Amari Hospice Care Inc.

“Based on interview and record review, the agency failed to ensure the Interdisciplinary Team’s (IDT - a collaborative group who work together to achieve a shared goal) responsibilities for coordinating and supervising services were maintained in accordance with the agency’s policies and procedures for five of seven sampled patients (Patient 1, Patient 2, Patient 3 Patient 4, and Patient 5) when Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 were discharged without appropriate indication, no discharge planning, and no coordination with the IDT.This failure had the potential to result in unmet care needs for Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5. During a review of Patient 1’s Plan of Care (POC), dated 7/17/26, the POC indicated Patient 1 had a Start of Care (SOC) date of 10/4/24 with diagnosis of Malignant neoplasm of overlapping sites of left female breast (a tumor originated in more than one quadrant of the left breast where the exact single point of origin cannot be distinctly identified). The POC further indicated Patient 1 had an End of Care (EOC - discharge date) date of 7/17/26.During a review of Patient 1’s Discharge Summary (DS - a comprehensive clinical document that summarizes a patient’s stay with the agency), dated 7/18/26, the DS indicated, “…Reason for Discharge: Patient goals not met…Discharge executed per agency directive from management, with all palliative [focused on relieving the symptoms, pain, and stress of serious illnesses to improve quality of life by prioritizing comfort] symptom and psychosocial goals remaining completely unmet…this writer was directed by management to terminate services immediately, outside of and prior to the regularly scheduled monthly IDT meeting held on the last Tuesday of the month…Case closed under administrative mandate with goals unmet…”During a review of Patient 2’s POC, dated 7/17/26, the POC indicated Patient 2 had a SOC date of 1/7/24 with diagnosis of malignant melanoma of skin (skin cancer). The POC further indicated Patient 2 had an EOC date of 7/17/26.During a review of Patient 2’s DS, dated 7/18/26, the DS indicated, “…Reason for Discharge: Patient goals not met…Palliative care goals remain completely unmet due to an abrupt transition, an unestablished relationship with her new oncologist (cancer physician), an unresolved high-risk biopsy [test to check cells if growth or illness is harmful, safe, of if it is cancer] plan, and an active, uninvestigated mandibular mass [abnormal growth in the jaw]… Case closed with palliative goals unmet…”During a review of Patient 3’s POC, dated 7/16/26, the POC indicated Patient 3 had a SOC date of 12/31/25 with diagnosis of Burkitt lymphoma of the intraabdominal lymph nodes (a fast-growing cancer that forms in the lymph glands inside the abdomen). The POC further indicated Patient 3 had an EOC date of 7/16/26.During a review of Patient 3’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…being discharged from palliative care services today due to an administrative transition…Palliative goals of care were not met prior to this discharge…”During a review of Patient 4’s POC, dated 