Dharma Hospice and Palliative Care, LLC

“Based on review of agency policies and procedures, clinical record reviews, and staff interviews it was determined the agency’s Interdisciplinary Group (IDG) failed to complete comprehensive assessments within five calendar days after patient is admitted to hospice services for 11 patients (P) (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15) of 11 active sampled patients. Additionally, the agency failed to update the plan of care (POC), with any changes in the patients’ needs and condition through comprehensive assessments every 15 days for nine patients P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#13, and P#14 of 11 active sampled patients. Findings include: Review of undated policy titled “Development of Plan of Care,” revealed the following:• The appropriate members of the hospice care team shall identify the needs of the patient and provide a complete assessment no later than seven (7) days after admission. This will include medical, nursing, psychosocial, and spiritual evaluations of the patient and family unit meeting the care needs and the need for bereavement services.• The hospice care team shall meet as a group to review each patient’s plan-of-care. The plan of care shall be updated as the patient’s condition changes and as additional services are needed, at intervals of no more than 15 days. All reviews and updates shall be documented in the patient’s medical record. Review of policy titled “IDG Care Planning Process,” dated 1/18/2021, revealed the following:• 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.• A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.• 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. Record reviews revealed P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14 and P#15 failed to reveal a completed Chaplain/Spiritual Counselor comprehensive assessment. Record review revealed the POC for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#13, and P#14 failed to contain updated care plan interventions and goals. On 9/24/2025 at 11:15 a.m., during an office interview, the Administrator acknowledged the agency’s Chaplain was not completing initial comprehensive assessments. The Administrator additionally acknowledged patients’ POC with interventions and goals were not being updated by the staff. On 9/24/2025 at 11:00 a.m., during an office interview, Licensed Practical Nurse (LPN) AA acknowledged she had never been to an IDG meeting and she was not aware frequencies for skilled nursing (SN) visits were not in her patients’ charts. Additionally, LPN AA acknowledged she was aware P#14 had a wound, but she was not aware the POC needed wound care interventions and goals added. Cross reference to L0523 relating completed comprehensive assessments within 15 daysCross reference to L0531 relating to bereavement assessmentCross reference to L0533 relating to updated POC and IDG signatures”

“Based on review of agency’s policy titled “Development of Plan of Care,” record reviews, and staff interviews, it was determined that the agency failed to develop an individualized plan of care to include all services necessary for the palliation and management of the terminal illness and related conditions for four patients (P#5, P#6, P#8, P#9 and P#14) of 11 active sampled patients and include in the POC updated detailed scheduled visits for services necessary to meet each patient and family needs for three patients (P) (P#5, P#6, and P#9) of 11 active sampled patients. Findings include: Review of undated policy titled “Development of Plan of Care,” revealed the following:The hospice care team shall meet as a group to review each patient’s plan-of-care. The plan of care shall be updated as the patient’s condition changes and as additional services are needed, at intervals no more than 15 days. All reviews and updates shall be documented in the patient’s medical record. Review of records for P#5, P#8, P#9 failed to include an updated care plan with interventions and goals for current benefit period. Review of POC for P#5, P#6 and P#9 revealed the POC failed to include scheduled visit frequencies for the Skilled Nurse (SN), Social Worker (SW) and Chaplain (CH) for current benefit period. Record review for P#14 failed to contain a wound care plan with interventions and goals for sacral wound identified during initial skilled nurse (SN) assessment at start of care (SOC) on 8/13/2025. Cross reference to L0545 related to plan of care requirements and content.Cross reference to L0547 related to plan of care frequency of services.”

“Based on review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” review of agency documents, and staff interview, it was determined the hospice failed to implement and maintain a data-driven quality assessment and performance improvement (QAPI) program. The agency failed to document quality indicator data as part of the QAPI program and failed to use measurable outcomes to demonstrate progress towards improvement in performance improvement projects (PIPs). Findings include: Review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” dated 1/18/2021 revealed the following:POLICYHospice has established an ongoing program of quality assessment and performance improvement. OBJECTIVES.To collect and analyze data to improve identified processes and outcomes of care. Review of QAPI meeting minutes dated 6/28/2025 failed to reveal audits or measurable data for use in QAPI. Review of documents titled “QAPI- Team Specific Process and Performance Improvement Projects,” revealed seven performance improvement projects (PIPs) that failed to include measurable data for use in measuring improvement. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who revealed she is currently the QAPI Coordinator. The Administrator revealed no standardized audit tools are used for measuring quality of patient care and was unaware of the need to include measurable quality indicators in the QAPI program. Cross-reference to L0562 relating to tracking quality indicatorsCross-reference to L0573 relating to performance improvement projects”

