Hospice Mercy

“Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §418.52, Patients Rights was out of compliance.This deficient practice constitutes Immediate Jeopardy as it created a situation in which the patient’s health and safety were at risk of serious injury, harm, impairment, or death. A total of 14 clinical records were reviewed for compliance with the Condition and Standards for Core Services. Record review revealed a pattern of failures related to the agency’s failure to respond timely to address changes in condition. Additionally, the hospice agency failed to maintain confidential clinical records. These failures affected all patients served by the hospice agency.L512 - Based on interviews and record reviews, the hospice failed to protect the patient’s right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Specifically, the agency failed to timely respond to and address changes in condition for 7 of 14 patients reviewed (Patients #1, #2, #5, #6, #8, #9, and #10). L516 - Based on observation, interviews, and record reviews, the hospice agency failed to maintain a confidential clinical record. Specifically, clinicians who were not employed by the hospice agency directly or under contract with the hospice agency were provided direct access to clinical records for 14 of 14 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14).”

“A total of 14 clinical records were reviewed for compliance with the Condition and Standards for Core Services. Record review revealed a pattern of failures related to the agency’s failure to conduct and document a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. L523 - Based on record review, observation and interview, the hospice failed to ensure initial comprehensive assessments by the interdisciplinary group (IDG) within five calendar days after the election of hospice care for 9 of 14 active patients reviewed (Patients #2, #3, #4, #5, #6, #7, #9, #11, #13, and #14). L532 - Based on interview and record review the hospice agency failed to make a referral for further evaluation by appropriate health professionals for 1 of 8 hospice patients provided services in their personal home (Patient #6).L533 - Based on record review, observation, and interview the hospice agency failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary group following a change of condition for 5 of 14 active patients (Patients #2, #5, #6, #8, and #9).”

“Based on record review and interview, the hospice agency failed to implement and maintain an effective, ongoing, hospice-wide, data-driven quality assessment and performance improvement (QAPI) program capable of identifying, analyzing, implementing, and sustaining effective corrective actions related to recurring patient care and operational concerns. Survey findings continued to identify recurring deficiencies related to timely completion of comprehensive assessment, coordination and integration of services, ongoing reassessments following changes in condition, symptom management interventions, escalation of unresolved patient care concerns, and implementation of treatments necessary to meet the patient needs. Findings include:1. The hospice agency’s QAPI was reviewed on 5/5/26. Review revealed the hospice agency failed to identify areas of concern for Quarter 1 or 2. Further review revealed the hospice agency identified concerns in Quarter 3 which included inaccurate medication profiles, inconsistent clinician documentation, lack of comprehensive pain assessment, medication order concerns, and infection monitoring activities. Record review failed to reveal ongoing quality assessments and performance improvement plans in place with the hospice agency to address the identified areas of concern.During an interview on 5/13/26 at 9:19 a.m. the hospice administrator and alternate hospice administrator stated the only performance improvement plan in place was for Volunteer hours. The hospice agency failed to create an improvement plan for any other areas of concern before the start of the survey.. Additionally, the hospice agency’s QAPI documentation following the change in ownership effective 10/1/25, contained incomplete quarterly review areas. Review of the QAPI documentation failed to reveal the hospice included concerns found in the survey such as triage calls for unmanaged pain, new or worsening symptoms, or canceled visits. The hospice agency’s QAPI program did not effectively identify, analyze, implement, and sustain corrective actions sufficient to prevent recurring operational and patient care deficiencies identified during the survey process. During an interview with the agency administration on 5/21/26 at 9:33 a.m., the administrator stated what the agency identified as trends were all included in the QAPI tool provided to surveyors. Cross reference: L523, L532, L533, L546, L549, L553, L554, and L663.2. Survey findings continued to identify recurring deficiencies related to timely completion of comprehensive assessment, coordination and integration of services, ongoing reassessments following changes in condition, symptom management interventions, escalation of unresolved patient care concerns, and implementation of treatments necessary to meet the patient needs.”

“Based on interviews and record reviews, the hospice failed to protect the patient’s right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Specifically, the agency failed to timely respond to and address changes in condition for 7 of 14 patients reviewed (Patients #1, #2, #5, #6, #8, #9, and #10). This deficient practice constitutes Immediate Jeopardy as it created a situation in which the patient’s health and safety were at risk of serious injury, harm, impairment, or death. Findings include:1. Patient #10 was admitted to hospice services with a start of care date of 9/11/25. Terminal diagnosis included pulmonary fibrosis, acute respiratory failure, and dementia. Additional pertinent diagnosis included a history of cerebral infarction and adjustment disorder with depressed mood.Record review revealed a care coordination note documented by Registered Nurse (RN) #1 on 1/21/26 at 9:03 a.m. Staff at the assisted living residence (ALR) where Patient #10 resided reported the patient had become increasingly emotional, tearful, and withdrawn. Documentation did not clarify whether the symptoms were new, worsening, or ongoing, which would support determination of the urgency and need for nursing assessment or intervention. Record review did not reveal a specific assessment of symptom severity, pain assessment, or timely intervention following notification of the patient’s acute change in condition. Documentation reviewed from the date of admission on 9/11/25 through the triage phone call on 1/21/26 did not identify prior episodes of tearfulness or emotional concerns. Review of a visit note dated 1/22/26 at 6:11 p.m. by RN #1 revealed ALR staff reported Patient #10 experienced stroke symptoms which included right sided facial drooping, difficulty speaking, and increased lethargy. RN #1 assessed Patient #10 during an in person visit on 1/22/26. RN #1 findings included Patient #10’s skin was ashen, excessive drooling, sweating, and a runny nose. This visit did not occur until 30 hours after the initial report of a change in condition made by ALR staff on 1/21/26. RN #1 documented she notified the hospice agency medical director for new orders for morphine. Review of the narrative note failed to reveal which specific symptoms were addressed with the hospice medical director. Additionally, RN #1 contacted Patient #10’s next of kin to discuss his condition.The hospice agency failed to address and manage reported increasingly worsening symptoms of emotional distress and tearfulness for over 30 hours, resulting in a delay in symptom management for Patient #10.2. Patient #9 was admitted to hospice services on 4/10/26 with a terminal diagnosis of malignant neoplasm of the prostate and bone and contributing diagnosis of neoplasm related pain.Review of a visit note dated 4/24/26 revealed RN #2 noted Patient #9 had a a reading impairment as evidence by Patient #9 holding the medication