All Seasons Hospice

“It is required that the patient has the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical records reviewed of a patient discharged with an extended prognosis, the agency did not ensure the patient was involved in the development of his or her plan of care. Document 2: Medicare Form “Notice Instructions for the Notice of Medicare Non-Coverage” (NOMNC) Center for Medicare and Medicaid Services (CMS)-10123 stated in part, “A Medicare provider/plan (Medicare Advantage plans and cost plans, collectively referred to as “plans”) must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare-covered services end, or the second to last day of service if care is not being provided daily.” Document 4: Agency policy titled “Live Discharge Policy (no date)” stated in relevant part(s): “ Written notification will be provided no later than 48 hours prior to discharge.” CLINICAL RECORD 16: The patient elected the hospice benefit on 08/05/2025 for senile degeneration of the brain. The agency discharged the patient for extended prognosis on 03/04/2026.” The patient signed an internal discharge form with a box checked “Discharge related to ineligibility effective March 4th, 2026.” It also noted the following: “Following careful review of my status, the Hospice Medical Director, the hospice Interdisciplinary Group, and my physician have determined I am no longer eligible for the Medicare hospice benefit. I will be discharged from services on the effective date listed below. I understand that I have the right to receive records, which led to this conclusion. I have received a copy of discharge instructions. Should my condition warrant hospice care in the future, I will be eligible for hospice care. I understand this decision was based on Medicare regulations.” The Notification of Medicare Non-Coverage (NOMNC) was not located in the patient’s chart. An interview and joint clinical record review were conducted with the Director of Clinical Services on 07/01/2026, during which time she confirmed the patient had not been given a NOMNC. She also confirmed, “that they recognized they had not realized until the beginning of the year that a NOMNC had to be given.””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (50%) clinical records reviewed, it was revealed that the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 2/ HOME VISIT 2: The patient elected the hospice benefit on 04/16/2026 for a diagnosis of protein-calorie malnutrition. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (Personnel Record 4) on 06/30/2026, the hospice medication profile (printed on 06/29/2026) was compared to the ALF medication profile (printed on 06/30/2026). The ALF medication profile contained the following medications that were not listed on the hospice profile: “Lorazepam 2mg/ml. Give 0.25 ml every 4 hours as needed (ordered 04/17/2026). Oxycodone 5 mg. Give 1 tablet every 4 hours as needed (ordered 04/17/2026).” The following discrepancy was also noted: “Hospice had Omeprazole 20 mg. Give 1 tablet daily as needed (ordered 05/09/2026) vs ALF Omeprazole 20 mg. Give 1 tablet daily (ordered 04/20/2026).” CLINICAL RECORD 3/ HOME VISIT 3: The patient elected the hospice benefit on 04/24/2026 for a diagnosis of cerebrovascular disease. The patient resided in a skilled nursing facility (SNF). During the home Visit with the Hospice Aide (Personnel Record 7) on 06/30/2026, the hospice medication profile (printed on 06/29/2026) was compared to the SNF medication profile (printed on 06/30/2026). The SNF medication profile contained the following medications that were not listed on the hospice profile: “Acetaminophen 500 mg. Give 2 tablets every 6 hours. (ordered 04/30/2026). Acetaminophen 325 mg. Give 2 tablets every 6 hours as needed (ordered 05/30/2026). Bisacodyl 10 mg suppository. 1 every 24 hours as needed (ordered 05/30/2024). Cetirizine 10 mg. Give 1 tablet daily (ordered 05/20/2026). Enema. Give daily as needed (ordered 05/30/2024). Milk of Magnesia. Give 30 ml daily as needed (ordered 05/30/2024). Senna Plus 8.6/50 mg. 1 tablet twice daily (ordered 05/30/2024). Triamcinolone cream 1%. Apply daily (ordered 05/06/2026).” Hospice medication profile contained the following medication not contained on the SNF medication profile: “Morphine 20 mg/ml. Give 0.5 ml every 2 hours as needed. (ordered 04/24/2026). The following discrepancy was also noted: “SNF had Zofran 4 mg. 1 tablet every 6 hours as needed (ordered 12/10/2024) vs hospice Zofran 4 mg every 4 hours scheduled (ordered 04/24/2026). An interview and joint clinical record review were conducted with the Director of Clinical Services on 07/01/2026, during which time she advised that the nurses should be conducting “medication reconciliations at least once every two weeks.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who accepted volunteer services, the agency did not ensure that the plans of care included volunteer services. CLINICAL RECORD 5: The patient elected hospice care on 03/18/2026 with a diagnosis of protein-calorie malnutrition. A clinical record review was conducted on 07/01/2026, which revealed volunteer services had been accepted, as evidenced by paper volunteer visit notes dated 05/06/2026 and two dated June 2026 that had been scanned to the EMR (electronic medical record). The plans of care reviewed did not include volunteer services, a volunteer visit frequency, or assigned tasks for volunteer services. CLINICAL RECORD 8: The patient elected hospice care on 01/21/2026 with a diagnosis of Degeneration of the nervous system due to alcohol. A clinical record review was conducted on 07/01/2026, which revealed volunteer services had been accepted, as evidenced by two paper volunteer visit notes dated April 2026 and one in June 2026 that had been scanned to the EMR (electronic medical record). The plans of care reviewed did not include volunteer services, a volunteer visit frequency, or assigned tasks for volunteer services. An interview and joint clinical record review were conducted with the Director of Clinical Services on 07/01/2026, during which time she confirmed “Volunteer services had not been included in the plan of care. These used to be put in by the social workers but should be put in by the volunteer coordinator now. We’re working on training that.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by the document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the volunteer program was conducted with the Executive Director and Volunteer Coordinator on 07/02/2026, during which time the volunteer percentage for the last twelve (12) months (June 2025 to May 2026) averaged 4.5%. The Volunteer Coordinator has hired and trained 20 new volunteers since she was hired in the past 1.5 years. The volunteer program is continuing to grow and hopes be above 5% with the recruitment of these new volunteers. A review of the volunteer program was conducted with the Executive Director and Volunteer Coordinator on 07/02/2026, during which time the volunteer percentage for the last twelve (12) months (June 2025 to May 2026) averaged to 4.5%. The Volunteer Coordinator has hired and trained 20 new volunteers since she has been hired in the past 1.5 years. The volunteer program is continuing to grow and will soon be above 5% with the recruitment of these new volunteers.”

