Bristol Home Care and Hospice Agency, Inc.

“Based on clinical record reviews, agency documentation and staff interviews, for three of six patients (Patient’s #3, 7 and 11) receiving volunteer services, the Registered Nurse/RN Coordinator failed to ensure all hospice disciplines contributed to the patient’s comprehensive and ongoing assessments and care planning process. The findings include: Patient #3 elected the Hospice benefit on 4/07/26 and resided at home. Patient #3’s diagnoses included hypertensive heart disease with failure, acute and chronic respiratory failure and chronic obstructive pulmonary disease. The physician’s orders for the certification period of 7/06/26 to 10/03/26 included nursing, hospice aide, social worker and chaplain services.Review of the clinical record identified volunteer visits weekly on 7/08/26, 7/15/26, 7/22/26, 7/29/26, 8/05/26, 8/11/26, 8/19/26 and 8/26/26 for respite, socialization/companionship, active listening, prayer and provided music.Review of the Inter-Disciplinary Group/IDG notes dated 7/08/26, 7/22/26, 8/05/26 and 8/19/26 identified that the volunteer coordinator participated in the IDG, documented a volunteer was in place but did not document the patient’s progress and response to care. Patient #7 elected the Hospice benefit on 2/27/26 and resided at home. Patient #7’s diagnoses included cerebrovascular disease, dementia and type II diabetes mellitus. The physician’s orders for the certification period of 6/24/26 to 8/25/26 included nursing, hospice aide, social worker and chaplain services.Review of the clinical record identified volunteer visits weekly on 7/02/26, 7/07/26, 7/14/26, 7/21/26, 7/26/26, 7/27/26, 7/28/26, 7/29/26, 7/30/26, 8/04/26, 8/12/26, 8/18/26 and 8/25/26 for respite, socialization/companionship, active listening, prayer and provided music.Review of the IDG notes dated 7/08/26, 7/22/26, 8/05/26 and 8/19/26 identified that the volunteer coordinator participated in the IDG, documented a volunteer was in place but did not document the patient’s progress and response to care. Interview and review of Patient’s #3 and 7’s IDG notes with the Interim Hospice Program Director on 9/01/26 at 2:30 PM indicated that the volunteer coordinator verbally discusses each patient’s volunteer roles but should have documented specific volunteer services provided during the IDG meetings and failed to ensure such documentation occurred. Patient #11 elected the Hospice benefit on 11/12/25 and resided in a skilled nursing facility. Patient #11’s diagnoses included hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease, chronic diastolic heart failure, and vascular dementia. The physician’s orders for the certification period from 7/10/26 through 9/7/26 included nursing, hospice aide, social worker, and chaplain services.Review of the clinical record identified volunteer visits on 7/14/26, 7/24/26, and 8/13/26 for socialization/companionship and active listening.Review of the IDG notes dated 7/15/26, 7/29/26, 8/12/26, and 8/26/26 identified that although the volunteer coordinator participated in the IDG and documented that volunteer services were in place, there was no documentation to reflect the patient’s progress and response to care.Interview and review of Patient’s #11’s IDG notes with the Interim Hospice Program Director on 9/02/26 at 10: 50 AM indicated that the volunteer coordinator verbally discussed each patient’s volunteer roles but should have documented specific volunteer services provided during the IDG meetings and failed to ensure such documentation occurred.”

“Based on clinical record and agency documentation reviews and staff interview, for six of six patients (Patient’s #2, 3, 5, 7, 10 and 11) receiving volunteer services, the hospice agency failed to develop an individualized plan of care to include the provision of volunteer services. The findings include: Patient #5 elected the Hospice benefit on 8/6/26 at home. Patient #5’s diagnoses included heart failure and chronic kidney disease. The physician’s orders for the certification period of 8/6/26 to 11/3/26 included nursing, social services and hospice aide. Review of the clinical record identified volunteer visits May 22 and June 29,2026.Patient #2 elected the Hospice benefit 5/28/26 and resided at a skilled nursing facility. Patient #2’s diagnoses included Alzheimer’s disease, epilepsy and abnormalities of gait and mobility. The physician’s orders for the certification period of 5/28/26 through 8/26/26 included nursing, social services, and hospice aide. Review of the clinical record identified volunteer visits 6/3/26, 6/9/26, 6/24/26,and 6/30/26.Patient #10 elected the Hospice benefit 5/26/26. Patient #10 diagnoses included pulmonary fibrosis, COPD, and chronic kidney disease. The physician’s orders for the certification period 5/26/26 through 7/20/26 included nursing, social services and spiritual counseling. Review of the clinical record identified volunteer visits 6/27/26 and 6/30/26. Patient #11 elected the Hospice benefit on 11/12/25 and resided in a skilled nursing facility. Patient #11’s diagnoses included hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease, chronic diastolic heart failure, and vascular dementia. The physician’s orders for the certification period from 7/10/26 through 9/7/26 included nursing, hospice aide, social worker, and chaplain services.Review of the clinical record identified volunteer visits on 7/14/26, 7/24/26, and 8/13/26 for socialization/companionship and active listening.Interview and review of Patient #11’s physician’s orders with the Interim Hospice Program Director on 9/2/26 at 10:45 AM indicated that volunteer services with the frequency of services provided should have been included in the plan of care and failed to ensure volunteer services were included. Patient #3 elected the Hospice benefit on 4/07/26 and resided at home. Patient #3’s diagnoses included hypertensive heart disease with failure, acute and chronic respiratory failure and chronic obstructive pulmonary disease. The physician’s orders for the certification period of 7/06/26 to 10/03/26 included nursing, hospice aide, social worker and chaplain services.Review of the clinical record identified volunteer visits weekly on 7/08/26, 7/15/26, 7/22/26, 7/29/26, 8/05/26, 8/11/26, 8/19/26 and 8/26/26 for respite, socialization/companionship, active listening, prayer and provided music. Patient #7 elected the Hospice benefit on 2/27/26 and resided at home. Patient #7’s diagnoses included cerebrovascular disease, dementia and type II diabetes mellitus. The physician’s orders for the certification period of 6/24/26 to 8/25/26 included nursing, hospice aide, social worker and chaplain services.Review of the clinical record identified volunteer visits weekly on 7/02/26, 7/07/26, 7/14/26, 7/21/26, 7/26/26, 7/27/26, 7/28/26, 7/29/26, 7/30/26, 8/04/26, 8/12/26, 8/18/26 and 8/25/26 for respite, socialization/companionship, active listening, prayer and provided music. Interview and review of Patient’s #2, 3, 5, 7, and 10’s physician’s orders with the Interim Hospice Program Director on 9/01/26 at 2:40 PM indicated that volunteer services with the frequency of services to be provided should have been included in the plan of care and failed to ensure volunteer services were included.”