instruction sheet upside down. Further review revealed RN #2 advised all instructions provided to Patient #9 be read out loud, very clear, and allow extra time for the patient to ask questions. Record review failed to reveal alternative medication instructions were provided to Patient #9.Review of care coordination records revealed that on 4/26/26 at 8:53 a.m., Patient #9 contacted the on-call triage line requesting assistance with pain medication and clarification regarding which medication should be used for pain management. Documentation did not include the patient’s pain level or description of pain to support determination of the urgency or priority level for RN intervention or visit. Review of a care coordination note entered by RN #2 on 4/27/26 at 12:50 p.m. revealed a late entry for 4/26/26 with no time documented. The note indicated RN #2 returned a phone call from Patient #9; however, documentation did not identify the patient’s pain level. The narrative further revealed Patient #9 stated he was “feeling miserable,” but was unable to further clarify those feelings. Documentation did not indicate RN #2 pursued additional assessment or intervention related to the previously reported pain concerns or the patient’s statement of “feeling miserable” during the follow-up phone call.The record further revealed the RN’s ability to provide interventions was limited due to the lack of an in-person assessment and limited assessment completed over the phone. Record review revealed a second care coordination note dated 4/27/26 at 12:59 p.m. documented by RN #2. Documentation review revealed the note was a late entry for a follow-up telephone visit completed on 4/26/26 at 5:00 p.m. RN #2 documented a phone visit with Patient #9’s wife. Patient #9’s wife reported the patient was experiencing increased confusion and grumpiness. Further documentation failed to reveal an assessment of contributing factors causing the increased confusion, grumpiness, pain, or other reported symptoms. RN #2 failed to assess pain severity, response to pain medication, quality of pain, onset of symptoms, or progression of the patient’s condition related to the terminal diagnosis.Record review revealed RN #2 documented the symptoms reported by Patient #9 were due to pain, fear, and metastasis. RN #2 failed to document a complete assessment of symptoms. RN #2 failed to document education provided to address either pain or symptom management. Additionally, the care coordination note dated 4/27/26 included Patient #9’s wife expressed concerns regarding the patient’s unmanaged pain, emotional distress, fear related to the cancer diagnosis, and her increasing difficulty caring for the patient at home. RN #2 documented discussion regarding respite options. However, RN #2 did not address the psychosocial symptoms of fear and emotional distress. Moreover, RN #2 failed to provide interventions, referrals, or collaboration to address the reported concerns.Further record review revealed an addendum note dated 4/27/26 at 9:59 p.m. documented by RN #2 regarding a previous telephone call on 4/26/26 at 12:59 p.m. RN #2 documented that a nurse visit was offered and declined by Patient #9; however, documentation did not identify who RN #2 spoke with or when the visit was offered. Although the patient declined a visit, documentation did not indicate the physician was notified or that alternative guidance, interventions, or follow-up measures were provided to address the patient’s reported pain and overall condition. Review of care coordination notes documented by RN #2 on 4/26/26 did not include an assessment of pain, discomfort, or symptom management related to Patient #9’s terminal diagnosis. Documentation did not identify the severity, quality, or location of the pain reported by Patient #9 and did not include additional symptom assessment. Further, documentation did not indicate coordination with the physician, social worker, chaplain, or other hospice providers to address the patient’s reported feelings of misery. Review of a care coordination note dated 4/28/26 at 1:38 p.m. revealed Patient #9 contacted his previous primary care physician’s office requesting assistance. Documentation indicated Patient #9 reported confusion regarding which medication to take and how often to take the medication for pain management. During an interview conducted on 5/5/26 at 9:15 a.m., RN #2 stated Patient #9 did not verbalize symptoms well. RN #2 explained that upon admission, Patient #9 had been able to rate his pain. RN #2 acknowledged she did not obtain a pain rating from Patient #9 or the patient’s wife during the telephone interactions on 4/26/26.RN #2 further stated how she would complete assessment of pain to include evaluation of the location, timing, characteristics, and severity of pain, as well as associated symptoms related to the patient’s terminal diagnosis, including the patient’s reported feelings of misery. RN #2 acknowledged that when a patient was unable to verbalize or numerically rate pain, alternative methods of assessing symptom severity, including observation of facial expressions, behaviors, and other nonverbal indicators, should be utilized to determine the patient’s condition and need for intervention.During additional interview with RN #2, she stated Patient #9 had a history of complaining and indicated Patient #9 was unable to verbalize symptoms well. When asked why RN #2 did not complete an in person visit to manage the pain and symptoms reported by Patient #9, she stated her nursing’ “spidey sense” to decide on when the patient needed an in person visit. In this instance, RN #2 felt Patient #9 did merit an in-person nursing visit for assessment due to his reported pain and feelings of misery. However, RN #2 confirmed she did not coordinate follow-up care related to pain management or symptom control for Patient #9. RN #2 educated Patient #9 to contact hospice instead of primary care physician (PCP) regarding pain and medication management. The hospice agency failed to address and manage worsening symptoms of pain and increased confusion directly related to Patient #9’s disease process. This failure led to increased confusion for Patient #9 and his wife regarding who would be managing his pain and symptoms.3. Patient #2 was admitted to hospice services on 4/17/26 with a terminal diagnosis of ischemic stroke and a significant history of subarachnoid hemorrhage. On 4/27/26 at 7:21 p.m., Patient #2’s wife reported to the hospice agency triage line that Patient #2 had experienced an unwitnessed fall at home and requested assistance getting the patient off the floor. The triage documentation did not indicate whether the fall resulted in injury or include assessment details necessary to determine the urgency of nursing intervention in relation to the patient’s terminal diagnosis and overall condition. A second call was placed to the hospice agency triage line by Patient #2’s wife on 4/27/26 at 7:29 p.m., approximately eight minutes after the initial call. Patient #2’s wife reported she had been able to assist the patient from the floor to the bed and stated Patient #2 was comfortable. Review of the triage narrative indicated the on-call team would be notified for follow-up per procedure; however, documentation did not identify when the on-call team was notified. On 4/27/26 at 7:40 p.m., approximately 19 minutes after the initial triage call, RN #2 contacted Patient #2’s wife by telephone. Record review revealed a telephone visit note documenting Patient #2 had fallen in the bathroom and that his wife was able to assist him up. Documentation did not include review or assessment of potential injuries, neurological status, pain, or other symptoms with the patient or wife following the fall. Review of the visit note for Patient #2 revealed RN #2 completed an in-home visit on 4/28/26 at 10:58 a.m., more than 12 hours after the fall was initially reported to the hospice agency. Documentation from the visit did not include an assessment of symptoms or conditions which may have contributed to the fall.Review of the visit note included documentation indicating there was “no change in neurologic status”; however, RN #2 also documented Patient #2 was “less confused than the last visit.” Further review of the visit note did not indicate communication with the hospice medical director, any other physician, or interdisciplinary team member regarding Patient #2’s fall on 4/27/26. During an interview on 5/5/26 at 9:15 a.m., RN #2 stated she relied on Patient #2’s wife to assess the patient for injury during the telephone conversation on 4/27/26. RN #2 further stated she relied on information provided by Patient #2’s wife rather than completing an assessment during the in-person visit conducted on 4/28/26 following Patient #2’s reported fall. RN #2 acknowledged there was a failure to address the symptoms that may have led to the fall. Additionally, RN #2 stated there was a delay between the report of the fall and an in-person visit to manage Patient #2’s symptoms relating to his terminal diagnosis. RN #2 further stated an in-person assessment following the fall would have assisted in determining contributing factors for the fall and whether interventions were necessary. 