Hospice of Jackson County

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to perform an initial bereavement assessment, within 5 days of the patient’s election to the hospice benefit and as part of the initial comprehensive assessment, to determine patient and/or family bereavement needs and risk factors in a timely manner for 3 of 5 sampled patients that did not accept social work services at admission (Patients #9, #12 and #13). Failure to complete an initial bereavement assessment increased the risk that patient or family/caregiver grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors.Findings include: 3. Patient #12 had a hospice admission date of 2/12/25, a discharge date of 8/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/12/25 to 5/12/25, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, hospice aide and massage therapy services. b. The skilled nurse initial comprehensive assessment, dated 2/12/25, completed by Staff B, RN, lacked an initial bereavement risk assessment. The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment. The above findings were reviewed with the Administrator and Clinical Manager. According to the hospice policy titled Comprehensive Assessment of the Patient, dated 1/21/26, the comprehensive assessment of the patient is completed by designated members of the interdisciplinary group (IDG) in consultation with the patient’s attending physician no later than 5 calendar days after the patient elects the hospice benefit. During an interview on 6/23/26 at 11:34 AM, the Clinical Manager reported that the social worker is at each admission to do the admission paperwork with the patient and starts to assess bereavement risk, but does not perform or document a complete bereavement risk assessment unless the patient accepts social work services at admission.1. Patient #9 had a hospice admission date of 3/15/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The plan of care (POC), dated 3/18/25, identified the patient had a primary diagnosis of malnutrition and included physician orders for skilled nursing, hospice aide, chaplain, volunteer and massage therapy services.b. The skilled nurse initial comprehensive assessment, dated 3/15/25, completed by Staff B, Clinical Manager, lacked an initial bereavement risk assessment. The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment.2. Patient #13 had a hospice admission date of 7/29/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 7/31/25, identified the patient had a primary diagnosis of bladder cancer and included physician orders for skilled nursing services.b. The skilled nurse comprehensive assessments, dated 7/29/25 and 7/31/25, completed by Staff J, Registered Nurse (RN), lacked an initial bereavement risk assessment. The clinical record lacked documentation of completion of an initial bereavement risk assessment. The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 5 of 6 sampled patients with a wound (Patients #2, #6, #7, #9 and #12). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients’ wound status and effectiveness of treatments and interventions. Findings include: According to the agency policy titled Wound Care, dated 1/21/26, the goal of palliative wound treatment is to focus on patient comfort and to prevent infection and progression of the wound. The registered nurse (RN) is expected to document the treatment and dressing used, assess the wound at regular intervals with documentation specific on each wound site weekly, assess and document location, size, pain, odor, drainage and appearance of wound and surrounding skin and assess for signs and symptoms of infection. During an interview on 6/17/26 at 3:45 PM, the Clinical Manager stated hospice staff are expected to assess and measure (length, width, depth) wounds once a week. 1.Patient #2 had a hospice admission date of 1/19/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The IDG update to the Plan of Care (POC), dated 4/9/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nursing, social work, hospice aide, chaplain, massage therapy and volunteer services. b. The skilled nurse comprehensive assessment, dated 4/21/26, Staff E, RN, identified the patient continues to have an abrasion under left axillary rib. The hospice skilled nurse failed to assess and measure the patient’s wound. 