Brio Idaho Hospice LLC

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that each patient’s individualized written plan of care included all drugs and treatment necessary to meet the needs of the patient {HCPC.21. I/L549}; Failed to ensure that each patient’s individualized written plan of care included all measurable outcomes anticipated from implementing and coordinating the plan of care (50%) {HCPC.21.I/L548}; and Failed to ensure that each patient’s individualized written plan of care identified all planned interventions based on the problems identified in the initial and updated comprehensive assessments (36%) {HCPC.21.I/L545}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to ensure volunteers were provided in day-to-day administrative and/or direct patient care roles in the prior twelve months. {HCDT.21. I/L644/418.78(b)}; and Failed to ensure that that volunteers had provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers {HSLG.7.I/L647/418.78(e)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, the organization did not ensure that each comprehensive assessment included a drug profile containing the patient’s current prescription and OTC drugs, reviewed for effectiveness, side effects, actual or potential drug interactions, and duplicate drug therapy. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/03/2025 and revoked services to seek aggressive treatment after falling at home and fracturing a hip on 03/07/2026. The patient’s primary terminal and pertinent secondary diagnoses included severe protein calorie malnutrition, perforation of esophagus, dysphagia, chronic obstructive pulmonary disease, chronic pain syndrome, and a history of throat cancer. During a joint clinical record review and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON read aloud a RN nursing visit summary dated 03/05/2026 that the contracted pharmacy had “delivered more Tylenol and Ibuprofen” during the RN’s visit. The ADON confirmed that a drug profile with a prescription for the OTC Tylenol or Ibuprofen including dose, route, frequency, and duration was never written, and Tylenol and Ibuprofen were never added to the comprehensive assessment and analyzed for effectiveness, side effects, actual or potential drug interactions, or duplicate drug therapy.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care identified all planned interventions based on the problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/19/2025 with a primary terminal diagnosis of hypertensive heart disease with heart failure. The fifth benefit period effective 02/12/2026 was reviewed through 04/01/2026 when the patient was discharged/transferred to another hospice. The POC effective 02/12/2026 included the following non-patient-specific intervention: “Assess and monitor for edema.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the intervention did not specify that the patient had bilateral lower extremity edema that required monitoring and management as noted in skilled nursing assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/30/2026 with primary and pertinent secondary diagnoses that included heart failure, chronic fatigue syndrome and pain, and repeated falls. The POC effective 05/30/2026 included a non-patient-specific intervention written as, “Assess patient pain on level of 0-10, if appropriate.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the patient’s pain had been assessed and documented as required on all comprehensive assessments and that the patient was able to rank pain on a scale of 0-10 at this time. The ADON acknowledged that the POC should be updated to include the use of the 0-10 scale and what pharmacological and non-pharmacological patient-specific interventions were required to achieve the designated comfort level. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/07/2026. The second benefit period effective 04/07/2026 through 07/05/2026 with primary and pertinent secondary diagnoses of Amyotrophic lateral sclerosis, right foot drop, and dependence on enabling machines and devices was reviewed. The POC effective 04/07/2026 included a non-patient-specific intervention written as, “Titrate pain medication to control pain.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the patient’s pain had been assessed and documented as required on all comprehensive assessments and that the patient was able to rank pain on a scale of 0-10 at this time. However, the POC and intervention for titration did need to be updated to reflect the 0-10 pain scale that was to be used and the defined acceptable pain range for the patient in order for the titration intervention to be complete. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/03/2024. Benefit period thirteen (13) effective 05/23/2026 through 07/21/2026 included primary and pertinent secondary diagnoses of Chronic Obstructive Pulmonary Disease (COPD), calculus of kidney and ureter. The POC effective 05/23/2026 included the following non-patient-specific intervention: “Encourage elevation of edematous areas.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the intervention did not specify the location of the patient’s bilateral lower extremity edema that required monitoring and management as noted in skilled nursing assessments. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/12/2024. Benefit period ten (10) effective 05/05/2026 through 07/03/2026 included the primary terminal diagnosis of senile degeneration of the brain. The POC effective 05/05/2026 included a non-patient-specific intervention written as, “Assess patient pain on level of 0-10, if appropriate.