“Based on review of the policy titled “Development of Plan of Care,” clinical record reviews and staff interview, it was determined the hospice failed to provide core services by not providing chaplain services for 11 of 11 active sampled patients (P) sampled (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15) and failure to establish a bereavement plan of care for three patients (P) (P#1, P#2, P#3) of three sampled bereavement charts. Findings include: Review of the undated policy titled “Development of Plan of Care,” revealed the following:Dharma Hospice will designate a hospice care team for each patient. The hospice care team will be composed of professional individuals who will provide or supervise the care and services offered by hospice. The hospice care team shall Include: A physician, Registered Nurse (RN), Medical Social Worker, a member of the clergy or licensed professional counselors, dietitian and volunteers.The appropriate members of the hospice care team shall identify the needs of the patient and provide a comprehensive assessment no later than seven (7) days after admission. This will include medical, nursing, psychosocial, and spiritual evaluations of the patient and family unit in meeting the care needs and the need for bereavement services. Review of clinical records for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15 failed to reveal initial spiritual assessments or initial bereavement assessments and failed to reveal documentation by a Chaplin. Review of a binder labeled “Bereavement” failed to reveal bereavement care plans for P #1, P#2, and P#3. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who confirmed all documentation had been provided. The Administrator revealed the Chaplain, who also serves as the Bereavement Coordinator, had quit that morning without notice but could not explain why clinical records did not have chaplain documentation. Cross-reference to L0596 relating to bereavementCross-reference to L0598 relating to spiritual counseling”

“Based on facility document review and staff interviews, it was determined that the agency failed to conduct annual emergency testing including participating in a community-based exercise every two years or conduct mock disaster drill or tabletop exercise. Findings include: Review of the agency’s binder labeled “Emergency Preparedness” revealed the agency failed to reveal documentation indicating that the agency had conducted emergency plan testing. During an interview with the Administrator on 9/24/25 at 10:40 a.m. the Administrator confirmed that the agency failed to conduct annual emergency testing. The Administrator denied participating in a community-based exercise or conducting mock or tabletop exercises to meet emergency preparedness requirements.”

“Based on policy titled “Development of Plan of Care,” clinical record reviews, and staff interview, it was determined the agency’s Interdisciplinary Group (IDG) failed to complete comprehensive assessments, specifically the Chaplain/Spiritual Counselor, within five calendar days after patient is admitted to hospice services for 11 patients (P) (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15) of 11 active sampled patients. The findings include: Review of the undated policy titled “Development of Plan of Care,” revealed the following:• The appropriate members of the hospice care team shall identify the needs of the patient and provide a complete assessment no later than seven (7) days after admission. This will include medical, nursing, psychosocial, and spiritual evaluations of the patient and family unit meeting the care needs and the need for bereavement services. Record reviews revealed that 11 patients (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15) of 11 active sampled patients’ charts reviewed failed to have a completed Chaplain/Spiritual Counselor comprehensive assessment. On 9/24/2025 at 11:15 a.m., during an office interview, the Administrator acknowledged the agency’s Chaplain was not completing initial comprehensive assessments. The Administrator explained that during the initial Skilled Nurse (SN) assessments the patients and family were asked if Chaplain/Spiritual Counseling services were needed and nurse would document in the SN assessment notes the decline for Chaplain/Spiritual Counseling services. The agency Chaplain/Spiritual Counselor was not available for interview. The agency Chaplain/Spiritual Counselor resigned his position effective immediately on 9/22/2025.”

“Based on review of policies titled “Development of Plan of Care,” and “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 11 of 11 active sampled patients (P) (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15). Findings include: Review of the undated policy titled “Development of Plan of Care,” revealed the following:Dharma Hospice will designate a hospice care team for each patient. The hospice care team will be composed of professional individuals who will provide or supervise the care and services offered by hospice. The hospice care team shall Include: A physician, Registered Nurse (RN), Medical Social Worker, a member of the clergy or licensed professional counselors, dietitian and volunteers.The appropriate members of the hospice care team shall identify the needs of the patient and provide a comprehensive assessment no later than seven (7) days after admission. This will include medical, nursing, psychosocial, and spiritual evaluations of the patient and family unit in meeting the care needs and the need for bereavement services. Review of the policy titled “Bereavement Services,” dated 1/18/2021 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. Review of the clinical records for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15 failed to reveal initial spiritual assessments or documentation by a chaplain. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who revealed the agency’s chaplain is responsible for performing and documenting initial bereavement assessments. The Administrator confirmed that all clinical records lacked initial bereavement assessments and revealed the chaplain had quit without notice that morning.”