2. Patient #6 had a hospice admission date of 12/11/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nursing, hospice aide, chaplain and massage therapy services. b. The skilled nurse comprehensive assessment, dated 5/12/26, Staff E, RN identified the patient had a small site lateral to current scabbed shin wound measuring 0.5 centimeters (cm) by 0.4 cm by 0.1 cm and a wound to the left upper arm measuring 1 cm by 1 cm by 0.1 cm. c. The skilled nurse comprehensive assessment, dated 5/18/26, Staff E, RN identified the shin wound continues to be scabbed and healing but failed to assess and measure the small site lateral to current scabbed shin wound and failed to assess and measure the upper arm wound. The hospice skilled nurse failed to assess and measure all of the patient’s wounds one time a week. 3. Patient #12 had a hospice admission date of 2/12/25, a discharge date of 8/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/29/25, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, hospice aide and massage therapy services. b. The skilled nurse comprehensive assessment, dated 6/9/25, Staff I, RN, identified the patient has an open wound to the right gluteal fold measuring 1 cm by 0.75 cm but failed to include a depth measurement. c. The skilled nurse comprehensive assessment, dated 6/23/25, Staff I, RN, identified the patient has an open wound to the right gluteal fold measuring 0.5 cm by 0.5 cm but failed to include a depth measurement. The hospice skilled nurse failed to include complete wound measurements, including wound depth. 4. Patient #7 had a hospice admission date of 9/29/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/26, identified the patient had a primary diagnosis of chronic respiratory failure and included orders for skilled nursing and chaplain services.b. The skilled nurse, comprehensive assessment, dated 5/18/26, completed by Staff E, RN, identified the patient had an open area to the left inner coccyx that measured 0.2 cm by 0.2 by 0.1 cm open area.c. The skilled nurse, comprehensive assessment, dated 5/26/26, completed by Staff J, RN, identified an open area to the patient’s coccyx. d. The skilled nurse, comprehensive assessments, dated 6/1/26 and 6/8/26, completed by Staff K, RN, included documentation of an open area to the patient’s coccyx. The hospice skilled nurse failed to assess and measure the patient’s wound one time a week.5. Patient #9 had a hospice admission date of 3/15/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/21/26, identified the patient had a primary diagnosis of malnutrition and included orders for skilled nursing, hospice aide, chaplain and massage therapy services. b. The skilled nurse, comprehensive assessment, dated 5/26/26, completed by Staff B, Clinical Manager, identified an open area to the patient’s coccyx. Staff B identified a 0.5 cm by 0.6 cm by 0.0 cm superficial open area. c. The skilled nurse, comprehensive assessment, dated 6/1/26 and 6/8/26, completed by Staff B, identified the patient had 2 superficial open areas a little macerated with foam dressing discontinued 6/1/26, no drainage or odor noted. The hospice skilled nurse failed to assess and measure the patient’s wound one time a week and include a depth measurement.The above findings were reviewed with the Administrator, Clinical Manager, Staff J, Registered Nurse (RN), Staff E, RN, Staff M, Office Manager, Staff L, Social Worker, and Staff C, Hospice Aide. According to the agency policy titled Wound Care, dated 1/21/26, the goal of palliative wound treatment is to focus on patient comfort and to prevent infection and progression of the wound. The R is expected to document the treatment and dressing used, assess the wound at regular intervals with documentation specific on each wound site weekly, assess and document location, size, pain, odor, drainage and appearance of wound and surrounding skin and assess for signs and symptoms of infection. During an interview on 6/17/26 at 3:45 PM, the Clinical Manager stated hospice staff are expected to assess and measure (length, width, depth) wounds once a week. 1.Patient #2 had a hospice admission date of 1/19/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The IDG update to the Plan of Care (POC), dated 4/9/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nursing, social work, hospice aide, chaplain, massage therapy and volunteer services. b. The skilled nurse comprehensive assessment, dated 4/21/26, Staff E, RN, identified the patient continues to have an abrasion under left axillary rib. The hospice skilled nurse failed to assess and measure the patient’s wound. 2. Patient #6 had a hospice admission date of 12/11/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nursing, hospice aide, chaplain and massage therapy services. b. The skilled nurse comprehensive assessment, dated 5/12/26, Staff E, RN identified the patient had a small site lateral to current scabbed shin wound measuring 0.5 centimeters (cm) by 0.4 cm by 0.1 cm and a wound to the left upper arm measuring 1 cm by 1 cm by 0.1 cm. c. The skilled nurse comprehensive assessment, dated 5/18/26, Staff E, RN identified the shin wound continues to be scabbed and healing but failed to assess and measure the small site lateral to current scabbed shin wound and failed to assess and measure the upper arm wound. The hospice skilled nurse failed to assess and measure all of the patient’s wounds one time a week. 3. Patient #12 had a hospice admission date of 2/12/25, a discharge date of 8/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/29/25, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, hospice aide and massage therapy services. b. The skilled nurse comprehensive assessment, dated 6/9/25, Staff I, RN, identified the patient has an open wound to the right gluteal fold measuring 1 cm by 0.75 cm but failed to include a depth measurement. c. The skilled nurse comprehensive assessment, dated 6/23/25, Staff I, RN, identified the patient has an open wound to the right gluteal fold measuring 0.5 cm by 0.5 cm but failed to include a depth measurement. The hospice skilled nurse failed to include complete wound measurements, including wound depth. 