7/16/26, the POC indicated Patient 4 had a SOC date of 8/12/25 with diagnosis of Alcoholic cirrhosis of liver (permanent scarring of liver tissue caused by prolonged, heavy alcohol drinking). The POC further indicated Patient 4 had an EOC date of 7/16/26.During a review of Patient 4’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…Despite meeting clinical indicators for ongoing supportive care…[Patient 4] is currently being discharged from palliative care services…”During a review of Patient 5’s POC, dated 7/16/26, the POC indicated Patient 5 had a SOC date of 11/22/24 with diagnosis of Atelectasis (partial or complete lung collapse). The POC further indicated Patient 5 had an EOC date of 7/16/26.During a review of Patient 5’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…Palliative and restorative goals of care were not fully met prior to this discharge due to patient’s ongoing clinical decline and severe, persistent room-air hypoxia (tissues do not get enough oxygen to work normally)…”During a concurrent interview and record review on 7/22/26 at 12:02 p.m. with the Administrator (ADM), the ADM stated patients are discharged if care goals are met, and if these goals are not met, the patient is kept within the agency. The ADM reviewed the list of discharged palliative patients and confirmed Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5’s discharge reasons indicated, “Patient goals not met” and stated she was not aware of the discharges until the Department pointed them out. During an interview on 7/22/26 at 2:40 p.m. with the Director of Patient Care Services (DPCS), when asked about the agency’s discharge process, the DPCS stated nurses evaluate and discuss the findings with the IDT if a patient is going to be discharged or not. The DPCS confirmed Patient 1, Patient 2, Patient 3, Patient 4, Patient 5’s discharge summaries indicated care goals for the patients were not met. The DPCS acknowledged that discharge planning was not done related to the discharges, and the patients were discharged without discussing the patients’ status with the IDT. The DPCS stated patients should not be discharged if the care goals are not met. The DPCS further stated that a case conference should have been done for each patient, and the IDT was supposed to make a discharge plan.During a review of the agency’s policy and procedure (P&P) titled “DISCHARGE FROM THE PALLIATIVE CARE PROGRAM,” revised 7/2021, the P&P indicated, “…The organization will provide service to a patient and family/caregiver as long as the patient meets the criteria for palliative care services…Discharge Criteria…1. The palliative care team, in collaboration with the physician determines that the patient no longer meets the criteria to receive palliative care services. Goals of care have been established, communicated, and are being appropriately managed by the ongoing healthcare team…2. The patient’s symptoms are stable and can be effectively managed by the primary care provider or treating team…PROCEDURE…1. The palliative care interdisciplinary group will develop a discharge plan. The discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge…””

