Affinity Hospice

“Based on policies and procedures, facility documents review, and staff and family interviews, it was determined the facility failed to manage and provide hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. Specifically the hospice facility failed to identify that the facility could not adequately meet the needs one patient (P) P2 of three patients reviewed and failed to promote the patients’ rights to receive information about hospice services and any limitations. Findings Included: Cross reference to L0519 related to patient rights receive information about hospice services and any limitations.Cross reference to L0650 related to Optimizing comfort and dignity, patient needs and goals are priority.”

“Based on policy titled “PATIENT BILL OF RIGHTS,” facility documentation, and family and staff interviews, it was determined that the facility failed to communicate to the family of patient (P) (P2) as to reason for not being admitted for hospice services. This failure caused delay in providing hospice services for P2. Findings included: Review of the undated policy titled “PATIENT BILL OF RIGHTS,” revised 2018 revealed the following:“PURPOSETo encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning.POLICYEach patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient.PROCEDUREF. Be informed in advance of service about the care to be furnished, the organization’s scope of services and services under the Medicare Hospice Benefit and any limitations on these services.” Review of the undated referral document from the hospital for P2 revealed the request for start of services was 12/19. A phone interview was conducted with the family member of P2 on 06/26/2026 at 11:48 AM. The family member of P2 stated the hospice facility delayed admitting P2 to hospice services because the hospice facility was unable to provide the PCA (patient controlled analgesic computerized medical device, a pump for pain management).She stated that the hospice liaison informed her that there was a problem with getting the pump and medication but did not disclose that the hospice facility was unable to work with the pharmacy that had been selected by the hospital. She stated the hospice facility did not offer an alternative hospice facility to provide the care and caused the family of P2 to experience emotional and physical distress during the end of life care. The family member of P2 revealed that P2 was admitted to hospice services by another hospice facility on 12/23/2025 and expired on 12/25/2025. An office interview was conducted with the Area Director of Clinical Services on 6/26/2026 at 1:00 PM. The Area Director of Clinical Services revealed that P2 was scheduled to discharge from the hospital on December 19, 2025 with a PCA pump to manage pain. She revealed that the hospice facility was unable to provide the PCA pump due to a poor working relationship with the pharmacy that was selected by the hospital.The Area Director of Clinical Services revealed the hospice facility was unable to secure another resource to provide the PCA pump. She confirmed that the family of P2 was not made aware of the poor working relationship with the pharmacy. She acknowledged that this prolonged the hospital stay and delayed admission for hospice services for P2. The hospice liaison was unavailable for an interview as she no longer works for the hospice facility.”

“Based on review of policies, facility documents, staff and family interviews it was determined that the facility failed to provide hospice care that optimizes comfort and dignity; and is consistent with patient and family needs and goals, with the patient needs and goals as priority. Specifically, the hospice facility failed to obtain a PCA (patient controlled analgesic computerized medical device, pump for pain management) delaying the admission to hospice care of one patient (P) P2 of three patients reviewed. Findings Included: Review of policy titled “ADMISSION CRITERIA AND PROCESS,” with effective date February 2026 revealed that patients will be accepted for care based on need for hospice services. Consideration will be given to adequacy and suitability pf hospice personnel, resources to provide the required services, and the patient’s hospice care needs can be adequately met in the patient’s place of residence. A patient will be referred to other resources if the hospice cannot meet his or her needs. Review of the undated referral document from the hospital for P2 revealed the request for start of services was 12/19. Review of document titled “Client Coordination Note” dated 12/23/2025 revealed “PT CHOOSE ANOTHER HOSPICE.” An interview was conducted with the family member of P2 on 06/26/2026 at 11:48 AM. The family member of P2 stated the hospice facility delayed admitting P2 to hospice services because the hospice facility was unable to provide the PCA pump for (device for pain management)She stated that the hospice liaison informed her that there was a problem with getting the pump and medication but did not disclose that the hospice facility was unable to work with the pharmacy that had been selected by the hospital. She stated the hospice facility did not offer an alternative hospice facility to provide the care and caused the family of P2 to experience emotional and physical distress during the end of life care. The family member of P2 revealed that P2 was admitted to hospice services by another hospice facility on 12/23/2025 and expired 12/25/2025. An in office interview was conducted with the Area Director of Clinical Services on 06/26/2026 at 1:00 PM. The Area Director of Clinical Services revealed that P2 was scheduled to discharge from the hospital on December 19, 2025 with a PCA pump to manage pain. She revealed that the hospice facility was unable to provide the PCA pump due to a poor working relationship with the pharmacy that was selected by the hospital. The Area Director of Clinical Services revealed the hospice facility was unable to secure another resource to provide the PCA pump. She acknowledged that this prolonged the hospital stay and delayed admission for hospice services for P2. The hospice liaison was unavailable for an interview as she no longer works for the hospice facility.”

