Lily Hospice Care Inc.

“Based on record review and interview, the agency failed to ensure they maintained a designated person to act as administrator, who assumed full authority and responsibility for the management and provision of all hospice services. Findings Include: 1. Upon entrance to the agency for a complaint investigation on 1/8/26 at approximately 3:30 p.m., the surveyor introduced themself to Personnel #4 (office secretary). At this time, the surveyor stated the reason for the survey and requested to speak with the agency administrator. The agency failed to have a clear designated person appointed by the governing body responsible for the management and oversight of the hospice program. Personnel #4 on 1/8/26 at 3:30 stated they were unsure who the official agency administrator was, and further stated they answered to Personnel #1 and Personnel #7. When surveyors reviewed documentation on record with the state department and certification agency, neither Personnel #1 nor Personnel #7 was identified as an on-record administrator.When surveyors requested the organizational (ORG) chart on 1/8/26 at 3:33 p.m., they were directed to an org chart stating Personnel #3 was the administrator, and Personnel #2 was the alternate administrator. The office secretary stated they were not sure how accurate the org chart was. When surveyors read the names of those the department and the federal certification agency had on record for the designated administrators, the office manager was only familiar with Personnel #2. They stated, however, Personnel #2 was no longer employed with the agency. During an interview with Personnel #3 on 1/8/26 at approximately 4:00 p.m., Personnel #3 stated they were “helping out” at the agency; however, the agency did not service patients and therefore did not know the day-to-day operations, nor did they manage the program in its entirety, and it was mainly Personnel #2 who was responsible. During a phone interview with Personnel #2 on 1/9/26 at 2:35 p.m., Personnel #2 stated they were a previous employee of the agency. She stated as of 10/6/25, she had formally resigned from the agency. They continued to state they did not participate in any activities or administrative or clinical oversight since that time. On 1/12/26 at 3:23 p.m., the agency provided surveyors with an updated ORG chart, which stated the administrator was “to be determined,” and the alternate administrator was Personnel #3. During an interview with the agency owner on 1/12/26 at 3:24 p.m., the agency owner stated they did not update the correct agency databases; however, they would do so. They stated to the survey team they were the administrator until otherwise identified, and Personnel #3 was designated as the alternate administrator. On 1/12/26 at 5:53 p.m., the agency provided the submission for the change in the appropriate databases via email. During an interview on 1/20/26 at approximately 12:00 p.m., Personnel #3 again stated to the survey team they were not part of the overall oversight and had only begun recently. They further continued to state the agency did not have patients; therefore, they did not actively participate in the direct oversight of the hospice agency. They further stated if surveyors had questions regarding the previous care and administrative oversight, they would need to consult with Personnel #2.”

“Based on record review and interview, the agency failed to appropriately discharge patients who required ongoing services. The agency did not coordinate continuity of care with the appropriate persons to facilitate a safe and proper discharge for 2 of 3 patients discharged on 4/12/25. (Patients #2 and #3). Findings Include: 1. During a phone interview with Personnel #2 on 1/9/26 at 2:23 p.m., they stated they were no longer an employee with the agency as of 10/6/25. They continued to state before they resigned from the agency, they were the director of nursing (DON) and oversaw the clinical care of the patients served by the agency. The agency failed to appropriately discharge patients who required hospice services, specifically, the agency discharged patients for declining transfer to another hospice agency, and did not forward the appropriate documentation to the patient’s primary care provider.During continued interview with personnel #2 on 1/9/26, they stated the agency, after the completion of their accreditation survey, did not keep patients on service. She further stated they would transfer the patients to alternative agencies with administration and oversight for three separate hospices. Hospice A (the current hospice), Hospice B (a separate licensed hospice with the same staff, alternate administrator, and director of nursing as hospice A, C and D), Hospice C (a separate licensed hospice with the same staff and administration as Hospice B), and Hospice D (a previously owned hospice with the same staff and administration as Hospices A, B, and C). Record review completed on 1/12/26 of Patient #2’s record revealed discharge summary documentation for Patient #2, stating the patient was discharged due to declining to transfer to the alternate hospice agency. There was no documentation supporting continuity of care was provided beyond education to the patient to resume care with their primary care provider (PCP). During a follow-up interview with the agency owner on 1/12/26 at 3:24 p.m., he stated he was not clinical and questions regarding specific discharge questions needed to be referred to Personnel #2. He further stated the agency was not receiving compensation for care, and the patients needed to be discharged because they were not billable patients. 2. Similar findings of improper discharges related to the patient declining transfer to an alternate agency were found for Patient #3.”