Affinity Hospice

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to send a nurse to P1 for treatment and nursing interventions for pain symptom management for one patient (P) (P5) of three sample patients. Findings included: Review of document titled “Patient Bill of Rights,” revised November 2018 revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of text messages sent on 02/19/2026 from the family of P5 to the case manager revealed a request for a nurse visit to address a crisis and pain. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). The case manager failed to provide a nurse visit until 02/23/2026. Review of on call and complaint logs failed reveal the complaint from P5. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain.”

“Based on review of policies and procedures, record reviews, and staff and family interviews, it was determined that the hospice’s governing body failed to organize, manage, and administer its resources as evidenced by failure to:1. Provide on call staff 24 hours a day, seven days a week to meet the needs of the patient2. Provide pain assessments and management in a timely manner3. Provide staff for a patient visit for a significant change patient in condition4. Ensure all incoming complaints were documented and investigated in a timely manner5. Ensure the hospice administrator provided responsible oversight for day-to-day operations and supervision of hospice staffThese systemic failures impact the agency’s ability to provide care and services necessary for the management of the hospice patients’ terminal illness and related conditions. Findings included: An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who revealed the agency failed to send a nurse to address a crisis and manage pain. The Administrator confirmed the complaint from the family of P5 had been reported to her by the case manager. The Administrator confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction. An interview was conducted on 03/30/2026 at 2:00 PM with the case manager who stated that she received a text message from the family of P5 with a complaint. She stated she reported to the complaint to the Administrator. She states she failed to document the complaint per the agency’s policy An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction Cross reference to L0508 and L509 relating to patient rightsCross refer to L0651 relating to the governing body and administrator.Cross refer to L0653 relating to availability of staff on a 24-hour basis seven days a week”

“Based on policy titled “ON-CALL/WEEKEND SERVICES,” clinical record reviews, on-call log, and staff interviews, it was determined the agency failed to comply with the nursing services one-hour response time of a patient experiencing a crisis situation or change in condition for one patient (P) (P5) of three patients sampled from the agency’s on-call report. The findings included: Review of policy titled “ON-CALL/WEEKEND SERVICES,” Policy no. 4-036.1, revised November 2024” revealed the following:“PROCEDURE5. The on-call nurse will provide follow-up appropriate to the call:A. Call the patient/family/caregiverB. Visit the patient, if necessary6. The on-call nurse will document each patient/family interaction in a clinical note.7. The on-call nurse will maintain an on-call log of all patient contacts during on-call hours.8. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page.)” Review of on-call and complaint logs for the year of 2026 failed to reveal the complaint was documented and investigated. Review of text messages sent on 02/19/2026 from family member of patient P5 to the case manager revealed a request for a skilled nurse visit to assess the patient for a change in patient condition, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). The case manager failed to complete a nurse visit until 02/23/2026. Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication concerns or change in patient status or any follow up to medication effectiveness. On 03/30/2026 at 1:50 PM an interview was conducted with the case manager. The case manager revealed that she did receive a text message from the caregiver of P5 on 02/19/2026 who reported that P5 had a bowel impaction and was in severe pain and agitation and evidenced by screaming and crying. The case manager stated she had a family emergency and did not make the visit but advised the caregiver to medicate the patient for pain. The case manager reports she did pass the message to the Administrator but did not document any communication in the clinical record regarding communication with the caregiver or interventions provided. On 03/30/2026 at 2:10 PM an interview was conducted with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5. The Administrator confirmed that she did not have a nurse to send so she asked an as needed (PRN) nurse if she could complete the visit but did not follow up to see if the PRN nurse completed the visit. The PRN nurse did not complete the visit and the patient did not receive a skilled nurse visit until four days later on 02/23/2026. Cross reference to L0508 and L0509 relating to patient rights.Cross reference to L0546 relating to the care plan.Cross reference to L0651 relating to the governing body and administrator.Cross reference to L0653 relating to availability of staff on 24-hour basis seven days a week”

“Based on policy titled “COMPLAINT/GRIEVANCE PROCESS,” review of on call and complaint logs, and family and staff interview, it was determined that the agency failed to investigate a complaint for one patient (P) (P5) of three sampled patients related to a crisis and pain. Findings included: Review of policy titled “COMPLAINT/GRIEVANCE PROCESS,” revised date November 2018, revealed its purpose is to set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. The hospice agency staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five days of the alleged grievance. Review of on call and complaint logs failed to reveal the complaint from P5. During an interview on 03/30/2026 at 2:10 PM, the Administrator revealed the agency failed to document the complaint from the family of P5 and that the agency failed to send a nurse to address a crisis and manage pain. The Administrator confirmed the complaint from the family of P5 had been reported to her by the case manager. The Administrator confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction. An interview was conducted on 03/30/2026 at 1:19 PM with family member of P5 who stated that she texted the Case Manager (CM) requesting a nurse visit to manage a crisis and pain. The family member of P5 states the CM instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family member of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the CM made a visit on 02/23/2026 four days later. The family member of P5 stated she did not want any other patient to experience a delay in care.”

