Stand By U Hospice Care Inc.

“Based on interview and record review, the agency failed to ensure the written plan of care was individualized for one of five sampled patients (5) to reflect the patient’s needs when Patient 5 requested a volunteer and a volunteer was not provided. This failure resulted in the agency not honoring Patient 5’s request. Findings: Per the Hospice Election Statement form, Patient 5 was admitted to the agency on 7/1/26. A review of Patient 5’s clinical record was conducted on 9/9/26. Per the Clinical Note dated 7/1/26, Skilled Nurse (SN) 1 documented that Patient 5 requested volunteer services. A further review of Patient 5’s clinical record was conducted. No documented evidence showed that the plan of care was updated to reflect Patient 5’s wishes. On 9/9/26 at 12:30 P.M., a concurrent interview and record review was conducted with the Administrator and the Director of Patient Care and Services (DPCS). The Administrator stated that the skilled nurse coordinated with the volunteer director to ensure the agency provided services to patients. The DPCS stated the plan of care would then be updated to reflect the services that the agency provided to the patient. The DPCS stated that the volunteer service for Patient 5 was missed, and the plan of care was not updated. The agency could not provide a policy and procedure for the plan of care.”

“Based on interview and record review, the agency failed to ensure that the patient’s written plan of care was safe and accurate for one of five sampled patients (5) when the Director of Patient Care (DPCS) transcribed the lorazepam (medication to treat anxiety) order incorrectly. This failure could affect Patient 5’s safety if the wrong dose was administered. Findings: Per the Hospice Election Statement form, Patient 5 was admitted to the agency on 7/1/26. Per the Patient Medication List, dated 7/1/26, Patient 5 was taking Lorazepam 0.5 milligram (mg), take 14 tablets [7 mg, an unusually high dose for home use] by mouth every four hours as needed for anxiety. Per the Patient Care Plan, dated 9/8/26, indicated that Patient 5 was taking Lorazepam 0.5 mg, take 14 tablets by mouth every four hours as needed for anxiety. A further review of Patient 5’s clinical record on 9/9/26 showed no documented evidence that the agency identified the 7 mg dose every four hours as needed. This order could have resulted in a total daily dose of 42 mg, which exceeded the standard lorazepam dosage range of 2–6 mg per day. On 9/9/26 at 12:45 P.M., a concurrent interview and record review were conducted with the DPCS. The DPCS stated that the patient’s medication list was reviewed during routine home visits and interdisciplinary group (IDG) meetings. The DPCS further said that she transcribed the Lorazepam order, and made an error. The DPCS stated the order should have been Lorazepam 0.5 mg by mouth every 4 hours as needed for 14 days. The DPCS further said it was important for the medication list to be accurate to ensure patient safety. The agency could not provide a policy and procedure for the plan of care and medication reconciliation.”

“Based on interview and record review, the agency failed to complete home visits per the plan of care for two of five sampled patients (1, 3). As a result, patients did not receive the care and services as ordered by their physician. Findings: 1. Per the agency’s Plan of Care for the certification period 8/11/26 through 10/9/26, Patient 1 was admitted to the agency on 8/11/26 with diagnoses to include senile degeneration of brain (age related mental decline). Per the agency’s Order: Frequency Change, dated 8/13/26, Patient 1 had an order for the Certified Home Health Aide (CHHA) to visit two times per week as of 8/9/26. On 9/9/26 at 11:50 A.M., a concurrent interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, on the weeks of August 9th, 16th, and 23rd there was only one CHHA visit completed per week. The DPCS further stated, the visiting CHHA should have documented why they weren’t able to complete the ordered visit frequency of two visits per week for those three weeks, or changed the visit frequency. 2. Per the agency’s Plan of Care for the certification period 6/16/26 through 8/14/26, Patient 3 was admitted to the agency on 7/22/26 with diagnoses to include senile degeneration of brain (age related mental decline). Per the agency’s Order: Frequency Change, dated 7/25/26, Patient 3 had an order for the CHHA to visit three times per week as of 7/19/26. On 9/9/26 at 11:50 A.M., a concurrent interview and record review was conducted with the DPCS. The DPCS stated, on the week of 7/19/26 there was only one CHHA visit completed that week. The DPCS further stated, the visiting CHHA should have documented why they weren’t able to complete the ordered visit frequency for that week, or changed the visit frequency. The facility was not able to provide a policy on missed visits or updating the Plan of Care.”

