Loving Arms Hospice

“Based on review of policy titled “Initial Assessment/Comprehensive Assessment,” clinical record reviews, and staff interviews, it was determined the agency failed to assess psychosocial, emotional, and spiritual needs for six patients (P) (P1, P3, P5, P6, P7, P13) of 14 sampled patients. Findings included: Review of undated policy titled “Initial Assessment/Comprehensive Assessment,” revealed the following:“2. Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patient’s need for Hospice care and identify the patient’s need for:• Physical care.• Psychosocial and emotional care.• Spiritual care.3. The comprehensive assessment will take into consideration the following factors:• Patient/family spiritual orientation, including the desire for involvement of a religious group.• Spiritual concerns or needs identified by the patient or family, e.g., despair, suffering, guilt and forgiveness.• Patient and family support systems involvement in support group, if any.• Additional information about the patient’s psychosocial status, such as family relationships, social history, the source and adequacy of environmental and other resources, coping mechanisms and the patient’ and family’s reactions to illness.” Review of records for P1 failed to reveal a spiritual or psychosocial assessment. Review of records for P3 failed to reveal a spiritual or psychosocial assessment. Review of records for P5 failed to reveal a psychosocial assessment. Review of records for P6 failed to reveal a psychosocial assessment. Review of records for P7 failed to reveal a psychosocial assessment. Review of records for P13 failed to reveal spiritual or psychosocial assessments. On 05/12/2026 at 2:20 PM, an interview was conducted with the Administrator, who confirmed that all documentation had been provided for P1, P3, P5, P6, P7, and P13.”

“Based on review of policy titled “Bereavement Services,” clinical record reviews and staff interview, it was determined that the agency failed to conduct initial bereavement assessments as part of the initial comprehensive assessments for two patients (P) (P6, P7) of 14 sampled patients. Findings included: Review of the policy titled “Bereavement Services,” revised June 2019, revealed the following:“PROCEDURE2. An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain or Bereavement Counselor. The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery.9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record.” Review of the clinical records for P6 and P7 failed to reveal initial bereavement assessments or documentation by a chaplain. On 05/13/2026 at 1:40 PM, an in-office interview was conducted with the Administrator, who revealed the agency’s chaplain is responsible for performing and documenting all bereavement care. The Administrator was not aware that the clinical records lacked initial bereavement assessments.”

“Based on review of policy titled “IDG Care Planning Process,” review of records, and staff interview, it was determined that the agency failed to develop an individualized plan of care for each patient containing orders for staff visits for two patients (P) (P1 and P5) of 14 sampled patients. Findings included: Review of undated policy titled “IDG Care Planning Process,” reveals the following:“Procedure8. An individualized written plan of care is developed for each patient. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including:A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.Visit ranges may be used:The plan of care includes a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient.” 1. Review of records for P1 reveals document titled “IDG Meeting,” dated 03/12/2026, failed to contain an order for Chaplain (CH) visits. However, review of P1’s clinical chart reveals the agency’s CH made visits on 02/15/2026, 03/13/2026, 03/23/2026, 04/07/2026, and 04/21/2026. 2. Review of records for P5 reveals document titled “IDG Meeting,” dated 02/26/2026, failed to contain an order for Chaplain (CH), Social Worker (SW), Certified Nursing Assistant (CNA), Registered Nurse (RN) or Nurse Practitioner (NP) visits. However, review of P5’s clinical chart reveals the following:• CH visits on 02/20/2026, 03/11/2026, and 03.24/2026.• SW visit on 03/05/2026.• CNA visits on 02/17/2026, 02/25/2026, 02/.27/2026, 03/02/2026, 03/04/2026, 03/06/2026, 03/09/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/18/2026, 03/20/2026, and 03/23/2026.• RN visits on 02/28/2026, 03/05/2026, 03/12/2026, 03/19/2026, 03/26/2026, 04/02/2026, and 04/09/2026.• NP visits on 02/26/2026. On 05/12/2026 at 2:15 PM, during an office interview, the Administrator confirmed missing staff visit orders for P1 and P5.”