4. Patient #6 was admitted to hospice services on 12/1/25 with a terminal diagnosis of pulmonary disease. On 3/28/26 12:52 p.m., Patient #6’s caregiver called the hospice agency triage number to report a new sacral wound. Review of the triage documentation revealed the on-call RN was notified at the end of the triage called by the triage answering service.Record review revealed RN #1 spoke with Patient #6’s caregiver on 3/30/26 via telephone, two days after the initial report of a new wound. Review of the care coordination note revealed the caregiver was requesting education regarding lift assist equipment (Hoyer) to facilitate transferring Patient #6. Per the record, the caregivers for Patient #6 purchased a Hoyer to facilitate patient transfers. Record review failed to reveal an offer to provide education on safe transfers using the Hoyer lift. RN #1 failed to discern whether use of the Hoyer for transfers was the causation of the reported wounds. Further record review revealed the caregiver reported an additional new wound on Patient #6’s right hip. The record note failed to reveal a verbal assessment via telephone of the right hip wound. Record review revealed RN #1 failed to provide a verbal assessment for the wounds reported on 3/28/26 and 3/30/26 separately. Record review revealed an in-person RN visit was completed on 4/1/26, four days after the initial report of newly developed sacral wound made on 3/28/26 and a second wound to the right hip reported on 3/30/26 by the caregiver to a formerly employed RN. The documentation did not include visual assessments of the reported wounds nor coordination of care with the medical director, primary physician, or IDG team regarding the wounds and treatment provided. Wound care was provided by a formerly employed RN per orders received from RN #1.Documentation did not indicate Patient #6 received an assessment following reports of new wounds on 3/28/26 and 3/30/26. Also, the documentation did not indicate completion of a symptom assessment to determine contributing factors for the wounds or evaluate how the wounds related to Patient #6’s terminal illness and overall condition.During an interview conducted on 5/5/26 at 9:06 a.m., RN #1, who received this patient after formerly employed RN left the agency, confirmed the physician was not notified regarding the newly reported wounds or wound treatment provided to Patient #6. RN #1 stated she entered wound care treatment orders without contacting the hospice physician.Further interview revealed that after assuming care of the patient, RN #1 should have reviewed actions previously taken by RN A related to notifications, wound assessments, interventions, and physician communication regarding the newly identified wounds. RN #1 also stated that upon receiving notification from triage regarding newly developed wounds, the RN should have completed an assessment to determine wound characteristics, contributing factors, symptom severity, changes in condition related to the terminal diagnosis, and the need for additional interventions or services. RN #1 further stated the physician and interdisciplinary group (IDG) should be notified to ensure appropriate treatment, monitoring, and care planning interventions were implemented.The hospice agency failed to address symptoms of new wounds reported to the on-call triage line as they related to the terminal diagnosis for Patient #6.5. Similar failures were found for Patients #1, #5, and #8.6. A. Review of the hospice policy titled “Pain Assessment, Reassessment and Management” dated 1/2/25 read “Hospice will respond promptly to the patient’s request for pain medication or symptom management” and “Hospice will have methods in place to ensure that the patient’s pain and all other distressing symptoms, are controlled effectively 24 hours a day, seven days a week, in all settings and wherever the patient resides.” This policy failed to include methods on how to manage pain and symptoms for staff to follow.B. Review of the hospice policy titled “Comprehensive and Ongoing Assessment” dated 12/26/23 read “Data elements that allow for measurement of outcomes will be included in all assessments such as, outcomes of treatment for: pain, dyspnea, nausea, vomiting, constipation, emotional distress, and spiritual needs.” Additionally, the policy reads “Reassessments will be conducted and documented in the patient medical record by the hospice Interdisciplinary Group (IDG) (in collaboration with the individuals attending physician, if any) as frequently as the condition of the patient requires.”7. During interviews conducted on 5/5/26 with RNs #1 and #2, the clinicians revealed the hospice agency did not provide education or training regarding criteria for determining when patient concerns required an in-person nursing assessment versus follow-up by telephone. Further interviews revealed the clinicians were not aware of established expectations or clinical criteria for responding in-person to urgent patient concerns, changes in condition, symptom escalation, falls, or newly identified wounds. The clinicians confirmed there was no standardized guidance provided by the hospice agency regarding when an in-person assessment was required to ensure timely evaluation and intervention. 8. During an interview on 5/6/26, the agency Administrator and Director of Nursing (DON) acknowledged the hospice agency failed to provide staff with a policy establishing criteria to differentiate when patient concerns required an in-person nursing visit versus telephone triage follow-up to address unmanaged pain and symptom control. Further interview revealed the agency failed to provide guidance and education for a timely follow up regarding pain management and symptom control following a triage call. The Administrator and DON referred to an agreement with IntellaTriage named “CommonSpirit 24/7 Hospice Procedure Notes” dated 6/12/25 which provided procedure and process steps for escalation of the initial triage call to notification of the local on-call team. The steps included the triage team would notify the local on-call team for all falls, deaths, uncontrolled symptoms, new or worsening open wounds, and when the patient or caregiver contacts the triage line more than once in a 12-hour period.During the same interview, the Administrator and DON concluded there was not enough clearly defined guidance as to when an in-person visit should be conducted by the local on-call team. They agreed current policies lacked standardized criteria to guide staff decision-making regarding timely in-person assessment of urgent patient needs, changes in condition, symptom escalation, falls, or newly identified wounds. Additionally, the Administrator revealed the agency received reports of triage, reviewed daily, about inconsistencies which reflected a delay between the initial triage call and the follow up from the local team. The Administrator admitted the hospice agency failed to address these inconsistencies adequately.”

