Hope Hospice and Community Services Inc.

“Based on medical record review, hospice policy review and staff interviews, the hospice failed to maintain communication and coordination of care for 1(Patient #1) of 3 patients reviewed, by failing to ensure verbal orders were documented, signed and placed in the patient’s medical record. The findings included: Review of the hospice provided policy titled, “Verification of Physician Orders” with an effective date of 11/03/2022 revealed, “Policy. . . Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to hospice patients. Verbal orders will be taken and documented only by professional, licensed hospice personnel . . . Verbal orders will be documented in the electronic medical record or on a form provided by the Organization. . . A copy of the order will be kept in the patient’s clinical record. The original order will be delivered to the physician (or another authorized licensed independent practitioner) for his/her signature . . .”Review of Patient’s #1 medical record revealed a Hospice start of care date of 11/7/25. Diagnoses included Benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and functional urinary incontinence.Review of the Interdisciplinary Group Meeting notes for the Certification Period of 5/6/2026 through 7/4/2026 revealed that Patient #1 had a Foley catheter (catheter inserted into the bladder to drain urine) which was changed monthly by the Urologist. The goal was for the patient’s catheter to be maintained without discomfort or signs/symptoms of infection.On 5/22/26, Registered Nurse (RN) Staff A documented in a Hospice Nursing Assessment that she placed Urojet (topical anesthetic and lubricant) on Patient #1’s penis before changing the Foley Catheter. RN Staff A documented, “Foley Catheter size 20 FR (French) was changed without difficulty. Flash clear yellow urine. Patient tolerated the procedure well”.RN Staff A did not document the reason for the catheter change on the Hospice Nursing Assessment.Review of the physician’s orders failed to reveal an order for the Foley Catheter change.On 5/23/26 an “On Call Nursing Visit – In Person” documented that Patient #1 had hematuria (blood in urine) and “indwelling catheter flush”. The nurse documented that the urine in the tubing was now clear.On 5/23/26, a Hospice Discharge Summary documented that Patient #1 was transferred to an acute care hospital and was admitted.Review of the hospital discharge summary dated 5/28/26 revealed that Patient #1’s gross hematuria likely secondary to Foley trauma was resolved after catheter change and irrigation.On 6/29/26, at 1:45 p.m., in an interview, the Senior Compliance Manager confirmed that Patient #1’s care plan did not include urinary catheter changes. She also confirmed that the patient’s medical record did not have a physician’s order for the Foley catheter change done on 5/22/26.On 6/29/26, at 3:03 p.m., in an interview, RN Staff A verified that on 5/22/26, she changed Patient #1’s Foley catheter. The nurse said the hospice Resource Nurse Practitioner gave her a verbal order to order the supplies and change Patient #1’s Foley catheter. RN Staff A verified that the order to change the Foley catheter was not written.On 6/29/26, at 4:00 p.m., in an interview, the hospice Resource Nurse Practitioner said that she recalled speaking to RN Staff A about Patient #1’s Foley catheter and gave her the approval to order the supplies to change the catheter. She said that it was the Registered Nurse’s responsibility to write the verbal order to have it signed. The hospice Resource Nurse Practitioner said, “The order was never pushed back to me to sign. I did not sign a written order for catheter change.””