“Based on review of policies and procedures, facility documents, and staff interview, it was determined that the facility’s the governing body failed to assume full authority and responsibility for the management of the hospice and addresses the functioning of specific hospice operations, services and QAPI program. Specifically, the hospice failed to:1. Optimize comfort and dignity consistent with patient’s needs and goals.2. Promote the patients’ rights to receive information about hospice services and any limitations. Findings included: Review of policy titled “GOVERNING BODY,” revised November 2018, revealed the following:“PolicyThe Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organization’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program.Procedure2. The Governing Body will establish policies that are consistent with the organization’s mission and approve new or revised policies as needed.” Review of policy titled “INTAKE PROCESS,” revised November 2018 revealed the following:“PurposeTo establish the process for acceptance and entry of patient into the organization.PolicyThe organization accepts only those patients whose needs can be met by the services it provides.” Review of policy titled “ADMISSION CRITERIA AND PROCESS” with effective date February 2026 revealed that patients will be accepted for care based on need for hospice services. Consideration will be given to adequacy and suitability pf hospice personnel, resources to provide the required services, and the patient’s hospice care needs can be adequately met in the patient’s place of residence. A patient will be referred to other resources if the hospice cannot meet his or her needs. An interview was conducted with the Area Director of Clinical Services on 06/26/2026 at 1:00 PM. The Area Director of Clinical Services revealed the hospice facility failed to follow the policies for admission criteria and intake processes. Cross reference to L0519 relating to rights of the patientCross reference to L0650 relating to serving the hospice patient and family”

“Based on record reviews and staff interviews, it was determined the hospice failed to ensure that patient and primary caregiver received training and education provided by the agency as appropriate for their responsibilities for care and services for two patients (P) (P12, P13) of 20 patients sampled. Findings include: 1. Record review reveals P12 was admitted to hospice on 3/19/2024 with a diagnosis of hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure and the heart muscle doesn’t pump blood as well as it should). Review of a document dated 3/19/2024, titled, “;Hospice Certification and Plan of Care”, reveals P12 was admitted to home hospice on a Milrinone drip (a drug that treats heart failure by increasing the strength of heart muscles and widening blood vessels), infusing through a PICC line (a peripherally inserted central catheter that is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest) in the right upper arm and a PleurX catheter (a flexible tube that drains excess fluid from the pleural space, the area between the lung and chest wall), site not specified. Review of the “;Orders of Discipline and Treatments” on the Hospice Certification and Plan of Care reveals the following: · “;Hospice nurse to instruct regarding infusion procedure: Milrinone 400mcg/ml to infuse @ (at) 3.2ml/hr via right upper arm PICC line. Flush with 3cc Heparin (anticoagulant (blood thinner) that prevents the formation of blood clots) daily, care and use of equipment, record keeping, infusion pump, and signs/symptoms of infection/ infiltration/complications/phlebitis.” · “;Hospice nurse to instruct/ perform care of PleurX drainage tube site, draining procedure and frequency” Review of Coordination Notes and Visit Notes failed to reveal patient or caregiver education on Milrinone, PICC line care, or the PleurX catheter. 2. Record review reveals P13 was admitted to hospice on 5/13/2024 with a diagnosis of heart failure (when the heart muscle doesn’t pump blood as well as it should). Review of a document titled, “;Hospice Certification and Plan of Care,” dated 5/13/2024 reveals P13 was admitted to home hospice with a Milrinone drip, infusing through a PICC line in the right upper arm. Review of the “;Orders of Discipline and Treatments” on the Hospice Certification and Plan of Care reveals the following: “;Hospice nurse to instruct regarding infusion procedure: Milrinone 20 mg/100ml (200mcg/ml) infusing @ 2.7ml/hr via right upper arm PICC line. Instruct in care of line, flush PICC line with 100cc of SNS with each Milrinone bag change, care and use of equipment, record keeping, infusion CADD pump, operation, and signs/symptoms of infection/ infiltration/complications/phlebitis.” A review of Coordination Notes and Visit notes revealed the clinical record failed to reveal patient or caregiver education on Milrinone or care of the PICC line. On 9/9/2024 at approximately 2:00 pm, an interview with the Regional Vice President of Operations (RVPCO) revealed patients with PleurX catheters are given a package insert from the drainage kit to instruct and educate them on how and when to use the drainage catheter. The RVPCO confirmed that any patient/caregiver education provided should be documented in the clinical record. On 9/11/2024 at approximately 10:00 am, an interview with Clinical Managers (CM) A and B revealed teaching about Milrinone begins at the hospital before admission to home hospice. On admission, all patients are told to call the hospice for any problems. CM AA and BB confirmed that the PleurX package insert is routinely provided to patients with PleurX catheters and confirmed that all patient education provided should be documented in the clinical record.”

