 09/02/2025). The SNF medication profile included the following medications which were not listed on the hospice medication profile: “ Fleet enema, 1 daily as needed (ordered 07/01/2025); Milk of magnesia 1200 mg/5 ml, give 30 ml daily as needed (ordered 07/01/2025). The last nursing visits were 09/12/2025 by RN and 09/16/2025 by LVN. There was no documented evidence that the most recent RN or LVN visit included a medication review. A joint clinical record review and interview was conducted with the Vice President of Clinical Operations (Personnel Record 3) on 09/18/2025 in which the discrepancies were confirmed, and she said their policy was “reconciliations at a minimum of every 2 weeks but they preferred every visit.””

“It is required that written patient care instructions for a hospice aide are prepared by a registered RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 23 (26%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 3: The hospice aide care plan dated 07/23/2025 included the following relevant tasks: “Bed bath-complete, skin care-moisturize, apply barrier cream as directed, check pressure areas, hair care, shampoo, peri care, foot care, clean/file nails, assist with dressing, shave-when requested, patient/family emotional support, date of last BM (bowel movement), incontinence care (apply briefs), catheter care, empty urine bag, assist with feeding, encourage fluids tidy/clean patient area, change bed linens, equipment care, bed in low position, oxygen precautions, review care with facility nurse, reposition every two hours, ROM (range of motion).” All tasks were to be completed every visit. Aide frequency of twice weekly. The initial nursing assessment dated 07/23/2025 included the following notations: “DTI (deep tissue injury) to both heels. Use heel protectors.” A nursing assessment dated 08/18/2025 noted the following: “Left heel wound. Cleanse with betadine, cover with dry dressing. Right heel wound. Cleanse with betadine, cover with dry dressing.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. The hospice aide care plan did not provide the aide with notification of the heel protectors or instructions for them during tasks. CLINICAL RECORD 4: The hospice aide care plan dated 04/11/2025 included the following relevant tasks: “Bed bath-complete, skin care-moisturize, check pressure areas, hair care, shampoo, peri care, foot care, assist with dressing, transfer assist-chair, bed, patient/family emotional support, date of last BM (bowel movement), incontinence care (apply briefs), tidy/clean patient area, change bed linens, equipment care, bed in low position, maintain safe, clean environment, reposition.” The hospice aide care plan revision dated 06/05/2025 changed the “bed bath to shower via shower chair”, added “apply barrier cream as directed, added clean/file nails, added assist with ambulation, added assist with toileting, bedpan/urinal, encourage fluids, review care with facility nurse, and ROM (range of motion).” The hospice aide care plan revision dated 09/02/2025 added “weight every visit.” All tasks were to be completed every visit. Aide frequency of twice weekly. A nursing assessment dated 04/11/2025 included the following notations: “Use heel protectors.” A nursing assessment dated 04/29/2025 included the following notations: “skin tear to left elbow, apply xeroform.” A nursing assessment dated 06/12/2025 noted the following: “skin tears to RFA (right forearm) cleanse with NS (normal saline) or wound cleanser, pat dry, cover with xeroform gauze then dry dressing 2x/week and PRN (as needed). The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. The hospice aide care plan did not provide the aide with notification of the heel protectors or instructions for them during tasks. CLINICAL RECORD 15: The hospice aide care plan dated 03/30/2025 included the following relevant tasks: “Bed bath, skin care-moisturize, apply barrier cream as indicated, check pressure areas, hair care, shampoo, peri care, foot care, clean/file nails, assist with dressing, transfer assist, patient/family emotional support, date of last BM (bowel movement), incontinence care (apply briefs), tidy/clean patient area, change bed linens, equipment care, bed in low position, oxygen precautions, reposition every two hours, ROM (range of motion). An update on 06/16/2025 added “encourage fluids.” All tasks were to be completed every visit and the hospice aide visit frequency was twice weekly. A physician order dated 04/23/2025 noted the following: “right lateral heel open wound: cleansed with wound cleanser, pat dry and cover with foam dressing. Please keep pressure relieving boot on at all times.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. The hospice aide care plan did not provide the aide with notification of the heel protectors or instructions for them during tasks. CLINICAL RECORD 16: The hospice aide care plan dated 12/09/2024, reviewed 02/25/2025, and 05/23/2025 included the following relevant tasks: “Bed bath-complete, skin care-moisturize, apply barrier cream as indicated, check pressure areas, hair care, shampoo, peri care, foot care, clean/file nails, assist with dressing, transfer assist, patient/family emotional support, date of last BM (bowel movement), incontinence care (apply briefs), catheter care, empty urine bag, encourage fluids, tidy/clean patient area, change bed linens, reposition every two hours, ROM (range of motion).” An update on 06/16/2025 added “encourage fluids.” All tasks were to be completed every visit and the hospice aide visit frequency was twice weekly. A nursing visit dated 05/23/2025 noted: “Patient has Stage IV pressure ulcer on coccyx. Patient has developed 9 Stage I, Stage II and unstageable pressure ulcers on the left side of body and leg.