“Based on review of policy titled “IDG Care Planning Process,” review of records, and staff interview, it was determined that the agency failed to ensure patients clinical chart contained goals and interventions with measurable outcomes for implementing and coordinating the plan of care for 14 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) of 14 sampled patients. Findings included: Review of undated policy titled “IDG Care Planning Process” reveals the following:“8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including: o Interventions to manage pain and other symptoms.Effective pain and symptom management includes the ongoing assessment of the patient’s physical, psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current plan of care in order to address those needs.Symptoms such as pain, nausea, vomiting, dehydration, constipation, dyspnea, emotional distress, insomnia, neuropsychiatric symptoms and spiritual needs will be managed using accepted professional standards of practice.Alternative therapies may be utilized, e.g., music, light and pet therapy, message, yoga, etc.” 1. Review of P1’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 2. Review of P2’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 3. Review of P3’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 4. Review of P4’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 5. Review of P5’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 6. Review of P6’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 7. Review of P7’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 8. Review of P8’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 9. Review of P9’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 10. Review of P10’sIDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 11. Review of P11’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 12. Review of P12’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 13. Review of P13’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. 14. Review of P14’s IDG notes failed to reveal goals and interventions with measurable outcomes for implementing and coordinating the plan of care. On 05/12/2026 at 1:30 PM during an office interview the Director of Nursing (DON) confirmed P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14’s clinical chart did not contain goals and interventions with measurable outcomes for implementing and coordinating the plan of care. The DON stated, “I did not know every staff member seeing a patient needed to have their own specific care plan put into each patient’s clinical chart.””

“Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” record review, and staff interview, it was determined the agency failed to measure, analyze, and track quality indicators to assess the agency’s processes of care, services, and operations as part of the agency’s QAPI program. Findings included: Review of undated policy titled “Quality Assessment and Performance Improvement (QAPI) Plan” revealed the following:“PURPOSETo define the QAPI program• To collect and analyze data to improve identified processes and outcomes of care.• To collect and analyze data to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial processes, as indicated.DATA COLLECTION1. Data collection will include established priorities for improvement.2. Data collection may include:• High risk processes: patients are placed at risk of serious consequences or deprived of care if care is not provided correctly, not provided when indicated or provided when not indicated.• High volume processes: care/service/process occurs frequently or affects large numbers of patients/staff.• Problem prone processes: care/service/process tends to produce problems for patients or staff.3. Data collection will include process of care. hospice services and operations and includes developing indicators, criteria or performance levels for each process determined to be improved.AGGREGATION AND ANALYSIS1. The Administrator/Director will compile and analyze collected data.” Review of QAPI notebook revealed documents titled “Quality Assurance Meeting” dated 07/17/2025, 12/04/2025, and 02/12/2026. Review of documents failed to reveal quality indicator data was collected or discussed during QAPI meetings. On 05/11/2026 at 2:00 PM, an office interview was conducted with the Director of Nursing (DON), who revealed that she is responsible for the QAPI program but is new to hospice and the agency. The DON confirmed that all QAPI audits and documentation had been provided.”

“Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” record review, and staff interview, it was determined the agency failed to use measurable outcomes to document performance improvement projects and the progress achieved on the projects. Findings included: Review of the undated policy titled “Quality Assessment and Performance Improvement (QAPI) Plan” revealed the following:“PERFORMANCE EXPECTATION1. For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified.3. A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee.ACHIEVED AND SUSTAINED IMPROVEMENT1. The Administrator/Director is responsible for taking appropriate action. Aggregate measures of performance for each process will be compared to pre-established performance expectations to determine if additional evaluation is required. If the performance expectation is not met, the findings will be evaluated by the Administrator/Director to determine the systematic approach for making improvement. The systematic approach will include:• Analyzing data from the test to determine if change improved performance.7. Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them.” Review of documents titled “Performance Improvement Project,” revealed the following:• A Performance Improvement Project (PIP), dated 10/09/2025, revealed the problem to be missing physician certifications, but failed to reveal the number of records affected, project goals, or thresholds for follow-up.• A PIP dated 10/13/2025 revealed the problem of care plan goals not properly documented, but failed to reveal the number of records affected, project goals, or thresholds for follow-up.• A PIP dated 10/28/2025 revealed the problem of nursing care plans not addressed during nursing visits, but failed to reveal the number of records affected, project goals or thresholds for follow-up.• A PIP dated 03/13/2026 reveals problem of Registered Nurse Case Managers (RNCMs) not consistently completing follow-up visits within 24 hours of admission or transfer, but failed to reveal the number of records affected, goals, or thresholds for follow-up.• A PIP dated 03/20/2026 reveals the problem of Social Workers (SWs) not following up with patients within 5 days of admission, but failed to reveal the number of records affected, goals, or thresholds for follow-up. Agency records failed to reveal measurable data at the initiation of the PIP or data to evaluate progress or improvement achieved. On 05/13/2026 at 11:00 AM, an office interview was conducted with the Director of Nursing (DON) and the Administrator, who confirmed that all QAPI audits and documentation had been provided.”