4. Patient #7 had a hospice admission date of 9/29/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/26, identified the patient had a primary diagnosis of chronic respiratory failure and included orders for skilled nursing and chaplain services.b. The skilled nurse, comprehensive assessment, dated 5/18/26, completed by Staff E, RN, identified the patient had an open area to the left inner coccyx that measured 0.2 cm by 0.2 by 0.1 cm open area.c. The skilled nurse, comprehensive assessment, dated 5/26/26, completed by Staff J, RN, identified an open area to the patient’s coccyx. d. The skilled nurse, comprehensive assessments, dated 6/1/26 and 6/8/26, completed by Staff K, RN, included documentation of an open area to the patient’s coccyx. The hospice skilled nurse failed to assess and measure the patient’s wound one time a week.5. Patient #9 had a hospice admission date of 3/15/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/21/26, identified the patient had a primary diagnosis of malnutrition and included orders for skilled nursing, hospice aide, chaplain and massage therapy services. b. The skilled nurse, comprehensive assessment, dated 5/26/26, completed by Staff B, Clinical Manager, identified an open area to the patient’s coccyx. Staff B identified a 0.5 cm by 0.6 cm by 0.0 cm superficial open area. c. The skilled nurse, comprehensive assessment, dated 6/1/26 and 6/8/26, completed by Staff B, identified the patient had 2 superficial open areas a little macerated with foam dressing discontinued 6/1/26, no drainage or odor noted. The hospice skilled nurse failed to assess and measure the patient’s wound one time a week and include a depth measurement.The above findings were reviewed with the Administrator, Clinical Manager, Staff J, Registered Nurse (RN), Staff E, RN, Staff M, Office Manager, Staff L, Social Worker, and Staff C, Hospice Aide.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 1 sampled patients with missed visits (Patient #3). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice policy, titled Interdisciplinary Group, dated 1/21/26, identified the IDG is responsible for providing and coordinating care and services in accordance with the patient’s plan of care, and documenting all care and services provided in a timely manner. Patient #3 had a hospice admission date of 10/17/24, and received hospice services while residing in a private home. Clinical record review revealed: a. The IDG updates to the Plan of Care (POC), dated 4/9/26, included IDG direction to provide one to two Massage Therapy visits each month. b. Massage Therapy visit note, dated 4/23/26, completed by Staff F, Home Health Aide/Massage Therapist, included documentation patient declined a massage visit today. c. The clinical record lacked documentation of another massage therapy visit for the month of April. d. The IDG updates to the POC, dated 4/23/26 and 5/7/26, lacked documentation the IDG was notified of missed massage therapy visit for the month of April. The hospice failed to provide massage therapy visits as ordered per the IDG updates to the POC. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on hospice staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurses developed hospice aide instructions for patient care that were specific and individualized to the patients’ needs for 4 of 8 sampled patients receiving hospice aide services (Patients #1, #2, #8 and #9). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner. Findings include: 4. Patient #8 had a hospice admission date of 12/31/25 and received hospice services while residing in a private home. Clinical record review revealed: a. The hospice aide care plans, dated 4/10/26, 5/22/26 and 6/5/26, created by Staff E, Registered Nurse, included Registered Nurse instructions to the hospice aide to perform the task shave, but failed to specify face, legs or underarms. b. The hospice aide care plan, dated 4/23/26, created by Staff K, Registered Nurse, included Registered Nurse instructions to the hospice aide to perform the task shave, but failed to specify face, legs or underarms. c. The hospice aide visit notes, dated 4/13/26, 4/20/26, 4/27/26, 5/4/26, 5/11/26, 5/20/26, 6/1/26 and 6/8/26, completed by Staff H, Hospice Aide, included documentation the task shave was marked declined my offer. d. The hospice aide visit notes, dated 4/23/26, 5/1/26, 5/7/26, 5/14/26, 5/21/26, 5/26/26, 5/28/26, 6/4/26 and 6/11/26, completed by Staff C, Hospice Aide, included documentation the task shave was marked declined my offer. The aide care plan failed to provide specific instructions to the hospice aide on what area the aide was to shave. The above findings were reviewed with the Administrator and Clinical Manager. 