“Based on observation, interviews, and record reviews, the hospice agency failed to maintain a confidential clinical record. Specifically, clinicians who were not employed by the hospice agency directly or under contract with the hospice agency were provided direct access to clinical records for 14 of 14 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Findings include:1. The clinical record for Patient #8 was reviewed on 5/5/26. The patient was admitted to hospice care and services on 12/29/25 with a terminal diagnosis of malignant breast cancer. The plan of care for the certification period dated 3/30/26 to 6/26/26 included orders for Skilled Nurse (SN) visits two times a week for symptom management, patient and family support, Medical Social Worker (MSW) visits one time a month, and Chaplain visits two times a month.a) The hospice agency allowed and included Chaplain #2 in the interdisciplinary group (IDG) meeting on 5/7/26 in which clinical findings were discussed.The surveyor observed the IDG meeting on 5/7/26 at 8:33 a.m. IDG meeting was coordinated by RN #4. RN #4 provided delivery of patient information for care coordination of the patients who are managed by RN #2 and RN #5 due to their absence. Surveyor observed Chaplain #2 discussed findings and assessment for the past two weeks made by Chaplain #1 who was not attending the meeting. Chaplain #2 discussed Patient #8 specifically regarding an increase in emotional stress from the disease process and the increased needs of Patient #8’s caregivers. Chaplain #2 was not listed as an employee of the hospice agency directly or by contract. The hospice agency failed to provide an employee file for Chaplain #2 due to the fact that he was not employed directly by the agency. Chaplain #2 had direct access to confidential patient clinical records. Chaplain #2 did not work for the hospice agency as an employee. 2. Review of the staff list provided by the hospice agency on 4/28/26 failed to include Chaplain #2. A second staff list was provided on 5/13/26. Review of this staff list failed to include Chaplain #2 as an employee of the hospice agency.3. The hospice agency administrator team was interviewed on 5/18/26 at 11:00 a.m. The Administrator revealed the hospice agency shared staff within the corporation. The Administrator and Regional Director confirmed shared staff did not work directly for the hospice agency nor was there a contract in place to allow the staff to work for the hospice agency. The Regional Director stated the hospice agency considered all staff employed by the corporate umbrella organization as employees who could provide care to the hospice agency’s patients.The hospice agency Administrator and Regional Director stated this oversight was a learning experience for the hospice agency. They confirmed the on-call administrator, Chaplain #2, and other clinicians had direct access to the hospice agency patients’ confidential medical records without oversight.4. During the exit interview on 5/21/26 at 9:30 a.m., the Regional Director stated the hospice agency worked with the corporate umbrella organization to develop a contract as a fix for on-call employee coverage to manage those who were not directly employed by the hospice agency. The Regional Director admitted this correction was not in place prior to 5/18/26.”

“Based on record review and interview, the hospice failed to ensure initial comprehensive assessments by the interdisciplinary group (IDG) within five calendar days after the election of hospice care for 2 of 14 active patients reviewed (Patients #7 and #9). Specifically, the medical social worker (MSW) failed to complete their assessment.This failure created the potential for unidentified and unmet patient care needs. AGENCY POLICY According to the agency’s policy dated 12/26/23 and titled, “83.00, Comprehensive and Ongoing Assessment,”“The Hospice Interdisciplinary Group (IDG), in consultation with the individuals attending physician (if any), must complete the comprehensive assessment no later than five (5) calendar days after the election of hospice care.”1. The clinical record for Patient #9 was reviewed on 5/4/26. The patient was admitted for hospice care and services on 10/23/25, with a terminal diagnosis of malignant neoplasm of the prostate. The Plan of Care orders for the 90 day time period dated 4/10/26 to 7/8/26 included skilled nursing visits (SN) twice a week for 10 weeks and MSW visits once a month for four months. Patient #9 resided at home.a) The hospice IDG MSW failed to complete Patient #9’s comprehensive assessment within five (5) days following the patient’s admission for care and services. Clinical record review revealed Patient #9 was admitted for hospice services on 4/10/26. Additional review revealed MSW #1 had not made an initial assessment visit to Patient #9 to assess their psychosocial needs until 4/21/26, 11 days after the patient elected hospice benefits. Record review failed to reveal communication between MSW #1 and Patient #9 prior to 4/21/26. Interview on 5/19/26 at 9:29 a.m. with MSW #1 revealed the reason for not completing initial assessments within the five days they had failed to complete some initial comprehensive assessments within five days because of new admission notification issues from transitioning to a new electronic medical record (EMR) system.2. Similar findings of the agency revealed that the agency’s IDG group failed to complete an initial comprehensive assessment were found for Patient #7.”

“Based on interview and record review the hospice agency failed to make a referral for further evaluation by appropriate health professionals for 1 of 8 hospice patients provided services in their personal home (Patient #6). Findings Include:The clinical record for Patient #6 was reviewed on 4/29/26. The patient was admitted to hospice care and services on 12/1/25 with a terminal diagnosis of chronic respiratory failure. The plan of care for the certification period dated 3/31/26 to 5/29/26 included orders for Skilled Nurse (SN) visits one time a week for symptom management and Hospice Health Aide (HHA) visits one time a week.a) The hospice failed to make a referral for therapy services to provide evaluation and education on the safety and use of a Hoyer lift for transfers.Review of a care coordination note dated 3/30/26 at 5:15 p.m. revealed a phone visit made by Registered Nurse (RN) #1 to Patient #6’s caregiver. The caregiver reported difficulty understanding the proper technique to use the Hoyer lift to transfer Patient #6. Further review revealed the caregiver reported a new wound on Patient #6’s right hip. Review failed to reveal an offer of an in person visit was made to assess Patient #6.Record review revealed a Skilled Nurse (SN) visit note dated 4/1/26 at 10:59 a.m. by a formerly employed RN. The formerly employed RN documented she demonstrated use of the Hoyer lift for transfers to Patient #6’s caregivers. The agency was unable to provide competency check off or skills validation for use of a Hoyer lift in the home documented by the former RN. During an interview conducted on 5/5/26 at 8:15 a.m. RN #1 revealed she was aware a Hoyer lift was in the home to assist with Patient #6’s transfers. RN #1 stated she did not provide education on safety or the use of the Hoyer lift to Patient #6’s caregivers. RN #1 stated she failed to make a referral for therapy services. RN #1 agreed a referral would benefit Patient #6.An interview was conducted on 5/13/26 at 9:15 a.m. with the Administrator and Director of Nursing (DON). The Administrator and DON agreed a referral for therapy services should have been made for Patient #6 to evaluate the transfer safety in relation to the Hoyer lift. Further, the Administrator indicated caregivers should be offered education on equipment use in the home.”