“Based on medical record review and staff interviews, the hospice failed to notify the responsible party of patient’s death for 1 (Patient #4) of 4 patients reviewed for patients’ rights.The findings included: Review of the medical record revealed Patient #4 was admitted to hospice services on 12/10/25, during a hospital stay. On 12/30/25, Patient #4 was transferred to a skilled nursing facility, under hospice care.Review of the hospice Patient profile revealed:Daughter A was listed as “EMERGENCY CONTACT, Bereaved, Primary Care Giver”Patient #4’s spouse was listed as, “Spouse, Emergency Contact 2, Bereaved”Daughter B was listed as “Emergency Contact 3, Daughter, Bereaved”.Daughter C was listed as, “Daughter, Bereaved”.The hospice agreement dated 12/10/25 was signed by Daughter A.The patient profile did not specify whether the listed emergency contacts possessed legal decision-making authority, including power of attorney or legal guardianship.Review of the hospice death visit dated 4/6/26 at 6:00 p.m., revealed that when the Registered Nurse (RN) arrived at the facility, Patient #4’s spouse and daughters were at bedside. The RN affirmed death by no respirations, no heartbeat and no pulse. The RN offered condolences to the family and verified the funeral home with the family. Daughter C asked to help with postmortem care.The hospice note did not specify whether Daughter A listed as the “EMERGENCY CONTACT and Primary Care Giver” was notified of Patient #4’s passing.On 5/26/26 at 3:55 p.m., in an interview, Registered Nurse (RN) Staff D said that she was the admitting nurse for Patient #4. She could not remember if she received any power of attorney or legal guardianship paperwork upon admission for the emergency contacts listed on the patient’s profile.On 5/26/26 at approximately 4:10 p.m., RN Staff D provided a “Letters of Successor Guardian of the Person” signed and dated 9/15/24 by a Circuit Court Judge indicating that Daughter A “has been appointed successor guardian of the person of the Ward [Patient #4]”On 5/26/26 at 4:30 p.m., in an interview, the Vice President/Executive Director said that the guardianship letter should have been in the patient’s file. She said that there was a failure along the process in obtaining the patient’s information and records. She said that the legal guardian should have been notified of the patient’s passing.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 44 (5%) clinical records reviewed, the agency did not ensure interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 6: The election of the hospice benefit was dated 03/11/2026 with a primary diagnosis of Degenerative Brain Disease. The patient resided in a skilled nursing facility (SNF). The updated plan of care dated 05/06/2026 documented a treatment for Foley catheter prn (as needed). The Foley catheter intervention was not individualized for size, frequency of change, or drainage orders on the updated plan of care dated 05/06/2026. CLINICAL RECORD 26: The election of the hospice benefit was dated 12/04/2025 with a primary diagnosis of prostate cancer. The patient was admitted with a feeding tube in place. The plan of care dated 12/04/2025 and updated every two weeks until the patient’s death on 12/25/2025 included the intervention, enteral feeding of Kate Farms 1.4, amount none. The HOPE (Hospice Outcomes and Patient Evaluation) assessment dated 12/04/2025 documented that feedings would now be per patient request. The nursing assessment documentation on 12/06/2026 that the patient was complaining of tasting the feedings and instructed to hold for an hour and give every 4 hours. The HOPE assessment dated 12/15/2025 documented that the patient was NPO (nothing by mouth) and only ice chips. The updated plan of care dated 12/25/2026 continued with the same intervention for Kate Farms but was not clear about the frequency or amount of feeding. During an Interview on 05/21/2026, the Case Manager stated that the patient determined his feedings and agreed the plan of care did not document this. During an interview on 05/22/2026, the Clinical Manager and the Senior Compliance Director stated that the orders were not clear and complete for the patients. The tube feeding was per patient request, but the plan of care did not document this.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 30 (10%) clinical records reviewed for patients receiving hospice aide services, the agency did not ensure the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 6: The aide plan of care dated 03/25/2026 included the assigned task of complete bed bath every visit, provide peri care and foot care during shower. A Foley catheter was inserted on 03/23/2026 and was in place at the time of record review, however, the hospice aide plan of care did not assign tasks related to foley care as the date of record review on 05/19/2026. In addition, the foot care during shower was unclear since a complete bed bath had been ordered. CLINICAL RECORD 17: The election of the hospice benefit was dated 05/08/2026. The hospice aide was ordered 2 times a week to begin the week 05/10/2026, however, the aide plan of care was not documented as of the date of record review on 05/20/2026. The Case Manager stated during an interview on 05/20/2026 that the family refused the aide but agreed this should have been documented and the order discontinued. CLINICAL RECORD 19: The election of the hospice benefit was dated 04/30/2026 with a primary diagnosis of CHF (congestive heart failure). The hospice aide was ordered 2 times a week. The hospice aide plan of care was dated 05/01/2026 and assigned task of bath complete/chair and a shower was ordered each bath every visit. For skin care, the task was to apply barrier cream as directed. The type of bath was not specific and the task for skin care was not specific as to where to apply the barrier cream as of the date of record review on 05/20/2026. During interview on 05/21/2026, the Senior Director of Compliance stated this was a process improvement that they had made progress on and will continue as a process improvement.