2. Patient #1 had a hospice admission date of 6/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 6/12/26, included RN instruction to the hospice aide to apply lotion to the patient’s skin with each visit.b. The hospice aide visit note, dated 6/15/26, completed by Staff C, Hospice Aide, included documentation that lotion was applied to the patient’s back, shoulders, chest, arms and legs.The aide care plan failed to provide specific instruction to the hospice aide on what area the aide was to apply lotion.3. Patient #9 had a hospice admission date of 3/15/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 5/14/26, included RN instruction to the hospice aide to apply lotion to the patient’s skin with each visit.b. The hospice aide visit notes, dated 6/1/26 and 6/8/26, completed by Staff C, Hospice Aide, included documentation that lotion was applied to the patient’s skin.c. The hospice aide visit note, dated 6/10/26, completed by Staff H, Hospice Aide, included documentation that lotion was applied to the patient’s skin.The aide care plan failed to provide specific instruction to the hospice aide on what area the aide was to apply lotion. According to the hospice policy titled Plan of Care-Hospice Aide, dated 1/21/26, all services provided by hospice aides shall be based on an individualized written plan of care developed by the Interdisciplinary Group (IDG), ordered by the attending physician or hospice physician and supervised by a registered nurse. The hospice aide care plan shall include specific instructions for aide services. During an interview on 6/17/26 at 3:45 PM, the Clinical Manager stated aide care plans are created by a registered nurse (RN). 1.Patient #2 had a hospice admission date of 1/19/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The hospice aide care plan, dated 6/8/26, created by Staff B, Clinical Manager, included instructions to the hospice aide to perform 2 assist with stand pivot transfer, but failed to specify what durable medical equipment to use when transferring the patient.b. The hospice aide visit note, dated 6/12/25, completed by Staff C, Hospice Aide, included documentation a gait belt used during transfer. The aide care plan failed to provide specific instructions to the hospice aide on what durable medical equipment to use when transferring the patient.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 2 of 8 sampled patients receiving hospice aide services (Patients #6 and #11). The hospice reported a current census of 19 patients, including 16 who received hospice aide services at the time of the survey. Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: 1.Patient #6 had a hospice admission date of 12/11/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the Plan of Care (POC), dated 5/7/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 4/10/26, included aide instructions to provide a bed bath, perform peri care, provide oral care, comb/brush hair, shave face, lotion dry skin, provide back rub, assist with feeding if present during mealtime, trim/clean/file fingernails, assist with transfers using a mechanical lift and assist with dressing. c. The hospice aide visit note, dated 5/7/26, completed by Staff C, Hospice Aide, documented performing range of motion to patient hands. d. The hospice aide visit note, dated 5/28/26, completed by Staff E, Hospice Aide, documented performing range of motion to patient hands. The hospice aides failed to complete tasks only as instructed by the RN assignment. 2. Patient #11 had a hospice admission date of 1/13/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. The hospice aide care plans, dated 4/23/26 and 5/18/26, included aide instructions to assist with transfers using gait belt and two person assist. c. The hospice aide visit notes, dated 5/11/26 and 5/18/26, completed by Staff C, Hospice Aide, documented transferring the patient with gait belt and 1 person assist. d. The hospice aide visit notes, dated 5/13/26 and 5/20/26, completed by Staff H, Hospice Aide, documented transferring the patient with gait belt and 1 person assist. The hospice aides failed to complete tasks as instructed by the RN assignment. The above findings were reviewed with the Administrator and Clinical Manager. According to the hospice policy, titled Plan of Care - Hospice Aide, dated 1/21/26, all services provided by the hospice aides shall be based on an individualized written plan of care (POC) developed by the Interdisciplinary Group (IDG), ordered by the attending physician or hospice physician as appropriate, and supervised by a registered nurse. Hospice aides shall follow care instructions exactly as written. During an interview on 6/17/26 at 3:45 PM, the Clinical Manager reported if the aide is unable to complete an assigned task they are to document the refusal on the aide visit note.”