“Based on review of the policy titled “Bereavement Services,” clinical record review, and staff interview, it was determined that the hospice failed to establish a bereavement plan of care to reflect the needs of the bereaved for two patients (P) (P9, P11) of two sampled bereavement charts. Findings included: Review of the policy titled “Bereavement Services,” revised June 2019, revealed the following:“PROCEDURE1. Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient’s death. Bereavement services will be coordinated with the individual’s spiritual counselor or Hospice Chaplain as well as with other community resources judged to be useful and beneficial to the family/caregiver.2. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain or Bereavement Counselor. The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery.3. Within two weeks of the patient death, a condolence card will be mailed to the family. Within a month of death, a twelve-month bereavement-mailing program will be initiated for designated family members.4. After a patient death has occurred, the case will be discussed at the next IDG meeting. Recommendations for bereavement will be made based on the severity of grief and determined by the family member’s consent for further services. Bereavement services must reflect the needs of the bereaved.5. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated, which may include:o Telephone supporto Letters and cards.o Referral to other community resourceso Memorial serviceso Bereavement campso Telephone contactso Individual or family counseling and bereavement groupso The plan of care will note the kind of bereavement services to be offered and frequency of service delivery.9. Bereavement assessment and clinical notes are documented in the patient’s permanent clinical record.” Record reviews revealed the date of death for P9 as 04/15/2026. The clinical record failed to reveal an updated bereavement assessment or a bereavement plan of care. Record reviews revealed the date of death for P11 as 01/13/2026. The clinical record failed to reveal an updated bereavement assessment or a bereavement plan of care. On 05/13/2026 at 1:40 PM, an in-office interview was conducted with the Administrator, who revealed the agency’s chaplain is responsible for performing and documenting all bereavement care. The Administrator was not aware that the clinical records lacked updated bereavement assessments or bereavement plans of care.”

“Based on review of personnel files and staff interview, it was determined that the hospice failed to ensure that the annual Certified Nurse Aide (CNA) competency evaluation included all required subject areas for one of one CNA sampled. Findings included: Review of the personnel file for CNA AA revealed a hire date of 10/03/2023. Further review of the personnel file for CNA AA revealed an annual competency evaluation completed on 01/27/2026.Review of the competency evaluation failed to reveal that the competency evaluation included the following required subject areas:• Reading and recording temperature, pulse, and respiration.• Sponge, tub, and shower bath.• Hair shampoo (sink, tub, and bed).• Nail and skin care• Oral hygiene• Toileting and elimination.• Safe transfer techniques and ambulation.• Normal range of motion and positioning. On 05/13/2026 at 10:30 AM, an in-office interview was conducted with the Administrator, who revealed that she was unaware that the CNA competency evaluation lacked required specific subject areas.”