“It is required that the hospice assess the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 3 of 10 (30%) personnel records reviewed, the agency did not ensure the skills and competencies of all individuals providing care, including volunteers, were assessed. Document 1: Agency policy titled “Orientation and Team Training Policy (no date)” stated in relevant part(s): “Policy: All volunteers and staff will participate in an annual review with their direct supervisor. One purpose of the annual review is to assess staff and volunteer competency specific to that individual’s role and responsibilities with **********.” PERSONNEL RECORD 2: Registered Nurse Administer date of hire 09/01/2022. A personnel record review was conducted on 06/30/2026, which revealed that there were no documented skills competencies in the years 2024 or 2025. PERSONNEL RECORD 8: Music Therapist, date of hire 06/20/2025. A personnel record review was conducted on 06/30/2026, which revealed that there were no documented skills competencies. PERSONNEL RECORD 9: Volunteer Coordinator, date of hire 04/08/2025. A personnel record review was conducted on 06/30/2026, which revealed that there were no documented skills competencies. An interview and joint personnel record review was conducted with the Administrator on 07/01/2026, during which time she stated she didn’t even “think about getting her annual competencies completed and wasn’t sure where the others were.””

“It is required that a patient’s clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the clinical notes were documented in accordance with agency policy. Document 3: Agency policy titled “Visit Documentation Timeliness Policy (no date)” stated in relevant part(s): “All patient visits conducted by ******** team members----including Nurses, Social Workers, Chaplains, and Certified Nursing Assistants (CNA)-----must be fulling documented in the electronic medical record (EMR) within five (5) calendar days of the date of service. Exceptions to this policy must be approved by hospice leadership and documented.” CLINICAL RECORD 11: The hospice aide care plan dated 03/01/2026 had an aide frequency of once weekly on Wednesdays. A nursing note dated 03/25/2026 noted: “Patient was in his bedroom receiving a bed bath from CNA (certified nurse’s aide). Patient is unable to tolerate the transfer to the shower chair and is requesting bed baths moving forward.” There was no documented hospice aide visit in the clinical record for 03/25/2026. Nursing notes dated 05/13/2026, 05/20/2026, 05/27/2026, 06/03/2026, and 06/10/2026 noted the “CNA had made a visit” on each of those days. There was no documentation of these aide visits in the clinical records. An interview and clinical record review were conducted with the Director of Clinical Services on 07/01/2026, during which time she said she would contact the aide assigned “and have her confirm the visits had been completed and if so she would have her come in to document them immediately.””