“Based on review of the written hospice agreements for services under arrangement, the hospice failed to ensure written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 3 of 3 sampled services (Durable Medical Equipment supplier, Pharmacy provider and Mobile Imaging services provider). Failure to include this provision within the contractual agreements increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: 1.Review of the contract between the hospice and the durable medical equipment supplier, dated 3/31/21, identified the contract lacked the following required component: All services are delivered in accordance with the patient’s plan of care. 2. Review of the contract between the hospice and the pharmacy provider, dated 8/1/25, identified the contract lacked the following required components: a. The hospice retains administrative management, b. The hospice retains oversight of staff and services, c. All services are authorized by hospice, d. All services are delivered in a safe and effective manner by qualified personnel and e. All services are delivered in accordance with the patient’s plan of care. 3. Review of the contract between the hospice and mobile imaging provider, dated 11/13/19, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services, c. All services are authorized by hospice, d. All services are delivered in a safe and effective manner by qualified personnel and e. All services are delivered in accordance with the patient’s plan of care. The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, policy review and staff interview, the hospice failed to ensure patient clinical records included a complete physician order for wound treatment for 1 of 1 sampled patients on census that receive wound treatment in a nursing home (Patient #9). Failure to have a complete physician order for all treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs.Findings Include: According to the hospice policy titled Wound Care, dated 1/21/26, one of the procedures for palliative wound treatment is to obtain a wound order from the physician. During an interview on 6/23/26 at 11:34 AM, the Clinical Manager reported that the frequency of dressing changes to wounds should be included in the physician’s order. The Clinical Manager reported that the reason a frequency was not included in the treatment order, dated 5/21/26, was because the frequency was part of the original treatment order, dated 4/14/26. The Clinical manager reported that there was no written documentation to direct who performs wound care, the hospice nurse or the nursing home nurse. Patient #9 had a hospice admission date of 3/15/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Interdisciplinary Group (IDG) update to the plan of care (POC), dated 5/21/26, identified the patient had a primary diagnosis of malnutrition and included physician orders for skilled nursing, hospice aide, chaplain and massage therapy services.b. The Interim Physician Order (IPO), dated 4/14/26, included orders to initiate skin prep followed by hydrophilic wound dressing paste topically and cover with foam dressing. Change every day and as needed until healed. c. The IPO, dated 5/15/26, included order to discontinue the order for moisture barrier ointment and skin protectant ointment to coccyx/buttocks wound, using hydrophilic wound dressing paste only with foam dressing. d. The IDG update to the POC, dated 5/21/26, included an order to apply a hydrophilic wound dressing paste and cover with a foam dressing to coccyx buttock wound. The hospice failed to obtain a complete order for treatment to the patient’s coccyx buttock wound to include the frequency of treatment and who performs the treatment.The above findings were reviewed with the Administrator, Clinical Manager, Staff J, Registered Nurse (RN), Staff E, RN, Staff M, Office Manager, Staff L, Social Worker, and Staff C, Hospice Aide.”