“Based on record review, observation, and interview the hospice agency failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary group following a change of condition for 5 of 14 active patients (Patients #2, #5, #6, #8, and #9). Findings Include:1. The clinical record for Patient #6 was reviewed on 4/29/26. The patient was admitted to hospice care and services on 12/1/25 with a terminal diagnosis of chronic respiratory failure. The plan of care for the certification period dated 3/31/26 to 5/29/26 included orders for Skilled Nurse (SN) visits one time a week for symptom management and Hospice Health Aide (HHA) visits one time a week.a) The hospice agency failed to update the comprehensive assessment for Patient #6 following a report of a change in transfer status and new wounds.On 3/28/26 12:52 p.m., Patient #6’s caregiver called the hospice agency triage number to report a new sacral wound. Review of the triage documentation revealed the on-call Registered Nurse (RN) #1 was notified at the end of the triage call by the triage answering service.Record review revealed RN #1 spoke with Patient #6’s caregiver on 3/30/26 via telephone, two days after the initial report of a new wound. Review of the care coordination note revealed the caregiver was requesting education regarding lift assist equipment (Hoyer) to facilitate transferring Patient #6. Per the record, the caregivers for Patient #6 purchased a Hoyer to facilitate patient transfers. Record review failed to reveal an offer to provide education on safe transfers using the Hoyer lift. RN #1 failed to discern whether use of the Hoyer for transfers was the causation of the reported wounds. Further record review revealed the caregiver reported an additional new wound on Patient #6’s right hip. The record note failed to reveal a verbal assessment via telephone of the right hip wound. Record review revealed RN #1 failed to provide a verbal assessment for the wounds reported on 3/28/26 and 3/30/26 separately. Record review failed to reveal an update to the comprehensive assessment which included the addition of a Hoyer lift for transfers. Review of an Interdisciplinary Group (IDG) note dated 4/3/26 at 12:00 p.m. entered by RN #1 revealed the wound on Patient #6’s right hip was included in the IDG discussion. Review of the IDG note failed to reveal discussion of the sacral wound reported on 3/28/26. The Hoyer lift for Patient #6 was not addressed during the IDG meeting on 4/3/26. Observations of the IDG meeting on 5/7/26 at 8:33 a.m. showed the hospice agency failed to address the Hoyer lift and wounds for Patient #6. Further review failed to reveal an update to the comprehensive assessment to address using the Hoyer lift to assist with transfers for Patient #6.During an interview conducted on 5/5/26 at 9:06 a.m., RN #1 indicated she assumed care for Patient #6 after a formerly employed RN stopped working for the hospice agency in March, 2026. Further interview revealed RN #1 was aware of the addition of the Hoyer lift to Patient #6’s home to assist with transfers. She stated the Hoyer lift was purchased by Patient #6’s family. RN #1 indicated the Hoyer lift was not provided by the hospice agency which is why the hospice failed to address the use of the lift for transfers.Further interview revealed that after assuming care of the patient, RN #1 should have reviewed actions previously taken by RN A related to notifications, wound assessments, interventions, and physician communication regarding the newly identified wounds. RN #1 also stated that upon receiving notification from triage regarding newly developed wounds, the RN should have completed an assessment to determine wound characteristics, contributing factors, symptom severity, changes in condition related to the terminal diagnosis, and the need for additional interventions or services. RN #1 further stated the physician and IDG should be notified to ensure appropriate treatment, monitoring, and care planning interventions were implemented.2. During an interview on 5/13/26 at 9:15 a.m., the administrator and Director of Nursing (DON) verified the hospice agency failed to update the comprehensive assessment as was appropriate for Patient #6 regarding the Hoyer lift and reported wounds. The DON stated the Hoyer life and wounds should have been addressed at the IDG meeting on 4/3/26.The administrator stated any time a piece of new durable medical equipment is found in use in a patient’s home whether provided by the family or the hospice agency, the comprehensive assessment should be completed with coordination of the IDG.3. Observation of an IDG meeting completed on 5/7/26 failed to include discussion of the Hoyer lift or new wound for Patient #6. 4. Similar findings of the hospice agency’s failure to ensure the comprehensive assessment was updated by the hospice IDG following a change of condition were found for Patients #2, #5, #8, and #9. 5. During an interview on 5/18/26 at 11:00 a.m. the DON stated an in person assessment should be completed for all falls, new or worsening wounds, new or worsening unmanaged pain or symptoms, and reports of a change in condition The Administrator acknowledged the hospice agency failed to complete an updated comprehensive assessment as often as patient conditions indicated it should be.6. Cross Reference L512, L520, and L532.”

