Big Bend Hospice Inc.

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by document review, clinical record 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 1: 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.” Agency policy P3.04 Discharge, Revocation and Transfer from Hospice, date 01/21/97, current issue date 05/21/26, required in part: “This document has been developed to ensure that industry standards and regulations are understood and followed for discharge, transfer and revocation from hospice care.” CLINICAL RECORD 21: The patient elected the hospice benefit on 04/10/2025 for a diagnosis of malignant neoplasm of endometrium. The patient was discharged for extended prognosis on 12/12/2025. The clinical record did not include documentation that the patient had been given a Medicare Notification of Non-Coverage (NOMNC) prior to discharge. During a joint clinical record review and interview on 08/12/2026, the Director of Quality confirmed that they were unable to locate the NOMNC in the clinical record or in medical records.”

“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. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 30 (3%) clinical records reviewed, 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 5/HOME VISIT 5: The patient elected the hospice benefit on 02/17/2026 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the Registered Nurse (RN) (Personnel Record 5) on 08/12/2026, the hospice medication profile (printed on 08/11/2026) was compared to the SNF medication list (printed on 08/12/2026). The following discrepancies were noted: the SNF medication list include Trazadone 50 mg tablet, take 1 tablet three times daily (ordered 03/17/2026); the hospice medication profile included Trazadone 50 mg, take 1 tablet as needed (ordered 02/17/2026). The SNF had DuoNeb 1 vial every 6 hours as needed (ordered 02/17/2026); the hospice medication profile included DuoNeb 1 vial every 4 hours as needed (ordered 02/17/2026). The SNF had Acetaminophen 325 mg tablets, 2 tablets every 6 hours as needed (ordered 03/12/2026); the hospice medication profile included Acetaminophen 325 mg, 2 tablets every 4 hours as needed (ordered 02/17/2026). The hospice had the following medications that the SNF did not have on their medication list (all ordered 02/17/2026): “Amlodipine 10 mg, 1 tablet daily. Bisacodyl 10 mg suppository, daily as needed. Donepezil 5 mg, 1 tablet daily. Furosemide 40 mg tablet daily.” During a clinical record review and interview on 08/13/2026, the Regional Director of Homecare stated, “we will get this updated right away.””

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; and 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 1 of 30 (3%) clinical records reviewed, the agency did not ensure the individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 20: The patient elected the hospice benefit on 06/10/2026 for the diagnosis of Parkinson’s disease. There was a nursing triage note on 08/05/2026 that “patient had a fall.” A nursing visit on 08/07/2025 documented patient was “agitated and putting pants on backwards.” A nursing visit noted on 08/08/2026 documented “multiple falls and wife was interested in respite stay d/t falls. Increased Seroquel.” A nursing visit dated 08/08/2026 noted: “4th fall today, patient agitated, cannot be redirected. 4 doses of Ativan given. Extreme agitation could be terminal.” During this visit a physician’s order to transfer the patient from routine level of care to general inpatient (GIP) was written and patient was transferred to the hospice GIP unit for symptom management of agitation. A review of the plan of care (POC) on 08/12/2026 revealed it was not updated until 08/10/2026, two days after patient’s admission into the inpatient unit and five days after the initial start of the symptoms. The problems on the POC were as follows: 1. Risk for Falls (dated 06/11/2026) with interventions of assess cognitive status; assess for history of falls; assess for musculoskeletal deficits; assess for neurological deficits; assess need and proper use of DME (durable medical equipment); assess patient safety; assess risk for falls. 2. Pain Management (dated 06/11/2026). 3. Impaired Respiratory Status (06/11/2026) 5. Constipation (dated 06/10/2026) with interventions of assess bowel management regimen. 6. Wound Care (dated 07/14/2026); 7. Alteration in Urination (dated 06/10/2026). The POC was not modified to add a problem with interventions to address the agitation, the falls problem was not modified to reflect the changes the patient was experiencing, and the patient was on GIP status for two days until the POC was modified. During a clinical record review and interview on 08/13/2026, the Regional Director of Homecare agreed the plan of care should have been adjusted to reflect the changes as the patient was experiencing the changes.”