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON confirmed that the patient’s pain had been assessed and documented as required on all comprehensive assessments, including history of the patient’s pain, pain characteristics, medications, and goals for pain management. However, the ADON acknowledged that the patient’s pain goal with the specific scale for the confused patient who did not consistently or accurately verbalize pain using a 0-10 scale, and plan to achieve and maintain that goal had not been defined and included on the POC.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care included all measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/19/2025 with a primary terminal diagnosis of hypertensive heart disease with heart failure. The fifth benefit period effective 02/12/2026 was reviewed through 04/01/2026 when the patient was discharged/transferred to another hospice. The POC effective 02/12/2026 included a non-measurable outcome with no end date written as “Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the corresponding intervention “assess and monitor for edema” did nothing to define specifically for this patient what would be considered an adequate measure of cardiac/cardiac circulatory function or fluid volume and agreed that no timeframe was specified for any goal achievement. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/23/2024. Benefit period three (3) effective 05/22/2025 was reviewed until the patient’s death on 06/26/2025. The patient’s primary terminal diagnosis was senile degeneration of the brain and included a pertinent secondary diagnosis of localized edema. The POC effective 05/22/2025 included a non-measurable outcome with no end date written as “Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the corresponding intervention “assess and monitor for edema” did nothing to define specifically for this patient what would be considered an adequate measure of cardiac/cardiac circulatory function or fluid volume and agreed that no timeframe was specified for any goal achievement. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/30/2026 with primary and pertinent secondary diagnoses that included heart failure, chronic fatigue syndrome and pain, and repeated falls. The POC effective 05/30/2026 included a non-measurable outcome with no end date written as, “Patient’s pain will reach a comfortable level within 2 days of reporting pain exceeding tolerable limits.” During a concurrent review on 06/18/2026, the ADON confirmed that the patient’s pain had been assessed and documented as required on all comprehensive assessments, including history of the patient’s pain, pain characteristics, medications, and goals for pain management. However, the ADON acknowledged that the patient’s pain goal and plan to achieve and maintain that goal had not been defined specifically in the POC. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/07/2026. The second benefit period effective 04/07/2026 through 07/05/2026 with primary and pertinent secondary diagnoses of Amyotrophic lateral sclerosis, right foot drop, and dependence on enabling machines and devices was reviewed. The POC effective 04/07/2026 included non-measurable outcomes with no end dates written as, “Patient will achieve optimal physical comfort.”; and “Patient will maintain optimal swallowing this certification period.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON confirmed that the patient’s pain had been assessed and documented as required on all comprehensive assessments, including history of the patient’s pain, pain characteristics, medications, and goals for pain management. However, the ADON acknowledged that the patient’s pain goal and plan to achieve and maintain that goal had not been defined specifically in the POC. The ADON also acknowledged that the patient’s problem with swallowing and choking risk had not been defined on the plan of care and that there was no way to measure if any swallowing goals had been achieved. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/03/2024. Benefit period thirteen (13) effective 05/23/2026 through 07/21/2026 included primary and pertinent secondary diagnoses of Chronic Obstructive Pulmonary Disease (COPD), calculus of kidney and ureter. The POC effective 05/23/2026 included a non-measurable outcome with no end date written as “Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the corresponding intervention “encourage elevation of edematous areas” did nothing to define specifically for this patient what would be considered an adequate measure of cardiac/cardiac circulatory function or fluid volume and agreed that no timeframe was specified for any goal achievement. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/13/2026 and had a primary terminal diagnosis of Alzheimer’s Disease. The POC effective 04/13/2026 included a non-measurable outcome with no end date written as, “Patient will verbalize adequate relief of pain with the use of current pain medications.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON confirmed that the patient’s pain had been assessed and documented as required on all comprehensive assessments, including history of the patient’s pain, pain characteristics, medications, and goals for pain management. However, the ADON acknowledged that the patient’s pain goal with the specific scale for a patient the patient with Alzheimer’s dementia who did not consistently or accurately verbalize pain using a 0-10 scale, and plan to achieve and maintain that goal had not been defined specifically in the POC. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2026 and had a primary terminal diagnosis of multiple myeloma with a history of bladder cancer and chronic pain. The POC effective 04/10/2026 included a non-measurable outcome with no end date written as, “Patient will receive optimal level of pain and/or symptom management on a short-term basis.” During a concurrent review of the plan of care (POC) and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON confirmed that the patient’s pain had been assessed and documented as required on all comprehensive assessments, including history of the patient’s pain, pain characteristics, medications, and goals for pain management. However, the ADON acknowledged that the patient’s pain goal and plan to achieve and maintain that goal had not been defined specifically in the POC.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care included all drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2026 and had a primary terminal diagnosis of multiple myeloma with a history of bladder cancer and chronic pain. The plan of care (POC) effective 04/10/2026 included the following incomplete treatment orders: “Implantable port right upper chest. Normal Saline (NS) 500ml once weekly and as needed for dehydration __rate as tolerated. Flush Huber needle with NS and Heparin before and after IV fluids.” During a concurrent review of the POC and an interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the POC effective 04/10/2026 did not include the size of the Huber needle that was to be implanted into the patient’s port and did not include how the NS was to be infused (i.e. gravity or pump) and at what rate (drip or rate/ml/hr.). The ADON stated that she would contact the RN case manager to obtain the missing information in order to update the POC with the IDG.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, it was observed that the organization did not ensure that current CDC guidelines were followed as required by policy to prevent the transmission of infections and communicable disease. DOCUMENT 1: Policy: The organization’s policy titled Hand Hygiene Policy and Compliance Program, with no policy number and no revision date, stated in part, ...[Agency] will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: Indications for handwashing and hand antisepsis: No visible dirt, blood or body fluids on hands of health care worker in the following clinical situations: before direct patient contact...after contact with inanimate objects or medical equipment close to the patient...wash for 15 seconds....” The Administrator/Director of Nursing reviewed current CDC guidelines and stated that the organization’s hand hygiene policy required an update in order to be current with CDC guidelines. I understand that handwashing or hand sanitizing is at least for 20 seconds, not 15 seconds, and I see that there are additional indications for hand hygiene that are not included in this policy. We will update the hand hygiene policy right away.” HOME VIST 3: During the home visit observation with Chaplain [PERSONNEL RECORD 5] on 06/17/2026, the Chaplain was observed reading to and praying with the patient. The Chaplain touched the patient’s clothing and hands and then touched her tablet to access the patient’s medical record to document the visit. The Chaplain asked one of the facility staff to touch the screen of her tablet to write her signature on the screen, verifying the completion of her visit. The Chaplain ended the visit and exited the facility without sanitizing her hands. During the wrap up conference on 06/17/2026, the Administrator/Director of Nursing was informed of that observation and that the Chaplain did not perform hand hygiene after entering the facility, before or after touching the patient, before or after touching her tablet or asking facility staff to use their finger to sign her tablet, or after exiting the facility. The Administrator/Director of Nursing acknowledged that the Chaplain was not following organization’s Hand Hygiene policy as described during the home visit.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) clinical records that included aide services, the registered nurse did not ensure that all pertinent patient care instructions were written on each patient’s aide plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/13/2026 and had a primary terminal diagnosis of Alzheimer’s Disease. The patient was ordered to receive aide personal care services three times weekly. On 05/12/2026 the patient had a documented sacral wound with a new wound treatment and dressing ordered. On 5/29/2026 the patient had a documented left lateral ankle wound with a wound treatment ordered. During a concurrent review of the aide plan of care (POC) and an interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the aide POC effective 04/13/2026 was not updated to include that the patient had wounds or wound dressings and was not updated with instructions for covering or protecting the wound dressings during the performance of bathing and personal cares. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/12/2024. Benefit period nine (9) effective 03/06/2026 through 05/04/2026 and benefit period ten (10) effective 05/05/2026 through 07/03/2026 were reviewed. The patient’s primary terminal diagnosis was senile degeneration of the brain. Both Plans of Care reviewed indicated that the patient had a 16fr, 10cc foley catheter in place that was to be changed monthly by the hospice skilled nurse. During a concurrent review of the aide plan of care (POC) and an interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the Aide Plan of Care (POC) last updated 01/09/2026 did not include Foley catheter precautions or instructions for Foley Catheter or Bag Care. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/10/2026 and had a primary terminal diagnosis of multiple myeloma with a history of bladder cancer and chronic pain. The plan of care (POC) effective 04/10/2026 included that the patient had an 18Fr, 10cc Coude Catheter in place that the SN was to change monthly. During a concurrent review of the aide plan of care (POC) and an interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the Aide Plan of Care (POC) effective 05/13/2026 did not include Foley catheter precautions or Instructions for Foley Catheter or Bag Care. The ADON also acknowledged that the patient used Fentanyl 75mcg pain patches that were changed and rotated every 3 days, and that the Aide POC did not include instructions to the aide to be aware of the presence of the patch or to report of the patch was loose or missing. CLINICAL RECORD 13: The patient elected the hospice benefit on 06/07/2024. Benefit period twelve (12) effective 05/08/2026 through 07/26/2026 was reviewed and included primary and pertinent secondary diagnoses of Alzheimer’s Disease with early onset, dementia, and seizure and aspiration precautions. During a concurrent review of the aide plan of care (POC) and an interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON acknowledged that the Aide Plan of Care (POC) effective 05/08/2026 included aide personal care services ordered three times weekly and instructed the aide to give the patient a “shower with chair once weekly”. The Aide POC also instructed the aide give a “bed bath all day she refuses a shower”. The ADON stated that the aide would be required to call an RN for direction if care plan instructions were refused or could not be performed as ordered, and that the POC should contain instruction for one bath.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. The organization did not ensure that volunteers were used consistently in day-to-day administrative and/or direct patient care roles. A review of QAPI data provided on 06/16/2026 revealed that the organization did not provide volunteers in day-to-day administrative and/or direct patient care roles in the prior twelve months. During the entrance conference on 06/16/2026, the Administrator/Director of Nursing stated that the history of the organization’s Volunteer Program since the last deemed accreditation survey that ended on 07/14/2023 was documented in QAPI meeting minutes. A Performance Improvement Project titled “Meet or Exceed Volunteer Hour Requirements” was implemented on 07/23/2024. For approximately 6 months between 07/28/2025 and 01/20/2026, QAPI meeting minutes indicated the organization had no volunteers used in day-to-day administrative and/or direct patient care roles The Administrator/Clinical Manager also confirmed that QAPI data compiled for Quarters 1 and 2 of 2026 indicated that the organization had no active volunteers and that no volunteer services had been provided in administrative or direct patient care roles. The current Volunteer Coordinator was hired on 10/20/2025. During an interview with the Volunteer Coordinator on 06/17/2025, the Volunteer Coordinator stated that she recently identified two potential volunteers that were in the process of onboarding, and that she planned to begin providing volunteer direct patient care hours to patients herself during the current month. The Volunteer Coordinator confirmed that no administrative or patient care volunteer hours had been documented since she was hired in 4th Quarter of 2025 and to date in the first 6 months of 2026. Before the exit conference, the Administrator/Director of Nursing confirmed that volunteers had not been documented as used in day-to-day administrative and/or direct patient care roles during the prior 12 months. The organization did not ensure that volunteers were used consistently in day-to-day administrative and/or direct patient care roles. A review of QAPI data provided on 06/16/2026 revealed that the organization did not provide volunteers in day-to-day administrative and/or direct patient care roles in the prior twelve months. During the entrance conference on 06/16/2026, the Administrator/Director of Nursing stated that the history of the organization’s Volunteer Program since the last deemed accreditation survey that ended on 07/14/2023 was documented in QAPI meeting minutes. A Performance Improvement Project titled “Meet or Exceed Volunteer Hour Requirements” was implemented on 07/23/2024. For approximately 6 months between 07/28/2025 and 01/20/2026, QAPI meeting minutes indicated the organization had no volunteers used in day-to-day administrative and/or direct patient care roles The Administrator/Clinical Manager also confirmed that QAPI data compiled for Quarters 1 and 2 of 2026 indicated that the organization had no active volunteers and that no volunteer services had been provided in administrative or direct patient care roles. The current Volunteer Coordinator was hired on 10/20/2025. During an interview with the Volunteer Coordinator on 06/17/2025, the Volunteer Coordinator stated that she recently identified two potential volunteers that were in the process of onboarding, and that she planned to begin providing volunteer direct patient care hours to patients herself during the current month. The Volunteer Coordinator confirmed that no administrative or patient care volunteer hours had been documented since she was hired in 4th Quarter of 2025 and to date in the first 6 months of 2026. Before the exit conference, the Administrator/Director of Nursing confirmed that volunteers had not been documented as used in day-to-day administrative and/or direct patient care roles during the prior 12 months.