“Based on review of policy titled “Hospice Aide Supervision,” record reviews and staff interview, it was determined that the agency failed to ensure all Certified Nursing Assistants (CNA) received an onsite supervised patient home visit by a Registered Nurse (RN) at least every 14 days to assess for quality of care and services to meet patients’ needs for two patients (P) (P3 and P5) of 10 active patients clinical charts reviewed. Findings include: Review of policy titled “Hospice Aide Supervision,” with revised date February 2022, reveals the following:“PROCEDURE1. Hospice Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence.2. In addition to ensuring that Hospice Aides furnish the care identified in the plan of care, RNs must assess the adequacy of the aide services in relationship to the needs of the patient and family. The supervisory visits must be documented in the patient’s clinical record.3. If an area of concern is noted by the RN, then Hospice must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he/she is performing care. The patient record must indicate that direct on-site supervision of the Aide occurred during the next Aide visit in addition to any additional findings or related follow-up training.” Review of P3’s clinical record failed to reveal a RN supervisory visit after 03/12/2026, for physician ordered CNA services of three times a week, during certification period of 03/05/2026 through 06/02/2026. Review of P5’s clinical record failed to reveal a RN supervisory visit, for physician ordered CNA services of three times a week, during certification period of 03/01/2026 through 04/29/2026. On 05/12/2026 at 12:30 PM, during an office interview, the Director of Nursing (DON) confirmed P3 and P5’s clinical chart did not contain RN supervisory visit for physician ordered CNA services of three times a week.”

“Based on review of agency’s policies and procedures, record reviews, and staff interviews it was determined the hospice governing body and Administrator failed to assume responsibility for the management of the hospice and hospice services. Specifically, the hospice governing body failed to:1. Assess psychosocial, emotional, and spiritual needs for six patients (P) (P1, P3, P5, P6, P7, P13) of 14 sampled patients.2. Conduct initial bereavement assessments as part of the initial comprehensive assessments for two patients (P) (P6, P7) of 14 sampled patients.3. Ensure the Plan of Care was updated containing orders for staff visits for two patients (P) (P1, P5) of fourteen sampled patients charts reviewed.4. Ensure the Interdisciplinary Group (IDG) requirements were met for reviewing, revising, and documenting patients individualized plan of care with patient and family goals and interventions based on the problems identified for 14 patients (P) (P1,P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) of fourteen sampled patients charts reviewed.5. Measure, analyze, and track quality indicators to assess the agency’s process of care, service, and operation as part of the Quality Assurance and Performance Improvement (QAPI) program.6. Use measurable outcomes to document performance improvement projects (PIP) and any progress achieved on the projects. 7. Establish a bereavement plan of care to reflect the needs of the bereaved for two patients (P) (P9, P11) of two sampled bereavement charts.8. Ensure that the annual Certified Nurse Aide (CNA) competency evaluation included all required subject areas for one of one CNA sampled.9. Ensure all Certified Nurse Aides (CNA) received an onsite supervised patient home visit by a Registered Nurse (RN) at least every 14 days to assess for quality of care and services to meet patients’ needs for two patients (P) (P3 and P5) of 10 active patients clinical charts reviewed.10. Ensure hospice employees receive the required hospice orientation training for three employees [(Medical Director (M. Dir), Social Worker (SW), Chaplain (CH)] of eight sampled employees’ human resource (HR) files reviewed. Findings included: Cross Refer to citation L0524 for findings regarding psychosocial, emotional, and spiritual assessments.Cross Refer to citation L0531 for findings regarding bereavement assessments.Cross Refer to citation L0545 for findings regarding Plan of Care.Cross Refer to citation L0548 for findings regarding Interdisciplinary Group (IDG) requirements for individualized plan of care (POC).Cross Refer to citation L0562 for findings regarding Quality Assurance and Performance Improvement (QAPI) program.Cross Refer to citation L0573 for findings regarding measurable outcomes for performance improvement projects (PIP).Cross Refer to citation L0596 for findings regarding bereavement plan of care.Cross Refer to L0615 for findings regarding the annual CNA competency evaluationsCross Refer to L0629 for findings regarding the onsite supervision of CNACross Refer to L0662 for findings regarding Hospice employee training”