“Based on record review and interviews the hospice agency failed to provide interventions to manage pain and symptoms related to the terminal disease for 1 of 14 active patients reviewed (Patients #9). Findings include:The clinical record for Patient #9 was reviewed on 5/4/26. The patient was admitted to hospice care and services on 4/10/26 with a terminal diagnosis of malignant prostate cancer. The plan of care for the certification period dated 4/10/26 to 7/8/26 included orders for Skilled Nurse (SN) visits one time every two weeks for symptom management, Medical Social Worker (MSW) visit one time a month, and Chaplain visits one time a month.a) The hospice agency failed to manage pain and symptoms for Patient #9.1. A. Review of the hospice policy titled “Pain Assessment, Reassessment and Management” dated 1/2/25 read “Hospice will respond promptly to the patient’s request for pain medication or symptom management” and “Hospice will have methods in place to ensure that the patient’s pain and all other distressing symptoms, are controlled effectively 24 hours a day, seven days a week, in all settings and wherever the patient resides.” The policy did not include the methods included in the policy.B. Review of the hospice policy titled “Comprehensive and Ongoing Assessment” dated 12/26/23 read “Data elements that allow for measurement of outcomes will be included in all assessments such as, outcomes of treatment for: pain, dyspnea, nausea, vomiting, constipation, emotional distress, and spiritual needs.” Additionally, the policy reads “Reassessments will be conducted and documented in the patient medical record by the hospice Interdisciplinary Group (IDG) (in collaboration with the individuals attending physician, if any) as frequently as the condition of the patient requires.”2. Patient #9 was admitted to hospice services on 4/10/26 with a terminal diagnosis of malignant neoplasm of the prostate and bone and contributing diagnosis of neoplasm related pain.Review of a visit note dated 4/24/26 revealed Registered Nurse (RN) #2 noted Patient #9 had a a reading impairment as evidence by Patient #9 holding the medication instruction sheet upside down. Further review revealed RN #2 advised all instructions provided to Patient #9 be read out loud, very clear, and allow extra time for the patient to ask questions. Record review failed to reveal alternative medication instructions were provided to Patient #9.Record review revealed a care coordination note dated 4/26/26 at 8:53 a.m. entered by the hospice agency on-call triage line which showed Patient #9 contacted the hospice agency requesting assistance with pain management medication clarification. The hospice agency on-call triage line staff failed to assess Patient #9’s pain description or to obtain a pain level to determine the urgency for RN intervention.Review of a care coordination note dated on 4/27/26 at 12:50 p.m. revealed a late entry for 4/26/26 with no time documented. The note revealed RN #2 returned a phone call to Patient #9. Patient #9 stated he felt “miserable” and had pain. Further review failed to reveal a completed pain assessment for Patient #9. RN #2 failed to address pain level indicators, qualifications, or causation.Record review revealed a second care coordination note dated 4/27/26 at 12:59 p.m. documented by RN #2. Documentation review revealed the note was a late entry for a follow-up telephone visit completed on 4/26/26 at 5:00 p.m. RN #2 documented Patient #9’s wife reported the patient was experiencing increased confusion and grumpiness. Additional review of documentation failed to reveal a completed assessment which addressed factors which attributed to increased confusion, grumpiness, pain, or other reported symptoms. RN #2 failed to assess pain severity, response to pain medication, quality of pain, onset of symptoms, or progression of the patient’s condition related to the terminal diagnosis.Record review revealed a third care coordination note was entered by RN #2 on 4/27/26 at 9:59 p.m. which reads as a late entry for 4/27/26 at 12:59 p.m. The note revealed RN #2 offered Patient #9 an in person visit which was declined. Review revealed inconsistencies in the care coordination note dates and times.A care coordination note dated on 4/28/26 at 1:38 p.m. revealed RN #2 made an appointment for an in person visit on 4/29/26 at 10:30 a.m. Record review failed to reveal a completed pain assessment which addressed the severity, causation, or description of Patient #9’s pain. Further review failed to reveal new orders for Patient #9 until 5/11/26 after the hospice agency was found to be in Immediate Jeopardy (IJ) level noncompliance. The pain reported by Patient #9 was not fully addressed for 12 days. Review of an order dated 5/11/26 revealed a change in dose frequency of morphine from every 12 hours to every eight (8) hours for pain management.During an interview conducted on 5/5/26 at 9:15 a.m., RN #2 stated Patient #9 did not verbalize symptoms well. RN #2 explained that upon admission, Patient #9 had been able to rate his pain. RN #2 acknowledged she did not obtain a pain rating from Patient #9 or the patient’s wife during the telephone interactions on 4/26/26.RN #2 further stated how she would complete assessment of pain to include evaluation of the location, timing, characteristics, and severity of pain, as well as associated symptoms related to the patient’s terminal diagnosis, including the patient’s reported feelings of misery. RN #2 acknowledged that when a patient was unable to verbalize or numerically rate pain, alternative methods of assessing symptom severity, including observation of facial expressions, behaviors, and other nonverbal indicators, should be utilized to determine the patient’s condition and need for intervention.The hospice agency failed to address and manage worsening symptoms of pain and increased confusion directly related to Patient #9’s disease process. This failure led to increased confusion for Patient #9 and his wife regarding who would be managing his pain and symptoms.3. During interviews conducted on 5/5/26 with RNs #1 and #2, the clinicians revealed the hospice agency did not provide education or training regarding criteria for determining when patient concerns required an in-person nursing assessment versus follow-up by telephone. Further interviews revealed the clinicians were not aware of established expectations or clinical criteria for responding in-person to urgent patient concerns, changes in condition, symptom escalation, falls, or newly identified wounds. The clinicians confirmed there was no standardized guidance provided by the hospice agency regarding when an in-person assessment was required to ensure timely evaluation and intervention. 4. During an interview on 5/6/26, the agency Administrator and Director of Nursing (DON) acknowledged the hospice agency failed to provide staff with a policy establishing criteria to differentiate when patient concerns required an in-person nursing visit versus telephone triage follow-up to address unmanaged pain and symptom control. Further interview revealed the agency failed to provide guidance and education for a timely follow up regarding pain management and symptom control following a triage call. The Administrator and DON referred to an agreement with IntellaTriage named “CommonSpirit 24/7 Hospice Procedure Notes” dated 6/12/25 which provided procedure and process steps for escalation of the initial triage call to notification of the local on-call team. The steps included the triage team would notify the local on-call team for all falls, deaths, uncontrolled symptoms, new or worsening open wounds, and when the patient or caregiver contacts the triage line more than once in a 12-hour period.During the same interview, the Administrator and DON concluded there was not enough clearly defined guidance as to when an in-person visit should be conducted by the local on-call team. They agreed current policies lacked standardized criteria to guide staff decision-making regarding timely in-person assessment of urgent patient needs, changes in condition, symptom escalation, falls, or newly identified wounds. Additionally, the Administrator revealed the agency received reports of triage, reviewed daily, about inconsistencies which reflected a delay between the initial triage call and the follow up from the local team. The Administrator admitted the hospice agency failed to address these inconsistencies adequately.”