“Based on interview and record review, the agency failed to ensure patients were discharged appropriately and in accordance with the regulations for five of seven sampled patients (Patient 1, Patient 2, Patient 3 Patient 4, and Patient 5) when Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 were discharged without appropriate indication, no discharge planning, and no coordination with the Interdisciplinary Team (IDT - a collaborative group who work together to achieve a shared goal).This failure had the potential to result in unmet care needs for Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5. During a review of Patient 1’s Plan of Care (POC), dated 7/17/26, the POC indicated Patient 1 had a Start of Care (SOC) date of 10/4/24 with diagnosis of Malignant neoplasm of overlapping sites of left female breast (a tumor originated in more than one quadrant of the left breast where the exact single point of origin cannot be distinctly identified). The POC further indicated Patient 1 had an End of Care (EOC - discharge date) date of 7/17/26.During a review of Patient 1’s Discharge Summary (DS - a comprehensive clinical document that summarizes a patient’s stay with the agency), dated 7/18/26, the DS indicated, “…Reason for Discharge: Patient goals not met…Discharge executed per agency directive from management, with all palliative [focused on relieving the symptoms, pain, and stress of serious illnesses to improve quality of life by prioritizing comfort] symptom and psychosocial goals remaining completely unmet…this writer was directed by management to terminate services immediately, outside of and prior to the regularly scheduled monthly IDT meeting held on the last Tuesday of the month…Case closed under administrative mandate with goals unmet…”During a review of Patient 2’s POC, dated 7/17/26, the POC indicated Patient 2 had a SOC date of 1/7/24 with diagnosis of malignant melanoma of skin (skin cancer). The POC further indicated Patient 2 had an EOC date of 7/17/26.During a review of Patient 2’s DS, dated 7/18/26, the DS indicated, “…Reason for Discharge: Patient goals not met…Palliative care goals remain completely unmet due to an abrupt transition, an unestablished relationship with her new oncologist (cancer physician), an unresolved high-risk biopsy [test to check cells if growth or illness is harmful, safe, of if it is cancer] plan, and an active, uninvestigated mandibular mass [abnormal growth in the jaw]… Case closed with palliative goals unmet…”During a review of Patient 3’s POC, dated 7/16/26, the POC indicated Patient 3 had a SOC date of 12/31/25 with diagnosis of Burkitt lymphoma of the intraabdominal lymph nodes (a fast-growing cancer that forms in the lymph glands inside the abdomen). The POC further indicated Patient 3 had an EOC date of 7/16/26.During a review of Patient 3’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…being discharged from palliative care services today due to an administrative transition…Palliative goals of care were not met prior to this discharge…”During a review of Patient 4’s POC, dated 7/16/26, the POC indicated Patient 4 had a SOC date of 8/12/25 with diagnosis of Alcoholic cirrhosis of liver (permanent scarring of liver tissue caused by prolonged, heavy alcohol drinking). The POC further indicated Patient 4 had an EOC date of 7/16/26.During a review of Patient 4’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…Despite meeting clinical indicators for ongoing supportive care…[Patient 4] is currently being discharged from palliative care services…”During a review of Patient 5’s POC, dated 7/16/26, the POC indicated Patient 5 had a SOC date of 11/22/24 with diagnosis of Atelectasis (partial or complete lung collapse). The POC further indicated Patient 5 had an EOC date of 7/16/26.During a review of Patient 5’s DS, undated, the DS indicated, “…Reason for Discharge: Patient goals not met…Palliative and restorative goals of care were not fully met prior to this discharge due to patient’s ongoing clinical decline and severe, persistent room-air hypoxia (tissues do not get enough oxygen to work normally)…”During a concurrent interview and record review on 7/22/26 at 12:02 p.m. with the Administrator (ADM), the ADM stated patients are discharged if care goals are met, and if these goals are not met, the patient is kept within the agency. The ADM reviewed the list of discharged palliative patients and confirmed Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5’s discharge reasons indicated, “Patient goals not met” and stated she was not aware of the discharges until the Department pointed them out. During an interview on 7/22/26 at 2:40 p.m. with the Director of Patient Care Services (DPCS), when asked about the agency’s discharge process, the DPCS stated nurses evaluate and discuss the findings with the IDT if a patient is going to be discharged or not. The DPCS confirmed Patient 1, Patient 2, Patient 3, Patient 4, Patient 5’s discharge summaries indicated care goals for the patients were not met. The DPCS acknowledged that discharge planning was not done related to the discharges, and the patients were discharged without discussing the patients’ status with the IDT. The DPCS stated patients should not be discharged if the care goals are not met. The DPCS further stated that a case conference should have been done for each patient, and the IDT was supposed to make a discharge plan.During a review of the agency’s policy and procedure (P&P) titled “DISCHARGE FROM THE PALLIATIVE CARE PROGRAM,” revised 7/2021, the P&P indicated, “…The organization will provide service to a patient and family/caregiver as long as the patient meets the criteria for palliative care services…Discharge Criteria…1. The palliative care team, in collaboration with the physician determines that the patient no longer meets the criteria to receive palliative care services. Goals of care have been established, communicated, and are being appropriately managed by the ongoing healthcare team…2. The patient’s symptoms are stable and can be effectively managed by the primary care provider or treating team…PROCEDURE…1. The palliative care interdisciplinary group will develop a discharge plan. The discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge…””

