Monarch Hospice and Palliative Care

“Based on interview and record review, the hospice failed to ensure the Administrator accurately depicted the hospice’s accreditation and deeming status (when a third party determines the hospice meets or exceeds an established standard of care) for a census of 90. This failure led to the misinformation and misrepresentation to the public regarding the hospice’s deeming and accreditation status. Findings: During an interview on 7/22/25 at 9:58 a.m. the hospice’s Chief Nurse Executive (CNE) confirmed the hospice was accredited and provided a framed certificate from The Joint Commission (accredits and certifies health care organizations), dated 3/13/23, that indicated the hospice met the requirements for the accreditation program. Review of a letter from The Joint Commission dated 6/4/24 indicated as of 6/3/24 the hospice was denied accreditation and was no longer deemed. During an interview on 7/22/25 at 10:04 a.m. with the CNE she stated she was not aware of the letter from The Joint Commission and was not aware the hospice had lost their accreditation and deeming status. The CNE was informed the letter was addressed to the hospice’s Chief Financial Officer/Secretary (CFO/Secretary). The CNE confirmed the person listed on the letter was still employed as the hospice’s CFO/Secretary.”

“Based on interview and record review, the Hospice agency failed to ensure they had an effective Quality Assessment and Performance Improvement (QAPI) program that demonstrated measurable improvement related to improved palliative care outcomes (L561), measured, analyzed and tracked quality indicators (L562), was designed from quality indicator data including patient care (L563), and used data collected to monitor effectiveness, quality of care and identified opportunities for improvement (L564). The cumulative effect of these systemic practices resulted in the hospice agency’s inability to ensure the patients received quality palliative care and services. Based on interview and record review, the Hospice agency failed to ensure they had an effective Quality Assessment and Performance Improvement (QAPI) program that demonstrated measurable improvement related to improved palliative care outcomes (L561), measured, analyzed and tracked quality indicators (L562), was designed from quality indicator data including patient care (L563), and used data collected to monitor effectiveness, quality of care and identified opportunities for improvement (L564). The cumulative effect of these systemic practices resulted in the hospice agency’s inability to ensure the patients received quality palliative care and services.”

“Based on interview and record review, the hospice agency failed to demonstrate evidence of recruitment and retention of volunteers (L645), failed to demonstrate evidence of cost savings achieved through use of volunteers (L646) and failed to demonstrate evidence of a minimum of 5% of total patient care hours as a result of use of volunteers (L647). The cumulative effect of these systemic practices resulted in the hospice agency’s inability to ensure the patients received volunteer services. Based on interview and record review, the hospice agency failed to demonstrate evidence of recruitment and retention of volunteers (L645), failed to demonstrate evidence of cost savings achieved through use of volunteers (L646) and failed to demonstrate evidence of a minimum of 5% of total patient care hours as a result of use of volunteers (L647). The cumulative effect of these systemic practices resulted in the hospice agency’s inability to ensure the patients received volunteer services.”

“Based on interview and record review, the hospice agency failed to organize, manage, and administer its resources to provide care and services to patients, caregivers and family members necessary to manage symptoms and suffering of the terminally ill. This failure resulted in the hospice agency’s inability to admit patients since 3/6/23. The agency reported zero admissions for the last 12 months and there were no active patients since 3/6/23. In an interview on 7/30/24 starting at 10:07 a.m., the Administrator stated the agency had no active patients and the agency had not actively looked for patients.”

“Based on interview and record review, the agency failed to furnish services in accordance with State regulations when there was no evidence the agency was actively marketing and getting referrals for patients from 12/6/2021 when the agency was initially licensed. During the entrance conference on 7/30/24 at 10:07 a.m., the Administrator stated the agency did not have active patients at present and did not actively look for patients since the last patients were discharged. During a telephone interview with the Administrator on 7/31/24 at 1:30 p.m., the Administrator validated that the agency discharged last patients on 3/6/23.”