“Based on review of policy titled “Human Resource Policy,” review of the personnel files and staff interview, it was determined that the hospice failed to ensure hospice employees received the required hospice orientation training for three employees [Medical Director (M. Dir), Social Worker (SW), Chaplain (CH)] of eight sampled employees. Findings included: Review of the undated policy titled “Human Resource Policy,” revealed the following:“ORIENTATION AND TRAINING1. All new employees shall complete the orientation prior to providing patient care independently.2. Orientation shall include• Infection control• Emergency preparedness• Patient rights• Abuse, neglect, and exploitation reporting• Hospice philosophy and standards of carePERSONNEL RECORDSPersonnel records shall include:• Orientation records” 1. Review of the personnel file for M. Dir revealed a hire date of 04/01/2026. Further review of personnel files failed to reveal documentation of the required hospice orientation training. 2. Review of the personnel file for SW revealed a hire date of 03/23/2021. Further review of personnel files failed to reveal documentation of the required hospice orientation training. 3. Review of the personnel file for CH revealed a hire date of 09/12/2023. Further review of personnel files failed to reveal documentation of the required hospice orientation training. On 05/13/2026 at 10:30 AM, an in-office interview was conducted with the Administrator, who revealed that she was unaware that the personnel files lacked documentation of the required orientation training. The Administrator further revealed that whenever the hospice hires employees from the hospital, they usually bring their information from their hospital employment which is added to their hospice personnel file.”

“Based on review of policies “IDG Care Planning Process” and “Reassessments/Update to the Comprehensive Assessment,” clinical record reviews and staff interview, it was determined the agency failed to include spiritual and psychosocial assessments and care plans in the clinical records for 14 patients (P) (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14) of 14 sampled patients. Findings included: Review of the undated policy titled “IDG Care Planning Process,” revealed the following:“PURPOSETo define the IDG care planning process and documentation of care planning.1. Hospice has designated an interdisciplinary group which, in consultation with the patient’s attending physician, prepares a written plan of care for each patient.3. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice. IDG supervises the care and services.9. The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days.• The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management. and spiritual and psychosocial needs.” Review of policy titled “Reassessments/Update to the Comprehensive Assessment,” revised May 2023, revealed the following:“1. The update of the comprehensive assessment must be accomplished by the Hospice IDG (in collaboration with the patient’s attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.• The update to the comprehensive assessment will include assessments of changes in physical, psychosocial, emotional and spiritual needs.” Review of the clinical charts for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 failed to reveal care plans for Social Worker or Chaplain. On 05/12/2026 at 1:30 PM, an interview was conducted with the Director of Nursing (DON), who revealed she was new and she did not know that the Social Workers and Chaplains were required to have care plans.”

“Based on review of policy titled “Hospice Physician Certification and Recertification,” clinical record reviews, and staff interviews, it was determined the agency failed to include current physician certifications in the clinical record for one patient (P) (P6) of 14 sampled patients. Findings included: Review of the undated policy titled “Hospice Physician Certification and Recertification,” revealed the following:“PolicyLoving Arms Hospice, Inc. shall ensure that all patients admitted to hospice services have a valid certification of terminal illness completed in accordance with Medicare hospice regulations. The certification must support a prognosis of six (6) months or less if the illness follows its normal course.Recertification Requirements2. Recertification is required:• Prior to the second 90-day benefit period, and• Prior to each subsequent 60-day benefit period.4. Recertifications must be completed prior to the start of the new benefit period.Director of Nursing/Clinical Manager• Monitors compliance with certification timelines.” Clinical records were reviewed from the electronic medical record (EMR) and paper charts. The records failed to reveal current physician certifications of terminal illness (CTI) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14. On 05/13/2026 at 10:30 AM, current CTIs were provided to surveyors by the Administrator for P1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P12, P13, and P14. Review of document titled “Written Certification,” revealed P6 had a certification period date of 03/07/2026 – 05/05/2026. Further review of the clinical records for P6 failed to reveal a physician’s certification for dates after 05/05/2026. On 05/12/2026 at 2:45 PM, an office interview was conducted with the Administrator, who revealed that the Medical Director had been out with an extended illness and that the physician’s responsibilities were behind. On 05/13/2026 at 12:45 PM, an office interview was conducted with the Administrator, who revealed that certifications were current “because I made a phone call.””