“Observed in Patient Home. In 2 of 2 home visits conducted with a nurse, the nurse did not conduct a medication assessment. Agency Medication policy (3-002.1) states that medication review will be performed on admission and comprehensive assessment and then the medication will be used on subsequent hospice visits for care planning and teaching. In addition, the agency policy for ongoing assessment (2-031.1) states that patient will be assessed for ongoing medication compliance on each visit. On RRHV #2, the RN did not conduct a medication assessment, use the medication list for any care planning or teaching during the home visit or address ongoing medication compliance on the home visit. On RRHV #3, the nurse did not assess the patients compliance with medications on the visit or use the medication list for any teaching/care planning. This finding was reviewed with the administrator who was present for the visit.”

“Observed in Record Review. In 8 of 10 active patient records reviewed, the agency failed to document the recognition and resolution of duplicate drug therapy. On review of RRHV #1, it was noted that the patient had 3 PRN medications for constipation for Senna, Bisacodyl and Milk of Magnesium, while there were instructions for the Bisacodyl there were no clear indication when to use the other two duplicate therapies. On review of RRHV #2 and RRNHV #3, it was noted that patient had PRN Tylenol and PRN Morphine for pain with no clear indication when to use each on for pain. On review of RRHV #3 it was noted that there were no clear indications for the use of duplicate therapies of Hydromorphone and Tylenol for Pain. On review of RRNHV #2, RRNHV #4, RRNHV #5 patient had duplicate PRN medications for constipation that had no indication for when to use each duplicate therapy. On review of RRNHV #7, it was noted patient had multiple PRN medications for Pain with no indication for use for each pain medication. This finding was reviewed with the DCPS.”

“Observed in Record Review. In 2 out of 14 patient records reviewed, the organization failed to maintain complete and accurate records. On review of RRHV #1, it was observed by the nurse surveyor during the home visit that the aide performed a full assist transfer to wheelchair and then transferred patient with full assist from wheelchair to shower bench for shower, however the documentation states patient used walker. In addition, it was observed during the care that patient did not have hair blow dried or lotion applied to patient but it is documented that this was performed on the visit record. On review of RRHV #3, it was observed by the nurse on the home visit that the LVN took vital signs. The LVN took the vital signs and then stated what the numbers were for me and the caregiver. She stated the temp was 97.4 and the respirations were 20, however the medical record for the visit states a temp of 97.9 and resp of 24. It was also observed that the LVN did not write down or document those vital signs after she took them. In addition, it was noted that on arrival to the home the family/caregivers reported that patient had tried to stand up and had a fall, the LVN assessed the patient but had documented in the visit note that there were no falls to report today. This observation was reviewed with the DPCS.”

“Observed in Record Review. In 2 of 10 active patient records reviewed, the organization did not have orders for all care needs of the patient. On RRNHV #1, it was noted that the patient had a coccyx wound and wound care was being provided without a physician order. On RRNHV #2, it was noted in the nursing notes that patient had a Right Leg wound that nurse was performing wound care on during the visit and there was no physician order for the wound care. This finding was reviewed with DPCS.”

“Observed in Record Review. In 4 of 10 active patient records reviewed, plan of care had not been updated with goals that reflect changes to the patient’s assessment. On review of RRHV #2, patient had need for Hoyer lift while on service, while their is documentation that the Hoyer lift was ordered and on the nursing visit the check box on the assessment for DME taught was checked, there was no updated to the plan of care to reflect goals and care needs for this change in care. On review of RRHV #3, it was noted that the patient had antibiotic therapy 3 months ago and the goals for the teaching of the medication that is not finished has not been updated in the goals on the plan of care. On review of RRNHV #1, it was noted in the record that pain medications had been increased in the frequency of delivery and care plan was not updated to reflect this change in care. On review of RRNHV #3, the patient got a right leg wound and the plan of care was not updated to reflect the patients assessed change. This finding reviewed with the DCPS.”

“Observed in Tracer Activities. During the review of the Volunteer Program, the organization did not provide volunteers for at least 5% of the total patient care hours of all paid hospice employees and contract staff in 2023 and YTD for 2024. Agency only had 4.4% since the public health emergency ended in 2023. And YTD for 2024 the agency is at 3.3%. The Agency does not have an active performance improvement plan in place related to recruitment of volunteers but state they are actively recruiting volunteers. This was reviewed and validated with the DPCS.”

“Observed in Record Review. In 2 of 10 active patient records, the hospice nurse surveyor noted that the medical record did not contain medical equipment used by the patient in the home. On review of RRHV #1, it was noted during the home visit that patient had a bedside commode in her room and that she was using a shower bench for her showers an these DME items were not documented in the patient’s medical record. On review of RRHV #2, it was noted during the home visit that patient was using a hospital bed with overlay mattress and had a bedside commode, these DME supplies were not document in the patient’s medial record.”