“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 (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific written instructions for the hospice aide. HOME VISIT 6: The hospice aide care plan dated 08/11/2026 assigned the aide the tasks: “Incontinent care; change patient linens; bed bath; nail care; oral care; perineal care; shampoo; skin care-apply lotion to areas of dryness, apply barrier cream to areas of redness; report any changes in patient condition to registered nurse.” The tasks were to be completed every visit with a visit frequency of twice weekly. During the home visit observation with the Hospice Aide (HA) (Personnel Record 6) on 08/12/2026, the patient was observed to be wearing oxygen, which was removed by the aide to complete the shampoo and remove the patient’s gown. The patient’s daughter also advised the aide upon arrival that the “patient just had hip surgery on Thursday and had a dressing on the left hip that the aide needed to be careful with movement and not to get the dressing wet.” The aide acknowledged these items however specific instructions were not noted on the aide care plan. During the bed bath, the aide also noted the patient had a bandage on the coccyx. The coccyx bandage was not noted on the aide care plan, nor was the aide given instructions if the dressing became soiled, dislodged or wet. The coccyx wound, surgical incision, and oxygen were noted on the Registered Nurses initial nursing assessment dated 08/09/2026, however instructions for the coccyx bandage, surgical incision, and oxygen were not include in the aide care plan. CLINICAL RECORD 7: The hospice aide care plan dated 01/19/2026 assigned the aide the tasks: “Bath, change patient linens, foot care, nail care, oral care, peri care, skin care, promote skin integrity, change adult diapers, document bowel movements, incontinent care, clean bathroom, notify nurse of significant changes.” The tasks were to be completed every visit with an aide frequency of three times weekly. A hospice physician order dated 02/12/2026 noted the following: “Cancer lesion/ulcer. Left shoulder mass. Non adhesive pad, 6x6 border gauze dressing, and cover with abdominal pad.” The lesion was not included on the hospice aide care plan, and the aide was not provided with instructions if the dressing became soiled, dislodged, or wet. During a clinical record review and interview on 08/13/2026, the Regional Director of Homecare agreed the aides needed notification of the wounds and specific instructions regarding the dislodgement of the bandages.”

“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. A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure that the IPU complied with all applicable provisions of the National Fire Protection Association’s Life Safety Code, 2012 edition. IPU TOUR: During a tour of the agency’s free-standing IPU on 08/12/2026, there was no remote annunciator indicating the operating status of the IPU’s generator present in an area that was routinely monitored by staff. Additionally, this references “K916 Electrical Systems – Essential Electric System Alarm Annunciator: A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.” During an interview on 08/12/2026, the agency’s IPU’s Facility Manager, who was present for the IPU tour, confirmed that there was no remote annunciator in a routinely monitored area within the IPU. A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure that the IPU complied with all applicable provisions of the National Fire Protection Association’s Life Safety Code, 2012 edition.”