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing(s) became soiled, dislodged, or wet. CLINICAL RECORD 19: The hospice aide care plan revision dated 02/26/2024 included the following relevant tasks: “Assist with ambulation-as needed; change bed linen-once a week and PRN (as needed).” The hospice aide care plan revision dated 03/06/2024 included the following relevant tasks: “Assist with ambulation-as needed; assist with toileting-as needed.” The hospice aide care plan revision dated 04/24/2024 included the following relevant tasks: “Assist with ambulation-PRN (as needed); assist with toileting-as needed.” The hospice aide care plan revision dated 06/26/2024 included the following relevant tasks: “Assist with ambulation-PRN (as needed); transfer assist-PRN (as needed); assist with toileting-PRN (as needed); prepare meals-PRN (as needed); change bed linens-weekly and PRN (as needed).” The hospice aide care plan revision dated 08/22/2024 included the following relevant tasks: “Bed bath-complete; shower-use shower chair every visit.” The hospice aide care plan revision dated 10/24/2024 included the following relevant tasks: “Complete bed bath and shower every visit.” The hospice aide frequency was three times weekly. These aide care plans did not provide the aide with specific instructions regarding the bath type to be given. They also did not give the aide specific instructions for the tasks labeled “as needed” by not giving them a specific frequency to complete these tasks. CLINICAL RECORD 23: The hospice aide care plan dated 07/17/2025 included the following relevant tasks: “shower-use shower chair, skin care-moisturize, apply barrier cream as directed, check pressure areas, hair care, shampoo, peri care, foot care, clean/file nails, assist with dressing, transfer assist-chair, bed, shower, patient/family emotional support, date of last BM (bowel movement), assist with toileting, incontinence care (apply briefs), encourage fluids, tidy/clean patient area, equipment care, bed in low position, maintain safe, clean environment.” All tasks were to be completed every visit. Aide frequency of twice weekly. A physician’s order dated 07/29/2025 noted the following: “Buttock wound. Cleanse with NS (normal saline), pat dry with dry gauze, skin prep and cover with Opti foam.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. A joint clinical record review and interview was conducted with the Vice President of Clinical Operations (Personnel Record 3) on 09/18/2025, in which she agreed the aides “should have only one bath type assigned unless they have specific instructions and the wounds need more details added for the aides.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure hospice aide provided services included in the plan of care. CLINICAL RECORD 9: The hospice aide care plan dated 08/22/2025 included the relevant tasks of “shower, oral care, shampoo, peri care and foot care.” All tasks are to be completed every visit. Aide frequency of twice weekly. The hospice aide visit dated 09/02/2025 noted the following: “Shower. Only Fridays” The hospice aide visit dated 09/09/2025 noted: “Shower. NA (not applicable) not today.” The hospice aide visit dated 09/16/2025 noted “NA (not applicable)” to the following tasks: “shower, oral care, shampoo, peri care and foot care.” CLINICAL RECORD 10: The hospice aide care plan dated 04/04/2025 included the relevant task of “bed bath (complete).” All tasks are to be completed every visit. Aide frequency of twice weekly. The aide visit dated 08/26/2025 noted “shower.” A joint clinical record review and interview was conducted with the Vice President of Clinical Operations (Personnel Record 3) on 09/18/2025 in which she agreed the aides did not complete the tasks as assigned in the care plan(s).”

“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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the patient’s discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 19: The patient was discharged for extended prognosis on 11/19/2024. The discharge summary dated 11/19/2024 noted “no longer terminally ill.” It did not include at least a summary of the patient’s hospice stay including treatments, symptoms and pain management. CLINICAL RECORD 20: The patient elected to revoke the hospice benefit on 12/19/2024. The discharge summary dated 12/19/2024 did not include at least a summary of the patient’s hospice stay including treatments, symptoms and pain management. The section under “care summary (including summary of patient’s stay including treatments, symptoms and pain management)” is blank. A joint clinical record review and interview was conducted with the Director of Quality on 09/18/2025 in which he confirmed the discharge summaries needed to be completed per the templates and they currently had a performance project (started July 2025) regarding discharge summaries.”