“Based on record review, staff and family interviews, it was determined that he agency failed to immediately investigate a complaint and resolve the complaint for one patient (P) (P5) of three sampled patients related to a crisis and pain. Findings included: Review of text messages sent on 02/19/2026 from family member of P5 to the case manager revealed a request for a nurse visit to address a crisis (potential bowel impaction) and pain. Review of text messages sent on 02/19/2026 from the family of P5 to the case manager revealed a request for a nurse visit to address a crisis (potential bowel impaction) and pain. An interview was conducted on 03/30/2026 at 2:00 PM with the case manager who stated that she received a text message from the family of P5 with a complaint. She stated she reported to the complaint to the Administrator. She states she failed to document the complaint according to the agency’s policy. An interview was conducted on 03/30/2026 at 1:19 PM with family member of P5 who stated that she texted the case manager requesting a nurse visit to manage a crisis and pain. The family of P5 stated she would forward the text messages to surveyors phone for viewing. The family member of P5 states the case manager instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family member of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the case manager made a visit on 02/23/2026 four days later. The family member of P5 stated she did not want any other patient to experience a delay in care. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to investigate the grievance for P5 and resolve the grievance to the patient’s satisfaction.”

“Based on policy titled “PATIENT BILL OF RIGHTS,” facility documents, record review, and staff and family interviews, it was determined that the agency failed to manage the patient’s pain and symptoms related to the terminal illness and related conditions in a timely fashion for one patient (P) (P5) of 19 patients reviewed. Findings included: Review of policy titled “PATIENT BILL OF RIGHTS,” revised November 2018 revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of text messages sent on 02/19/26 from the family member P5 to the case manager (revealed a request for a nurse visit to address a crisis and pain. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of record for P5 failed to reveal a nursed visit after request on 02/19/2026 until 02/23/2026. Review of on call and complaint logs failed to reveal the complaint from P5. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5.”

“Based on policy titled “THE PLAN OF CARE,” record review, and staff interview, it was determined that the agency failed to manage the pain and symptoms of the crisis for one patient (P) (P5) of 19 patients reviewed. The findings included: Review of policy titled “THE PLAN OF CARE,” Policy No. 4-027.1, revised November 2024 revealed the following:“PROCEDURE4. “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement.10. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.R. Pain and symptom management interventions.14. Care provided to the patient will be in accordance with the plan of care.” Review of text messages sent on 02/19/2026 from family member of patient P5 to the case manager revealed a request for a nurse visit to address a change in patient status, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication regarding the caregiver concerns or change in patient status or any follow up to medication effectiveness. Review of record for P5 failed to reveal a nursed visit after request on 02/19/2026 until 02/23/2026. Review of text messages sent on 02/19/2026 from family member of P5 to the case manager revealed a request for a nurse visit to address a crisis and pain. The case manager failed to complete a nurse visit until 02/23/2026. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5.”

“Based on review of policies and procedures, record reviews, staff and family interviews, it was determined the agency’s governing body failed to ensure hospice on call staff were available 24 hours a day, seven days a week to provide services to the patient such as change in patient condition, pain management and implementing and monitoring patients’ plans of care to include coordinating services based on the patient problems and needs for one patient (P) (P5) of 19 sampled patients. Additionally, the Governing Body failed to coordinate with members of the Interdisciplinary Group (IDG), to ensure staff were available at all times to meet the needs of the patient. Findings included: Cross reference to L0512 relating to right to effective pain managementCross reference to L0546 relating to Coordination of Services”

“Based on policy titled “HOSPICE NURSING CARE,” record review, staff and family interviews the hospice agency failed to ensure hospice staff were made available on a 24-hour basis 7 days a week to meet the needs of the patient for one patient (P) (P5) 19 patients reviewed. Findings included: Review of policy titled “HOSPICE NURSING CARE,” policy No. 4-002.1” revised November 2018 revealed the following:“3. The hospice nurse will: A. Manage discomfort and provide symptom relief5. A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of the patients and families/caregivers admitted to the hospice program.” Review of text messages sent on 02/19/2026 from the caregiver of patient P5 to the case manager revealed a request for a skilled nurse visit to assess the patient for a change in patient condition, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication regarding the caregiver concerns or change in patient status or follow up to medication effectiveness. The case manager failed to complete a nurse visit until 02/23/2026. An interview conducted on 03/30/2026 at 1:19 PM with family member of P5 stated that she texted the case manager requesting a nurse visit to manage a crisis and pain. The family of P5 states the case manager instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the case manager made a visit on 02/23/2026 four days later. The family of P5 stated she did not want any other patient to experience a delay in care. An interview on 03/30/2026 at 1:50 PM with the case manager who revealed that the she did receive a text message from the caregiver of P5 on 2/19/26 who reported that P5 had a bowel impaction and was in severe pain and agitation evidenced by screaming and crying. The case manager stated she had a family emergency and did not make the visit instead, advising the caregiver to medicate the patient for pain. The case manager reports she did pass the message to the Administrator but did not document any communication in the clinical record regarding communication with the caregiver or interventions provided. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5. The Administrator confirmed that she did not have a nurse to send so she asked an as needed (PRN) nurse if she could completed the visit but did not follow up to see if the PRN nurse completed the visit. The PRN nurse did not complete the visit and the patient did not receive a skilled nurse visit until four days later on 02/23/2026.”