“Based on facility document review, review of the facility’s website and staff interviews the Hospice failed to have Centers for Medicare and Medicaid Services (CMS) approval prior to opening and providing general inpatient services in a location not listed on the hospice’s license or on the CMS 855A Change of Information form, as required. The findings include:On 6/17/26 at approximately 9:30 AM a tour was conducted of the hospice’s General Inpatient unit (GIP) housed on the 3rd floor of a local hospital. Upon exiting the elevator, a reception desk was noted and there was a large etched glass sign advertising this as the location for the hospice’s compassionate care center. (photographic evidence obtained)On 6/17/26 at approximately 9:45 AM, an interview was conducted with the Day Shift Charge Nurse who stated that the unit had been open for approximately 3 years and that all staff are employed by the hospice with exception of Environmental Services and Kitchen. She clarified that this location is a general inpatient unit (GIP) for symptom management, to include pain, agitation, shortness of breath, secretions, etc, stating they do not provide routine home care or respite care, only GIP. She reported they have a separate electronic medical record system from the hospital and their education and training is provided by the hospice not the hospital. They have a Medical Director, several rounding physicians, and two nurse practitioners, who are all employees of the hospice.On 6/17/26 at approximately 10:23 AM, an interview was conducted with the Chief Nursing Officer (CNO) and the Manager of the GIP Unit. During the interview the CNO explained that the center does not have a license as they operate as a hospital within a hospital, offering that the hospice leases space from the hospital. At this time the Manager stated that they do not have an individual license for the unit because they are under the license of the hospital.On 6/17/26 at approximately 12:48 PM, an interview was conducted with the Chief Operating Officer (COO) for the hospice. During the interview she explained that she had been advised by their attorney that since this was not a free standing facility they were not required to add the location to their hospice license, update the CMS-855A “Change of Information” form or have approval from CMS or AHCA (Agency for Health Care Administration). She provided a copy of the most recent CMS 855A offering that the GIP location would not be found on the form as they had been advised by their attorney that it was not necessary. She stated that it was her understanding that this location falls under the umbrella of the hospital’s license since they just lease the space.Review of the most recent CMS 855A form revealed the hospice Practice Locations Information included the following 7 locations all with the same Medicare ID:2889 Crawfordville Hwy, Suite C, Crawfordville Effective date 3/21/20101723 Mahan Center Blvd, Tallahassee – Effective date 3/21/20101723-1 Mahan Center Blvd, Tallahassee – Effective date 3/21/2010402 E Ash St, Perry – Effective date 10/07/2016208 N Adams St, Quincy – Effective date 12/15/2020128 SW Sumatra Ave, Unit B, Madison – Effective date 3/31/2021187 E Walnut Street, Monticello – Effective date 12/09/2020It is noted that the location for the General Inpatient Unit (IPU) located on the 3rd floor of the hospital is not listed.A review of the lease agreement between the hospital and the hospice revealed the parties entered into the agreement on May 17, 2023. The document offers that the lease was for an Inpatient Unit (IPU) located on the 3rd floor of the hospital. The lease goes on to state that the IPU shall be used for the operation of up to eight hospice beds and the provisions of hospice services and items. The lease states that the hospice agrees to operate the hospice and provide hospice services in the IPU continuously on a 24 hour per day 7 days a week basis throughout the term of the lease. Under (c) Permits and Authorization. Tenant shall be responsible for obtaining, at its sole cost and expense, all necessary licenses, approvals, permits and authorization for construction of all improvements to the IPU. Tenant shall be responsible for obtaining all necessary licenses, approvals, permits and authorizations for the operation of the IPU for inpatient hospice care. All clinical services to patients in the IPU will be provided by the hospice. In the event any patient in the IPU needs clinical services normally provided to a hospice patient by a hospital, then the patient will be transferred to the hospital in the same manner as any patient that might otherwise be cared for in the (Hospice House).Review of a Survey Status Report dated 11/9/23 from the Agency for Health Care Administration has the facility name listed as the hospital; Project name: Med.-Surg, beds & Hospice Renov. @3B S. (Renovations located on the 3rd floor B unit); OPC Project #: 23/100135-13324. The letter stated, “On 10/23/2023, a construction survey of one or more phases or areas of the referenced project was conducted. The results of this survey along with the status of other phases of this project are detailed in the following page(s). Only those phases and areas identified as approved (if any) may be used for their intended purpose.” “Projects that create a new facility license, a new off-campus building, or add licensed beds are subject to survey and approval by the AHCA field office.”A review of the hospital’s website (www.tmh.org/location/the-first-commerce-center-for-compassionate-care) revealed the following:(General Inpatient Unit) is a (Hospice agency) inpatient unit on the third floor of (Hospital). It was designed to be a homelike atmosphere to allow families to focus on what matters most—quality of life and time together. Eight thoughtfully decorated patient rooms support family members staying with their loved ones in a warm, homelike, comforting environment. The unit features a reflection room, communal kitchen and spaces for family gatherings.The (GIP) unit is staffed by (Hospice Agency) specifically trained medical and support professionals. These staff members provide support for:Pain and other symptoms that require expert care around the clock.Patients’ and families’ emotional, spiritual, and practical needs.Plans for transitions in care depending on each situation.”