“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. A review of the agency’s emergency preparedness (EP) plan revealed the agency did not ensure it was reviewed and updated at least every two (2) years. A review and interview were conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time it was revealed the EP plan was reviewed and updated in 2022, then not again until 2025. She advised it was “because we did not have any patients in 2023 and 2024, so we did not review our EP plan.” A review of the agency’s emergency preparedness (EP) plan revealed the agency did not ensure it was reviewed and updated at least every two (2) years. A review and interview was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time it was revealed the EP plan was reviewed and updated in 2022, then not again until 2025. She advised it was “because we did not have any patients in 2023 and 2024 so we did not review our EP plan.””

“It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the patient was informed about the scope of services the hospice provides and any specific limitations on those services. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/17/2025 and requested the non-covered items addendum. A clinical record review on 11/25/2025 revealed that the electronic medical record (EMR) contained documentation indicating that this had been signed however the area where the non-covered items should be listed was not filled out. This should have been issued within five (5) days of the election of benefits, making it over two and half months outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/23/2025 and requested the non-covered items addendum. A clinical record review on 11/25/2025 revealed that the electronic medical record (EMR) did not contain documentation indicating that this had been completed or given to the patient. This should have been issued within five (5) days of the election of benefits, making it nine (9) months outstanding. A clinical record review and interview was conducted with the Administrator on 11/26/2025. She stated that “I didn’t realize we needed to send them anything.””

“It is required that the hospice takes action to improve performance and assesses the success of the action after implementing it. This standard was not met as evidenced by document review and interview. A review of the agency’s Quality Program revealed the agency did not ensure the agency took action to improve performance and assess the success of the action after implementing it at least annually. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she advised “they did not have Quality meetings or Performance Improvement Projects during 2023 or 2024 as there were not any patients. There was one in 2022 when there was a survey, and we had one again in 2025 because we had another survey coming.” A review of the agency’s Quality Program revealed the agency did not ensure the agency took action to improve performance and assesses the success of the action after implementing it at least annually. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she advised “they did not have Quality meetings or Performance Improvement Projects during 2023 or 2024 as there were not any patients. There was one in 2022 when there was a survey and we had one again in 2025 because we had another survey coming.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged live, revealed the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Document 2: Agency Policy titled “Discharge Summary Policy No 1-026 dated April 2020” stated in relevant parts: “Procedure: 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued which may include the patient’s current plan of care. A copy of the discharge summary will be provided to the patient’s attending physician.” CLINICAL RECORD 3: The patient elected to revoke their hospice Medicare benefit on 05/21/2025. The clinical record did not contain evidence of the discharge summary being forwarded to the patient’s attending physician. An interview and joint clinical record review was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she said “they declined our services and I didn’t realize we needed to fax something to the Dr.””

“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, document review and interview. In 1 of 2 (50%) 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. Document 2: Agency Policy titled “Discharge Summary Policy No 1-026 dated April 2020” stated in relevant part: “Procedure: Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued which may include the patient’s current plan of care. A copy of the discharge summary will be provided to the patient’s attending physician.” CLINICAL RECORD 3: The patient elected to revoke the hospice benefit on 05/21/2025. The discharge summary dated 05/21/2025 included the following note: “Visiting RN *** reported that patient wants to be discharge today because he is seeking further treatment with his doctor. Hospice physician notified and order to discontinue all medications and treatment, discharge patient per patient requests.” The discharge summary did not include at least a summary of the patient’s hospice stay including treatments, symptoms and pain management. An interview and joint clinical record review was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she stated, “I thought we just needed to obtain an order and write a note.””

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of patients who resided in a skilled nursing facility revealed the agency did not ensure that hospice care of the patient/resident was stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/11/202 and was a resident of a skilled nursing facility (SNF) per documentation in the admission nurse’s note. The patient remained a resident of the SNF until his discharge on 07/12/2025. A review of the clinical record on 11/25/2025 revealed that the clinical record did not contain documentation of a written plan of care that documented the collaboration between the hospice and the SNF. A joint clinical record review and interview was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 in which she was unable to locate documentation of a written plan of care for facility coordination.”