“Based on review of agency policies and procedures, clinical record reviews, and staff interview, it was determined that the agency’s Interdisciplinary Group (IDG) failed to ensure documentation of attendance by the IDG members in the plan of care (POC) every 15 days for 11 patients (P), (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12 P#13, P#14 and P#15) of 11 active sampled patients. Findings include: Review of policy titled “IDG Care Planning Process,” dated 1/18/2021, revealed 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.A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.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. Review of records revealed the POC for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12 P#13, P#14 and P#15 contained a late entry, dated 9/23/2025, interdisciplinary group (IDG) meeting signatures for each benefit periods. On 9/24/2025 at 10:30 a.m., during an office interview, the Administrator acknowledged P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#13, P#14 and P#15 had late IDG meeting signatures that were added on 9/23/2025. The Administrator added her staff did not know how to sign electronically therefore they were not electronically signed until yesterday. The Administrator admitted she did not have paper signatures for review. On 9/24/2025 at 11:00 a.m., during an office interview, Licensed Practical Nurse (LPN) AA acknowledged she had never been to an IDG meeting nor had she been invited to an IDG meeting. On 9/24/2025 at 10:30 a.m., during an office interview, the Social Worker (SW) acknowledged she had not signed agency IDG meetings for attendance. The agency Chaplain/Spiritual Counselor was not available for interview. The agency Chaplain/Spiritual Counselor resigned his position effective immediately on 9/22/2025.”

“Based on review of policy titled “Development of Plan of Care,” clinical record review and staff interviews, it was determined the agency failed to develop an individualized plan of care to include all services necessary for the palliation and management of the terminal illness and related conditions for nine patients (P) (P#5, P#8, P#9, and P#14) of 11 active sampled patients. Findings include: Review of undated policy titled “Development of Plan of Care,” revealed the following:The hospice care team shall meet as a group to review each patient’s plan-of-care. The plan of care shall be updated as the patient’s condition changes and as additional services are needed, at intervals no more than 15 days. All reviews and updates shall be documented in the patient’s medical record. Review of records for P#5, P#8, P#9 revealed P#5, P#8, P#9 failed to reveal an updated care plan with interventions and goals. Furthermore, P#5, P#6 and P#9 failed to reveal an updated scheduled frequencies for the Skilled Nurse (SN), Social Worker (SW) and Chaplain (CH). Record review for P#14 failed to reveal a wound care plan, with interventions and goals for sacral wound identified during initial skilled nurse (SN) assessment at start of care (SOC) on 8/13/2025. On 9/24/2025 at 10:30 a.m., during an office interview, The Administrator acknowledged frequencies for SN, SW, and Spiritual Counselor were not added to P#5, P#6, and P#9 POC. The Administrator added all scheduled visits for SN, SW, and Spiritual Counselor were communicated verbally. The Administrator acknowledged P#5, P#8, and P#9 POC interventions and Goals were not updated for the most recent benefit period. The Administrator acknowledged P#14’s POC had wound care orders at start of care, 8/13/2025 although the POC did not contain updated interventions and goals pertaining to wound care. The Administrator explained the nurses put in their own interventions and goals and this must have been an oversight on the nurses’ part. On 9/24/2025 at 11:00 a.m., during an office interview, Licensed Practical Nurse (LPN) AA acknowledged nurses were responsible for adding patient orders, intervention and goals into the patient’s charts and she was not aware frequencies for SN visits were not in her patients’ charts. LPN AA revealed she received her frequency orders from the Administrator via text messages and she was aware P#14 had a wound, but she was not aware the POC needed wound care interventions and goals added. The agency Chaplain/Spiritual Counselor was not available for interview. The agency Chaplain/Spiritual Counselor resigned his position effective immediately on 9/22/2025.”

“Based on review of policy titled “Development of Plan of Care,” clinical record reviews and staff interviews, it was determined the agency failed to update the patient’s plan of care (POC) with detailed statement of the scope and frequency of services necessary to meet each patients and family’s needs for three patients (P) (P#5, P#6, and P#9) of 11 active sampled patients. Findings include: Review of undated policy titled “Development of Plan of Care,” revealed the following:The plan of care shall detail the scope and frequency of services needed to meet the needs of the patient and the patient’s family unit. Review of records revealed the agency failed to update the plan of care (POC) for P#5, P#6, and P#9 with a detailed scope and frequency of services for the agency’s skilled nurse (SN), Social Worker (SW), and Chaplain (CH). On 9/24/2025 at 10:30 a.m., during an office interview, The Administrator acknowledged frequencies for SN, SW, and CH were not added to P#5, P#6, and P#9 POC. The Administrator admitted she communicated orders for visit frequencies by sending text to the staff. On 9/24/2025 at 11:00 a.m., during an office interview, Licensed Practical Nurse (LPN) AA acknowledged agency nurses were responsible for adding visit frequency orders into the patient’s charts, but she was not aware frequency orders for SN visits were not in her patient’s charts. LPN AA admitted she received her visit frequency orders from the Administrator via text messaging. The agency CH was unavailable for an interview. The agency CH resigned his position on 9/22/2025.”