“Based on record review and interview, the hospice agency failed to ensure drugs and treatment necessary to meet the needs of the patient by failing to ensure on-going assessment, monitoring, follow-up, and implementation of interventions related to identified patient care needs for 4 of 14 active patients records reviewed. (Patients #1, #5, #6, and #10) Findings include:1. The clinical record for Patient #1 was reviewed on 4/28/26. The patient was admitted to hospice care and services on 4/4/26 with a terminal diagnosis of Alzheimer’s Disease. The plan of care for the certification period dated between 4/4/26 to 7/2/26 included orders for Skilled Nurse (SN) visits one time a week for symptom management, medication management, and indwelling catheter management; Medical Social Worker (MSW) visits one time a month for patient and family support; Hospice Health Aide (HHA) visits one time a week for assistance with Activities of Daily Living (ADL), and Chaplain visit one time for spiritual care needs.a) The agency failed to ensure treatment necessary to meet the needs of Patient #1 by failing to ensure ongoing assessment, monitoring, follow-up, and intervention related to the patient’s recurrent leaking catheter concerns. Record review revealed a nursing visit note by RN #1 dated 4/16/26 indicating Patient #1 had a history of urinary tract infections (UTI). An additional nursing visit note dated 4/17/26 indicated a foley catheter change was completed related to increased infection concerns. Further record review revealed documentation of triage calls and notification to the hospice agency regarding Patient #1’s leaking catheter on 4/18/26, 4/19/26, and 4/22/26. Record review revealed the hospice agency failed to complete an assessment visit following the triage calls on 4/18/26 and 4/22/26. Additionally, an interdisciplinary group (IDG) comprehensive assessment and plan of care report dated 4/23/26 revealed the current problems listed for Patient #1 included need for bowel protocol assessment and instructions, hospice comfort medications, and medication management and instructions, nurse to insert or maintain indwelling catheter and wound care. The clinical record lacked documentation demonstrating implementation of additional skilled teaching interventions related to ongoing catheter management concerns. The IDG documentation further identified ongoing infection concerns, recurrent catheter leakage and repeated calls related to catheter management concerns. The IDG documentation further identified continued caregiver difficulty implementing catheter management instructions related to gravity drainage tubing and catheter backflow prevention. The IDG documentation further revealed the plan for the following two weeks was to continue weekly visits based on family request. The IDG failed to update the POC to address reported catheter management concerns or add interventions.Record review revealed the hospice agency failed to increase SN visit frequency to address the ongoing catheter management for Patient #1 despite the hospice agency’s acknowledged lack of caregiver assistance to manage the catheter in the home.During an interview completed on 5/5/26 at 8:15 a.m., RN #1 stated the patient’s catheter leakage concern had not been resolved. RN #1 reported Patient #1’s caregivers declined to participate in catheter management education. RN #1 acknowledged the catheter care need was not met for Patient #1 with the current visit frequency orders. 2. Similar findings related to the agency’s failure to ensure drugs and treatments necessary to meet the needs of patients through ongoing assessment, monitoring, follow-up, and implementation of interventions related to identified patient needs were found in Patients #5, #6, and #10. Cross reference: L523, L533, L546, L553, L554, L559, and L574Findings include:1. The clinical record for Patient #1 was reviewed on 4/28/26. The patient was admitted to hospice care and services on 4/4/26 with a terminal diagnosis of Alzheimer’s Disease. The plan of care for the certification period dated between 4/4/26 to 7/2/26 included orders for Skilled Nurse (SN) visits one time a week for symptom management, medication management, and catheter management; Medical Social Worker (MSW) visits one time a month for patient and family support; Hospice Health Aide (HHA) visits one time a week for assistance with Activities of Daily Living (ADL), and Chaplain visit one time for spiritual care needs.a) The agency failed to ensure treatment necessary to meet the needs of Patient #1 by failing to ensure ongoing assessment, monitoring, follow-up, and intervention related to the patient’s recurrent leaking catheter concerns. Record review revealed a nursing visit note by RN #1 dated 4/16/26 indicating Patient #1 had a history of urinary tract infections (UTI). An additional nursing visit note dated 4/17/26 indicated a foley catheter change was completed related to increased infection concerns. Further record review revealed documentation of triage calls and notification to the hospice agency regarding Patient #1’s leaking catheter on 4/18/26, 4/19/26, and 4/22/26. The clinical record lacked documentation demonstrating nursing reassessment of the ongoing catheter leakage concerns, implementation of interventions related to the recurrent leakage, physician notification, or documented resolution of the concern. Additionally, an interdisciplinary group (IDG) comprehensive assessment and plan of care report dated 4/23/26 revealed the current problems listed for Patient #1 included need for bowel protocol assessment and instructions, hospice comfort medications, and medication management and instructions, nurse to insert or maintain indwelling catheter and wound care. Additionally the need for skilled teaching regarding nutrition, hydration, pain, altered comfort, preservation of skin integrity. The clinical record lacked documentation demonstrating implementation of additional skilled teaching interventions related to ongoing catheter management concerns. The IDG documentation further identified ongoing infection concerns, recurrent catheter leakage and repeated calls related to catheter management concerns. The IDG documentation further identified continued caregiver difficulty implementing catheter management instructions related to gravity drainage tubing and catheter backflow prevention. The IDG documentation further revealed the plan for the following two weeks was to continue weekly visits based on family request. Despite ongoing infection concerns, recurrent catheter leakage, repeated calls related to catheter management concerns and continued caregiver difficulty to implement catheter management education, the clinical record lacked documentation demonstrating revised interventions, additional nursing reassessment, physician escalation, or implementation of additional measures related to the unresolved catheter management concerns. The unresolved recurrent catheter leakage created the potential for impaired skin integrity, infection risk, compromised catheter function, and unresolved patient discomfort for a patient with a documented history of UTI. During an interview completed on 5/5/26 at 8:15 a.m., RN #1 stated the patient’s catheter leakage concern had not been resolved. RN #1 further stated caregivers had not consistently participated in catheter management education due to frequent caregiver changes. On 5/7/26, the hospice agency obtained physician orders to change the catheter size for Patient #1. 2. Similar findings related to the agency’s failure to ensure drugs and treatments necessary to meet the needs of patients through ongoing assessment, monitoring, follow-up, and implementation of interventions related to identified patient needs were found in Patients #5, #6, and #10. Cross reference: L523, L533, L546, L553, L554, L559, and L574”