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview, the volunteer activity logs revealed that the agency did not ensure that 5% of services were provided by volunteers. On 05/20/2026 a review of volunteer hours for each quarter for 2025 revealed the year average was 3.34%. Interview with the Volunteer Manager and Administrator on 05/20/2026, they agreed that volunteer hours have been less than the required 5% of total patient care hours. The low percentage was attributed to several factors including: recent leave of the Volunteer Manager, the number of senior volunteers who are seasonal residents and leave the area during the warmer months, and the reluctance of some volunteers to utilize technology. Hospice also has a PIP currently in place to assist with increasing percentages and track volunteer utilization. A review of the volunteer activity logs revealed that the agency did not ensure that 5% of services were provided by volunteers. A 5/20/2026 review of volunteer hours for Q1 of 2025 revealed an average of 4.26% of total patient care hours, a review of Q2 of 2025 revealed an average of 4.39% of total patient care hours, a review of Q3 of 2025 revealed an average of 2.18% of total patient care hours; and a review of volunteer hours for Q4 of 2025 revealed an average of 2.53% of total patient care hours. The year average was 3.34% A review of volunteer hours for Q1 of 2026 revealed an average of 4.15% of total patient care hours (January - 3.2%, February - 3.8%, March - 3.8%, and April - 5.8%). Interview with the Volunteer Manager and Administrator on 5/20/2026 where they agreed that volunteer hours have been less than the required 5% of total patient care hours. The low percentage was attributed to several factors including: recent leave of the Volunteer Manager, the amount of senior volunteers who are seasonal residents and leave the area during the warmer months, and the reluctance of some volunteers to utilize technology. Discussion and ideas generated for increasing consistent volunteer utilization. Hospice also has a PIP currently in place to assist with increasing percentages and track volunteer utilization.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients that resided in a skilled nursing facility, the agency did not ensure that the plan of care directed which provider was responsible for performing the agreed upon functions. CLINICAL RECORD 6: The election of the hospice benefit was dated 03/11/2026 with a primary diagnosis of Degenerative Brain Disease. The patient resided in a skilled nursing facility. The updated plan of care on 05/06/2026 documented treatments for Foley prn (as needed). The Foley catheter remained in place and was managed by the facility staff; however, the plan of care did not specify that the facility staff was managing the Foley catheter. During interview on 05/21/2026, the Senior Director of Compliance, who reviewed the record and stated that the intervention was unclear and also incorrect and should have been updated for the patient.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. This standard was not met as evidenced by interview and observation. During tours of the Inpatient Unit #2 on 05/19/2026 and Inpatient Units #3 and #4 on 05/20/2026, the agency did not ensure electrical safety and compliance with NFPA 99, 2012 edition. During a tour of the Inpatient Unit #2 on 05/19/2026, there were two vending machines in the vending room that were not connected to ground fault (GFI) outlets, and were also not hard-wired in. During a tour of the Inpatient Unit #3 on 05/20/2026, there was one vending machine in the family kitchen/living room that was not connected to ground fault (GFI) outlets, and were also not hard-wired in. During a tour of the Inpatient Unit #4 on 05/20/2026, there was one vending machine in the family room that was not connected to ground fault (GFI) outlets, and were also not hard-wired in. Additionally, this references K912 Electrical Systems – Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99). During interviews on 05/19/2026 and 05/20/2016, the Regional Compliance Manager and the IPU Facilities Manager (both present for the IPU tours) agreed that there were no GFI outlets or hard wiring in place and also arranged to have this corrected immediately. During tours of the Inpatient Unit #2 on 5/19/2026 and Inpatient Units #3 and #4 on 5/20/2026, it was revealed that the agency did not ensure electrical safety and compliance with NFPA 99, 2012 edition. During a tour of the Inpatient Unit #2 on 5/19/2026, it was revealed that there were two vending machines in the vending room that were not connected to ground fault (GFI) outlets, and were also not hard-wired in. During a tour of the Inpatient Unit #3 on 5/20/2026, it was revealed that there was one vending machine in the family kitchen/living room that was not connected to ground fault (GFI) outlets, and were also not hard-wired in. During a tour of the Inpatient Unit #4 on 5/20/2026, it was revealed that there was one vending machine in the family room that was not connected to ground fault (GFI) outlets, and were also not hard-wired in. Interviews with the Regional Compliance manager and the IPU Facilities Manager (who were both present on the IPU tours) on 5/19/2026 and 5/20/2016 where they agreed that there were no GFI outlets or hard wiring in place and also arranged to have this corrected immediately.”