“Based on review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” review of agency documents, and staff interview, it was determined the hospice failed to utilize measurable quality indicators to assess care and services as part of the agency’s quality assessment and performance improvement (QAPI) program. Findings include: Review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” dated 1/18/2021 revealed the following:OBJECTIVES.To collect and analyze data to improve identified processes and outcomes of care.To educate and involve appropriate staff in QAPI activities.To collect and analyze data to improve identified processes of patient care/services well as outcomes of patient care, leadership and managerial processes, as indicated. To establish mechanisms to reprioritize QAPI activities in response to unusual and/or urgent events.To allocate adequate resources for QAPLTo create and maintain information systems (manual and/or computer) to support the collecting, managing and analyzing of data needed to facilitate ongoing QAPI. Review of 6/28/2025 QAPI meeting minutes revealed the agency failed to reveal completed audits or data used to measure the number of items out of compliance. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who revealed that QAPI documentation is kept in the computer and confirmed that all QAPI documentation had been provided. The Administrator explained that audits were done on “scratch paper” and not kept as part of the QAPI records.”

“Based on review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” review of agency documents, and staff interview, it was determined the hospice failed to document measurable progress in performance improvement projects (PIPs). Findings include: Review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” dated 1/18/2021 revealed the following:OBJECTIVES.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 well as outcomes of patient care, leadership and managerial processes, as indicated. To establish mechanisms to reprioritize QAPI activities in response to unusual and/or urgent events.To allocate adequate resources for QAPLTo create and maintain information systems (manual and/or computer) to support the collecting, managing and analyzing of data needed to facilitate ongoing QAPI.To apply principles and tools of QAPI to all aspects of the organization. To meet federal CMS requirements for QAPI. Review of the documents titled “QAPI- Team Specific Process and Performance Improvement Projects” failed to reveal completed audits, audit tools, or measurable data for analyzing and tracking compliance. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who explained that whenever a problem is identified, even if it only occurs once, the Administrator “does a PIP” until the problem no longer occurs. The Administrator acknowledged that the PIP documentation lacked measurable data used to track compliance and performance improvements. A QAPI PIP policy was requested but not received.”

“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 three patients (P) (P#1, P#2, P#3) of three sampled bereavement charts. Findings include: Review of the policy titled “Bereavement Services,” dated 1/18/2021 revealed the following:PROCEDURE1. Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient’s death. The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions which may interfere with the eventual resolution and integration of their losses. 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. 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.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:• Telephone support.• Letters and cards.• Referral to other community resources.• Memorial services.• Bereavement camps.• Telephone contacts.• Individual or family counseling and bereavement groups.The plan of care will note the kind of bereavement services to be offered and frequency of service delivery. Review of a binder labeled “Bereavement” failed to reveal bereavement care plans for P #1, P#2, and P#3. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who confirmed that all bereavement documentation had been provided. The Administrator revealed the Bereavement Coordinator had quit without notice that morning and could not explain why bereavement records did not include bereavement care plans.”

“Based on review of the policy titled “Development of Plan of Care,” clinical record review and staff interview, it was determined the hospice failed to assess spiritual needs for 11 of 11 active sampled patients (P) (P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15). Findings include: Review of the undated policy titled “Development of Plan of Care,” revealed the following:Dharma Hospice will designate a hospice care team for each patient. The hospice care team will be composed of professional individuals who will provide or supervise the care and services offered by hospice. The hospice care team shall include: A physician, Registered Nurse (RN), a Medical Social Worker, a member of the clergy or licensed professional counselors, a dietitian and volunteers.The appropriate members of the hospice care team shall identify the needs of the patient and provide a comprehensive assessment no later than seven (7) days after admission. This will include medical, nursing, psychosocial, and spiritual evaluations of the patient and family unit in meeting the care needs and the need for bereavement services. Review of the clinical records for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15 failed to reveal initial spiritual assessments or chaplain documentation. On 9/24/2025 at 1:22 p.m., an office interview was conducted with the Administrator, who revealed the chaplain is responsible for documenting spiritual assessments and refusals of chaplain services. The Administrator explained that none of the hospice agency’s patients received chaplain services due to patient and family refusals. The Administrator acknowledged the clinical records lacked documentation of spiritual assessments and could not explain why the clinical records did not have any chaplain documentation.”

“Based on record review, staff interviews and policy the agency failed to provide bereavement assessments or bereavement counseling services for 11 patients (P) P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15. Findings include: Review of the clinical records for P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15 failed to reveal initial spiritual assessments or chaplain documentation. During an interview with the Administrator on 9/24/25 at 1:22 p.m. the Administrator stated that when initial assessments were performed and the patient refused bereavement spiritual counseling upon admission, the chaplain was not added to the plan of care. The Administrator confirmed that spiritual counseling and bereavement services were not provided.”