“Based on record reviews, staff interviews, and review of policies titled “;Verification of Physician Orders,” and “;Interdisciplinary Group Plan of Care,” it was determined the hospice failed to develop an individualized plan of care that includes all services necessary for the management and palliation of the terminal illness and related conditions for two patients (P) (P12, P13) of 20 sampled patients. Findings include: Review of the policy titled “;Verification of Physician Orders,” Policy No. 4-028.1, revised November 2018, reveals the following: Policy Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients. Review of the policy titled “;Interdisciplinary Group Plan of Care,” Policy No. 4-031.1, revised November 2018, reveals the following: Policy The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals and interventions 1. P12 was admitted to hospice on 3/19/2024 with a diagnosis of hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure and the heart muscle doesn’t pump blood as well as it should). Review of a document titled, “;Hospice Certification and Plan of Care,” dated 3/19/2024 reveals P12 was admitted to home hospice with a Milrinone drip (a drug that treats heart failure by increasing the strength of heart muscles and widening blood vessels), infusing through a PICC line (a peripherally inserted central catheter that is a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest) in the right upper arm and a PleurX catheter (a flexible tube that drains excess fluid from the pleural space, the area between the lung and chest wall), site not specified. Review of the “;Orders of Discipline and Treatments” on the Hospice Certification and Plan of Care reveals the following: · “;Hospice nurse to instruct regarding infusion procedure: Milrinone 400mcg/ml to infuse @ 3.2ml/hr via right upper arm PICC line. Flush with 3cc Heparin daily, care and use of equipment, record keeping, infusion pump, and signs/symptoms of infection/ infiltration/complications/phlebitis.” · “;Hospice nurse to change central line dressing per physician/agency protocol” · “;Hospice nurse to instruct/ perform care of PleurX drainage tube site, draining procedure and frequency” · The clinical record failed to reveal specific physician orders prescribing care of the PICC line or frequency of dressing changes. The clinical record lacks specific physician orders related to the care and maintenance of the PleurX tube and insertion site, frequency of draining or dressing changes, or parameters for notifying the physician or draining. 2. P13 was admitted to hospice on 5/13/2024 with a diagnosis of heart failure (when the heart muscle doesn’t pump blood as well as it should). Review of document titled, “;Hospice Certification and Plan of Care,” dated 5/13/2024, reveals P13 was admitted to home hospice with a Milrinone drip, infusing through a PICC line in the right upper arm. Review of the “;Orders of Discipline and Treatments” on the Hospice Certification and Plan of Care reveals the following: · “;Hospice nurse to change central line dressing per physician/agency protocol” · “;Hospice nurse to flush IV access with 10 cc of NS with each dressing change using aseptic technique”. · “;Flush PICC line with 10 cc of SNS with each Milrinone bag change” The clinical record failed to reveal specific physician orders prescribing care of the PICC line or frequency of dressing changes. On 9/9/2024 at approximately 2:00 pm, an interview with the Regional Vice President of Operations (RVPCO) revealed nurses use a Lippincott Manual of Nursing Practice to guide nursing care for central lines. The RVP of CO revealed patients with PleurX catheters are given a package insert from the drainage kit as instructions and education on how and when to use the drainage catheter. The RVPCO agreed that specific physician orders need to be in the clinical record for both PICC line care and PleurX catheter use. On 9/11/2024 at approximately 10:00 am, an office interview was conducted with Clinical Managers (CM) A and B, who revealed nurses provide PICC line care weekly. They agreed the physician orders were not specific and individualized for each patient.”