“Based on Medical Record Reviews, and interviews, the hospice agency failed to ensure 1(patient #1) of 3 sampled patients, received services which prioritizing the patient and familys needs. Based on clinical record review, patient representative, and staff interviews, the hospice agency failed to ensure care provided to 1(Patient #1) of 3 sampled patients prioritized the patients and familys needs. The findings included: Clinical record review for Patient #1 revealed a hospice Certification date of 9/17/24. Diagnoses included Congestive Heart Failure recurrent at rest, and chronic kidney disease stage 4. The clinical record noted Patient #1 had pitting edema (swelling) and was unable to carry on any physical activity without symptoms. The patient required the use of oxygen at 2 liters. The Interdisciplinary Group (IDG) Meeting dated 10/2/24 noted Patient #1 was confused at time and used oxygen at 2 liters to manage shortness of breath. The patient had increased edema (swelling) and cellulitis (bacterial skin infection). The IDG meeting note listed Tylenol extra strength for pain management. The Hospice Nursing Assessment Visit summary dated 10/04/24 noted Patient #1 was transferred to inpatient hospice with the daughters agreement for management of congestive heart failure. The change in condition included increased edema, anxiety. The patients pain level was “;0” (no pain). The Care Plan Report dated 10/4/24 noted a dyspnea treatment plan. The physicians orders dated 10/4/24 included Morphine concentrate 20 milligrams per milliliter (mg/ml), 5 mg orally as needed every hour for pain or dyspnea (difficult or labored breathing). The medication administration history sheet noted Patient #1 received a dose of Morphine for pain/dyspnea on 10/5/24 at 11:30 p.m., 10/6/24 at 1:41a.m., 10/6/24 9:15 a.m., 10/6/24 11:09 a.m. On 10/7/24 due to the impending landfall of category 3 hurricane Milton, Patient #1 was evacuated to an inpatient hospice center, not in the path of the hurricane. On 10/7/24 the receiving inpatient hospice noted Patient #1s diagnoses included Congestive Heart Failure, and Kidney Disease. Patient #1 denied discomfort. On 10/7/24, the Advanced Practice Registered Nurse (APRN) issued an order for Morphine concentrate 20 mg/ml, administer 5 mg orally every 4 hours for pain/dyspnea. The Administration History sheet noted the Morphine was administered around the clock on 10/7/24 at 12:00 p.m., 5:00 p.m., and 9:00 p.m., and on 10/8/24 at 1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m. The clinical record did not contain a progress note from the APRN for the routine administration of Morphine every four hours. On 11/19/24 at 3:54 p.m., in a telephone interview Patient #1s daughter said her mother was admitted to the inpatient hospice facility for management of Congestive Heart Failure, including the swelling of her legs. The daughter said she explained to the nurses her mother was not receiving narcotics due to her kidney failure. She said on 10/8/24 she visited her mother at the hospice house. Her mother had become very lethargic. She intervened and stopped the nurse from administering a dose of Morphine. On 11/20/24 at 4:07 p.m., in an interview the APRN said she increased the Morphine to every four hours routinely, based on the frequency Patient #1 received Morphine as needed. The APRN said she ordered the Morphine to be administered routinely every four hours in anticipation of increased discomfort during the patients evacuation to a different hospice house. She did not want Patient #1 to be in pain. The Morphine was administered until the daughter refused. She did not recall communicating with the daughter when she increased the frequency of the Morphine. Review of the clinical record failed to show documentation on 10/7/24 Patient #1s daughter was informed of the Morphine order change. On 11/21/2024 at 11:15 a.m., in an interview the Regional Director verified the Morphine order was increased. She said there was no notes from the APRN on 10/7/24 stating why the Morphine order was changed, the APRN did not want her to fall through the cracks. The Regional Director said, “;I do not see anything documenting the family was notified of medication changes, and that shortness of breath was a reason for the change in the order. I do not see anything in the record that the family was notified of changes in condition since the evacuation. The morphine order was changed on 10/7/2024 which was the same day as the evacuation. The order was written before the patient was transferred to the second Inpatient Hospice Center.””

“Based on record review, review of hospice policy and procedure, and staff interviews, the facility failed to ensure physicians orders included the route of medication administration for 1 (Patient #3) of 3 sampled patients. The findings included: The facility policy, Medication Management for Hospice effective 12/26/2022, stated the medication profile reflects orders given by a Physician or Advanced Practice Nurse (APRN) that include the following elements . . . Dose, route, frequency, refills. Clinical Record review for Patient #3 showed on 9/30/2024 and 10/9/2024, an order was written on a prescription order form for patient #3 that did not contain a route for administration. The order dated 9/30/2024 was written as, “;Morphine 20 mg (milligram), ml (milliliter), 20mg, Give 20 mg (1ml) q (every) 4◦ (hours), ATC (around the clock), pain/dyspnea” The order dated 10/9/2024 was written, “;Morphine 20mg/ml, sol (solution), 20mg q 4h, (hours), ATC pain/dyspnea. On 11/21/2024 at 10:00 a.m., in an interview the Care Manager said staff checks the charts every night. The orders should have been flagged and brought to the attention of the APRN that wrote the order.”