“Based on record review and interview, the hospice agency failed to ensure the plan of care was revised to reflect updated comprehensive assessment findings and corresponding new and ongoing symptom management and care planning needs for 5 of 14 active patient records reviewed. (Patients #2, #5, #6, #8, and #9) Findings include:1. The clinical record for Patient #5 was reviewed on 5/4/26. The patient was admitted to hospice care and services on 10/23/25 with a terminal diagnosis of Alzheimer’s Disease. The plan of care for the certification period dated between 4/21/26 to 5/1/26 included orders for Skilled Nurse (SN) visits one time a week for symptom management, medication management, and wound care; Medical Social Worker (MSW) visits one time a month for patient and family support; and six as needed Chaplain visits for patient and family support.a) The agency failed to revise the plan of care to reflect updated assessment findings and corresponding new and ongoing symptom management needs for Patient #5. i. Review of the clinical record for Patient #5 revealed an assessment was completed by the RN Case Manager on 2/9/26. The assessment revealed Patient #5’s wounds were increased in size and severity. Review of the clinical record failed to reveal the plan of care was updated for Patient #5 to address the increased size of wounds. Review of an IDG meeting note dated 2/12/26 revealed the RN Case Manager discussed Patient #5’s wounds with the care team. However, the IDG failed to update the plan of care. Record review failed to reveal any updated plan of care orders to address Patient #5’s wounds.ii. Record review revealed an assessment was completed on 4/20/26 by the RN Case Manager for Patient #5. The assessment revealed Patient #5 had decreased oral intake, weakness, and new onset unclear speech. Additional review revealed Patient #5 required increased assistance for transfers.Record review revealed failed to reveal an update to Patient #5’s plan of care which reflected the increased weakness, decreased appetite, and slurred speech.During an interview on 5/6/26 at 11:22 a.m. with the administrator and alternate administrator, the administrator confirmed the record did not contain an update to the plan of care for Patient #5 to address the increased wounds. 2. Similar findings related to the hospice agency’s failure to revise plans of care to reflect updated assessment findings, changes in condition, new and ongoing symptom management needs were found in Patients #2, #6, #8, and #9. Cross reference: L523, L533, L546, L554, and L549”

“Based on observation, interview, and record review, the hospice agency’s governing body failed to appoint a qualified administrator with full legal authority and responsibility for the management of the hospice, the provision of all hospice services, and continuous quality assessment and performance improvement. Findings Include:1. The State Survey Agency (SA) entered the hospice agency on 4/28/26 at 9:05 a.m. in order to complete a re-licensure, recertification, Change of Ownership (CHOW), and complaint survey. The hospice agency did not have an administrator nor alternate administrator with access to all records available for the survey.a) The hospice agency’s governing body failed to ensure a qualified hospice administrator or alternate administrator was available to manage day to day hospice services.An observation made on 4/28/26 at 9:05 a.m. revealed the hospice administrator was not available for survey in person due to managing another hospice agency several hours away. The alternate hospice administrator was not available due to providing direct patient care until 10:31 a.m. During an entrance conference on 4/28/26 at 10:31 a.m., the alternate hospice administrator stated the hospice agency could not provide the SA with access to all the clinical records requested due to a change in the Electronic Medical Administration Record (EMAR) which was completed on 10/1/25 during the CHOW. The alternate hospice administrator revealed the hospice agency had limited access to the previous EMAR.The agency administrator joined the entrance conference by virtual meeting. She stated a new administrator would be starting at the agency on 5/5/26. The new administrator was not included in the virtual meeting.2. A request for records was made on 4/28/26 at 11:14 a.m. The hospice agency failed to provide access to complaints and incidents until 5/13/26 following the corporate management meeting with the SA held on 5/13/26 at 11:30 a.m. The SA reviewed low level incidents on 5/13/26 with the alternate hospice administrator. The hospice administrator was not available to review the high level complaints or incidents due to travel from the hospice agency to the other hospice agency. The hospice agency failed to provide an alternative person to review the high level complaints with the SA. The SA was unable to review high level complaint or incident records until 5/14/26.During an interview on 5/13/26 at 12:44 p.m., the alternate hospice administrator stated she did not have access to view high level complaints or incidents. Further, all of these records were coded with a number and difficult to review for trends.b. The governing body and administration failed to ensure continuous quality assessment and performance improvement. Specifically, the hospice failed to protect the patient’s right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness, maintain a confidential clinical record, ensure initial comprehensive assessments by the interdisciplinary group (IDG) within five calendar days, to make a referral for further evaluation by appropriate health professionals, failed to ensure the comprehensive assessment was updated by the hospice IDG following a change of condition, to provide interventions to manage pain and symptoms related to the terminal disease, failed to ensure drugs and treatment necessary to meet the needs of the patient by failing to ensure on-going assessment, monitoring, follow-up, and implementation of interventions related to identified patient care needs, ensure the plan of care was revised to reflect updated comprehensive assessment findings and corresponding new and ongoing symptom management and care planning needs, to maintain an appropriate system of communication and integration to ensure the (IDG) maintained responsibility for directing and coordinating all aspects of care and services provided, to implement and maintain an effective, ongoing, hospice-wide, data-driven quality assessment and performance improvement (QAPI) program capable of identifying, analyzing, implementing, and sustaining effective corrective actions related to recurring patient care and operational concerns, and to maintain an effective system for assessment, tracking, oversight, and validation of volunteer competency related to individuals identified by the agency within the volunteer service program. (Cross Reference L512, L516, L523, L532, L533, L546, L549, L553, L559, and L663)1. At an interview completed on 5/13/26 at 9:19 a.m. the hospice administrator and alternate hospice administrator stated they were unable to provide the SA with direct access to agency complaints or incidents until authorized to do so by the corporation. Further, the agency administrator stated each record has patient information redacted from it after it is reviewed at a corporate level. The agency administrator was unable to explain how the agency tracks trends for the hospice agency directly with the redacted information.2. During a review of incidents related to falls on 5/13/26 at 12:44 p.m., the SA requested to see falls reported for the patients whose clinical records were reviewed for the survey. It was observed that the alternate hospice administrator could not access those files directly without looking at each individual incident number.”

“Based on record review and interview, the hospice agency failed to maintain an effective system for implementation, tracking, oversight, and validation of volunteer orientation processes for 1 of 4 volunteer records reviewed. ( Volunteer #2) Findings include:1. Record review completed on 4/29/26 at 6:49 a.m. for Volunteer #2 did not reveal a documented volunteer start date within the volunteer record initially provided to surveyors. The volunteer roster provided by the hospice agency identified a date of “2/24/”; however, the record did not clarify the complete start date or corresponding year. Following surveyor inquiry, the agency administration later reported a volunteer start date of 2/1/24. a) The hospice agency failed to maintain a system of volunteer oversight. Record review revealed documentation of identification verification, tuberculosis (TB) testing, drug testing, influenza vaccination, background check and a safety quiz dated 7/10/26. Review of Volunteer #2’s record failed to reveal completed volunteer orientation or oversight. During an interview on 4/28/26 at 1:48 p.m., the alternate administrator described the hospice agency’s orientation process, including corporate orientation, hospice disciples education, and volunteer manuals. Record review further revealed inconsistent volunteer tracking and classification by the hospice agency. A volunteer roster provided to surveyors on 4/28/26 identified thirty-four (34) active volunteers and two (2) inactive volunteers. Following surveyor inquiry regarding selected volunteer records, the hospice agency later provided an updated volunteer roster on 5/20/26 identifying fourteen (14) active volunteers and did not identify inactive volunteer personnel. During survey review activities, the hospice agency later reported Volunteer #2 had been inactive and had not furnished volunteer services since the change in ownership effective 10/1/25. However, volunteer rosters previously provided to surveyors identified Volunteer #2 as active and did not identify inactive classification status. Cross reference: L559, and L574”