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of QAPI meeting minutes documented from 4th Quarter of 2023 provided on 06/16/2026 revealed that the organization did not provide volunteers in day-to-day administrative and/or direct patient care roles in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and A Performance Improvement Project (PIP) titled “Meet or Exceed Volunteer Hour Requirements” was implemented on 07/23/2024. The following PIP progress and action items were documented, indicating the maximum amount of costing savings achieved in 3-year period was 0.41% at the initiation of the PIP:7/23/24-Reviewing regulations for Volunteer Program-Goal 5% by 12/31/24-Current-0.41% VC position accepted 5/6/24-1 volunteer onboarded, 1 need to schedule, others waiting onboarding 10/15/24-Onboarded 1 volunteer-GOAL 5% by 12/31/2024-Current 0.10% Action-attempting to recruit for 1-2 new volunteers -[Name] CNA LEAD is to assist VC. 1/7/25-Onboarded 1 volunteer...GOAL 5% by 07/1/2025-Current 0.20%-Action [Name] taking over VC duties; scheduled visit with new volunteer and patient tomorrow-2-3 volunteers onboarding; 7/28/25 -pending volunteer…. GOAL-5% by 07/01/2025-Current-NONE-Action-VC will develop binder tracking efforts and will report on monthly manager meeting; 10/31/25-Intervention-1 VOL identified; back out—GOAL-5% by 12/31/2025—Current status 0% QAPI meetings/PIP- “Meet or Exceed Volunteer hour requirements” 1/20/2026-Intervention-Volunteer onboarding packet reviewed-marketing material developed in all patient admission packets-GOAL-5% by 12/31/2026-Current-0% Before the exit conference, the Administrator/Director of Nursing confirmed that volunteers had not been documented as used in day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024, 2025, or to date in 2026. A review of QAPI meeting minutes documented from 4th Quarter of 2023 provided on 06/16/2026 revealed that the organization did not provide volunteers in day-to-day administrative and/or direct patient care roles in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and A Performance Improvement Project (PIP) titled “Meet or Exceed Volunteer Hour Requirements” was implemented on 07/23/2024. The following PIP progress and action items were documented, indicating the maximum amount of costing savings achieved in 3-year period was 0.41% at the initiation of the PIP: 7/23/24-Reviewing regulations for Volunteer Program-Goal 5% by 12/31/24-Current-0.41% VC position accepted 5/6/24-1 volunteer onboarded, 1 need to schedule, others waiting onboarding 10/15/24-Onboarded 1 volunteer-GOAL 5% by 12/31/2024-Current 0.10% Action-attempting to recruit for 1-2 new volunteers -Crystal CNA LEAD is to assist VC. 1/7/25-Onboarded 1 volunteer...GOAL 5% by 07/1/2025-Current 0.20%-Action Crystal taking over VC duties; scheduled visit with new volunteer and patient tomorrow-2-3 volunteers onboarding 7/28/25 -pending volunteer….GOAL-5% by 07/01/2025-Current-NONE-Action-VC will develop binder tracking efforts and will report on monthly manager meeting 10/31/25-Intervention-1 VOL identified; back out—GOAL-5% by 12/31/2025—Current status 0% QAPI meetings/PIP- “Meet or Exceed Volunteer hour requirements” 1/20/2026-Intervention-Volunteer onboarding packet reviewed-marketing material developed in all patient admission packets-GOAL-5% by 12/31/2026-Current-0% Before the exit conference, the Administrator/Director of Nursing confirmed that volunteers had not been documented as used in day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024, 2025, or to date in 2026.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed in which a patient revoked the election of hospice care, the hospice did not ensure that it forwarded the patient’s attending physician a copy of the hospice discharge summary. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/03/2025 and revoked services to seek aggressive treatment after falling at home and fracturing a hip on 03/07/2026. During a joint clinical record review and interview with the Alternate Administrator/Assistant Director of Nursing (ADON) on 06/18/2026, the ADON confirmed that a discharge summary was documented on 03/07/2026 but the summary was not forwarded to the patient’s attending physician. The ADON stated, “I confirmed that we have a way to send a discharge summary to the attending [physician] but confirmed that we did not do so in this case.””

“It is required that a hospice may contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards; has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. The organization did not ensure that it contracted for durable medical equipment services with a Medicare-certified DME point-of-service supplier. During an interview on 06/17/2026, the Administrator/Director of Nursing stated that the organization’s only contracted DME company has completed an application to become Medicare-certified but confirmed that the DME provider is not currently accredited. The organization did not ensure that it contracted for durable medical equipment services with a Medicare-certified DME point-of-service supplier. During an interview on 06/17/2026, the Administrator/Director of Nursing stated that the organization’s only contracted DME company has completed an application to become Medicare-certified but confirmed that the DME provider is not currently accredited.”