“Based on interview and record review, the hospice agency (HA) failed to ensure the Skilled Nurses (SNs) followed the physicians order contained in the plan of care (POC) for one of five sampled patients (Patient 1), when the SNs did not document the presence of Patient 1’s Foley catheter (a tube placed in the bladder to drain urine) and did not provide catheter care as directed by the physician. This failure increased the risk potential for infections for Patient 1. A review of the clinical record indicated the agency admitted Patient 1 at the end of 2022 with a terminal diagnosis of end stage renal disease (chronic kidney failure). A review of the document titled “;Plan of Care/Physician Orders” for certification period from 12/12/22 to 3/11/23, indicated the patient had declined in his health and required hospice care. The plan of care included orders for weekly home visits by SN for symptoms management and comfort measures. The plan of care contained a physician order which indicated, “;May change insert 16 Fr [size of the tube] Foley Cather [sic] and provide catheter care, change foley every month.” A review of the Initial Comprehensive Assessment dated 12/12/22 indicated Patient 1 had Foley catheter since 10/10/22 and contained a description of patients urine color and clarity. A review of the individualized care plan established by the hospice interdisciplinary group (IDG) and in collaboration with the attending physician dated 12/12/22, indicated Patient 1 had potential for infection related to Foley catheter. The interventions included to assess the patient for signs and symptoms of infection, including flank pain, dark colored urine with cloudy sediments, foul odor urine and to teach patients caregivers regarding infection control prevention. A review of the SN visit notes dated 12/15/22, 12/19/22, 1/2/23, and 1/16/23 indicated the SN documented monitoring of Patient 1’s urine color and clarity but there was no documentation of the presence of a Foley catheter. A review of Patient 1s clinical record did not contain documented evidence that SN changed the catheter as ordered, provided catheter care, and conducted caregiver teaching related to catheter care and prevention of bladder infection. During a concurrent interview and review of Patient 1s clinical record with the Administrator /Director of Patient Care Services (ADM/DPCS), on 7/30/24, at 3:20 p.m., the ADM/DPCS stated she was unable to find notes that SN addressed Patient 1s catheter and provided catheter care as ordered by the physician. The ADM/DPCS reviewed IDG notes dated 12/23/22 and 1/6/23 and acknowledged that the notes on both dates indicated that the patient was incontinent for bladder which was inaccurate documentation. The ADM/DPCS stated Patient 1s Foley catheter and risk for infection were not addressed at IDG meetings. The ADM/DPCS stated that it was an oversight on the agencys part and added, “;Not documented means not done.” The ADM/DPCS verified that Patient 1s clinical records did not contain documentation that SN educated patients caregiver on catheter care and infection prevention as indicated in his care plan. A review of the agencys policy, titled, “Hospice Nursing Care,” dated October 2020, indicated that nursing services will be provided with accepted standards of practice. The policy indicated, “;A hospice registered nurse will be assigned as the Case Manager for each patient ...The Case Manager will ensure that components of the plan of care ...are implemented ...The hospice nurse will ...Incorporate specialized nursing skills ...into all clinical care provided ...Provide patient and family/caregiver education.””

“Based on interview and record review, the hospice agency failed to ensure there was a Quality Assessment and Performance Improvement (QAPI) program that demonstrated measurable improvement related to improved palliative care outcomes when there was no documented evidence they had patients since April 2023. This failure resulted in the agency’s inability to identify improvements and measurable outcomes related to quality palliative care. A review of the agencys “;QAPI 4th Quarter 2023,” “;QAPI 1st Quarter 2024,” and QAPI 2nd Quarter 2024” revealed no data information due to the agency not having any patients since April 2023. There was no documented evidence of the hospice’s measurable improvement related to improved palliative care outcomes due to the agency not having any patients since April 2023. During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients. During an interview on 7/31/24 at 10:02 a.m. with the agencys Administrator, the Administrator confirmed the agency has not had any patients since April 2023.”

“Based on interview and record review, the hospice agency failed to ensure there was a Quality Assessment and Performance Improvement (QAPI) program that measured, analyzed and tracked quality indicators including patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations when there was no documented evidence they had any patients since April 2023. This failure resulted in the agency’s inability to measure, analyze and track quality indicators. A review of the agencys “;QAPI 4th Quarter 2023,” “;QAPI 1st Quarter 2024,” and QAPI 2nd Quarter 2024” revealed no data information due to the agency not having any patients since April 2023. There was no documented evidence the hospice had a QAPI program (QAPI) program that measured, analyzed and tracked quality indicators including patient events and other aspects of performance that enabled the hospice to assess processes of care, hospice services and operations when there was no documented evidence the agency had patients since April 2023. During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients. During an interview on 7/31/24 at 10:02 a.m. with the agencys Administrator, the Administrator confirmed the agency has not had patients since April 2023.”

“Based on interview and record review, the hospice agency failed to demonstrate they had a Quality Assessment and Performance Improvement (QAPI) program that used quality indicator data including patient care and other relevant data when there was no documented evidence they had any patients since April 2023. This failure resulted in the agency’s lack of a functional QAPI program. A review of the agencys “;QAPI 4th Quarter 2023,” “;QAPI 1st Quarter 2024,” and QAPI 2nd Quarter 2024” revealed no data information due to the agency not having patients since April 2023. There was no documented evidence the hospice had a program that used quality indicator data including patient care and other relevant data when there was no documented evidence, they had patients since April 2023. During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients. During an interview on 7/31/24 at 10:02 a.m. with the agencys Administrator, the Administrator confirmed the agency has not had patients since April 2023.”

“Based on interview and record review, the hospice agency failed to demonstrate they had a Quality Assessment and Performance Improvement (QAPI) program that used data collected to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement when there was no documented evidence, they had patients since April 2023. This failure resulted in the agency’s lack of an effective QAPI program. A review of the agencys “;QAPI 4th Quarter 2023,” “;QAPI 1st Quarter 2024,” and QAPI 2nd Quarter 2024” revealed no data information due to the agency not having patients since April 2023. There was no documented evidence the hospice had a QAPI program that used data collected to monitor effectiveness and safety of services and quality of care and identify opportunities for improvement when there was no documented evidence the agency had patients since April 2023. During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients. During an interview on 7/31/24 at 10:02 a.m. with the agencys Administrator, the Administrator confirmed the agency has not had patients since April 2023.”

“Based on interview, facility documents review and policy and procedure review, the hospice agency failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers for a census of zero patients. This failure resulted in patients not being given an opportunity to receive volunteer services. During an interview and concurrent review of facility documents on 7/31/24 at 10:10 a.m. with the agency’s Administrator, she confirmed she was unable to provide documentation or demonstrate that the hospice agency made ongoing efforts to recruit, train, and retain volunteers. The Administrator produced a flyer that she stated was sent to local churches. Review of this flyer indicated the “Next Training will be in Oct 13, 2023/Oct 20, 2023/Oct 27, 2021/Nov 3, 2023.” Review of the agency’s policy and procedure (P&P) titled, “ Volunteer Services,” undated indicated, “The volunteer coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.” During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients.”

“Based on interview and volunteer record review, the hospice agency failed to document the cost savings achieved through the use of volunteers. Documentation must include the following: (1) The identification of each position that is occupied by a volunteer. (2) The work time spent by volunteers occupying those positions.(3) Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. This failure resulted in no documented evidence of cost savings for the agency through the use of volunteers. During an interview and concurrent review of facility documents on 7/31/24 at 10:10 a.m. with the agency’s Administrator, she provided documentation for the agency’s volunteer services for the 1st Quarter 2023, 2nd Quarter 2023, 3rd Quarter 2023, 4th Quarter 2023, and 1st Quarter 2024 with the following exact verbiage for each quarter: “Volunteer Services Total Manhours Field & Office = 100 hours” “Total Volunteer Hours in the Office =8 hours” “8 hours/ 100 hours x 100% =8%” The Administrator confirmed she had no documentation that included the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions or the estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. During a review of the agency’s policy and procedure (P&P) titled, Volunteer Serivces,” undated indicated, “The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteers services exceed 5% of the total patient care hours of paid and contracted hospice personnel.” During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients.”

“Based on interview and volunteer record review, the hospice agency failed to maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. This failure resulted in no cost savings for the agency through the use of volunteers. During an interview and concurrent review of facility documents on 7/31/24 at 10:10 a.m. with the agency’s Administrator, she provided documentation for the agency’s volunteer services for 1st Quarter 2023, 2nd Quarter 2023, 3rd Quarter 2023, 4th Quarter 2023, and 1st Quarter 2024 with the following exact verbiage for each quarter: “Volunteer Serivces Total Manhours Field & Office = 100 hours” “Total Volunteer Hours in the Office =8 hours” “8 hours/ 100 hours x 100% =8%” The administrator confirmed she had no documentation on the use of volunteers for patient care and administrative services, including the type of services and time worked. During a review of the agency’s policy and procedure (P&P) titled, “Volunteer Services,” undated indicated, “The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5% of total patient care hours of paid and contracted hospice personnel.” During an interview on 7/30/24 at 10:07 a.m. with the Administrator, the Administrator confirmed they had no active patients and did not actively look for patients.”