Comfort Plus Hospice Inc.

“It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related 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 the Interdisciplinary Group completed the patient’s initial comprehensive assessments within five calendar days after admission {HCPC.9.I/L523/418.54(b)}; Failed to ensure that hat the patient’s medication profile was updated {HCPC.15.I/L530/418.54(c)(6)(i}; and Failed to ensure that the Registered Nurse (RN) performed visits to the patient in order to update the comprehensive assessment at least every 15 days {HCPC.17. I/L533/418.54(d)}. 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 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review, clinical record review, and interviews revealed the following issues regarding Hospice Aide services: Failed to ensure that the hospice aide was provided patient-specific instructions by the Registered Nurse (RN) to safely and effectively meet the needs of the patient, (HCDT.15.I/L625/418.76(g)(1)); Failed to ensure the hospice aide communicated changes in the patient’s condition {HCDT.18.I/L628/418.76(g)(4)}; and Failed to ensure that the registered nurse supervised the hospice aide no less frequently than every 14 days {HSRM.25.I/L629/418.76(h)(1)(i)}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from 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. Volunteer services are noted in the plan of care. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, clinical record review, and interview which revealed the agency: Failed to ensure o document activities that demonstrated ongoing efforts to recruit and retain volunteers {HSRM.30.I/L645/418.78(c)}; Failed to ensure to demonstrate that the agency maintained and utilized an active volunteer program sufficient to meet hospice volunteer requirements. Documentation provided for review reflected only 3.88 volunteer hours during the first quarter of 2026 and 5.42 volunteer hours during the second quarter of 2026. No information was provided for the calendar years 2023, 2024, and 2025 {HSLG.7.I/L646/418.78(d)}; and Failed to ensure that volunteer services were provided 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 {HSLG.7.I/L647/418.78(e)}. The cumulative effect of these deficiencies indicates a lack of effective oversight and implementation of an effective volunteer program and could result in the hospice agency’s inability to ensure the provision of quality health care, in a safe environment, in order to meet all patients’ needs for the Condition of Participation CFR 418.78 Volunteer Program. The deficient practice demonstrates systemic process failures that have the potential to affect all patients cared for by the hospice agency.”

“It is required the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to: a second full-scale exercise that is community-based or a facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the hospice’s Emergency Preparedness (EP) program documentation revealed that the organization did not ensure annual testing of its emergency preparedness plan. Records included a Hazard Vulnerability Analysis (HVA), a full-scale earthquake exercise, and a tabletop influenza pandemic exercise, all completed on 08/26/2024. However, the hospice was unable to provide evidence of any additional EP testing activities after that date, including an actual emergency activation, a full-scale exercise, a tabletop exercise, a workshop, or a mock disaster drill. During an interview on 07/02/2026, the Administrator (Personnel Record 2) stated she had interpreted the requirement to mean EP testing was required every two years. After reviewing the applicable regulations, she acknowledged the interpretation error and confirmed that the organization had not conducted or documented any emergency preparedness testing since 08/26/2024. A review of the hospice’s Emergency Preparedness (EP) program documentation revealed that the organization could not demonstrate annual testing of its emergency preparedness plan. Records included a Hazard Vulnerability Analysis (HVA), a full-scale earthquake exercise, and a tabletop influenza pandemic exercise, all completed on 08/26/2024. However, the hospice was unable to provide evidence of any additional EP testing activities after that date, including an actual emergency activation, a full-scale exercise, a tabletop exercise, a workshop, or a mock disaster drill. As a result, the organization could not demonstrate that its emergency preparedness program was tested annually. During an interview on 07/02/2026, the Administrator (Personnel Record 2) stated she had interpreted the requirement to mean EP testing was required every two years. After reviewing the applicable regulations, she acknowledged the interpretation error and confirmed that the organization had not conducted or documented any emergency preparedness testing since 08/26/2024. The lack of annual testing limited the hospice’s ability to evaluate plan effectiveness, identify operational gaps, assess staff readiness, and implement corrective actions to improve emergency response capabilities.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure the Interdisciplinary Group completed the initial comprehensive assessment no later than five (5) days after admission. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/05/2025. Review of the clinical record revealed that the initial Social Work and Chaplain assessments were not completed and documented until 12/15/2025, 10 days after admission to hospice services. There was no documented evidence in the clinical record explaining the delay in the Social Worker or Chaplain assessments. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/25/2026. Review of the clinical record revealed that the initial Registered Nurse (RN) and Social Work (SW) assessments were completed on 06/25/2026. The initial Chaplain assessment was scheduled for 07/02/2026, more than five days after hospice admission. There was no documented evidence in the clinical record explaining the delay in the Chaplain assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/19/2025. Review of the clinical record revealed that the initial Registered Nurse (RN) assessment was completed on 06/19/2025; the initial Social Work (SW) assessment was completed on 06/24/2025, however, the initial Spiritual Care Coordinator (SCC)/Chaplain assessment was not completed until 06/27/2025, more than five days after admission to hospice services. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/19/2025. Review of the clinical record revealed that the initial Registered Nurse (RN) assessment was completed on 12/19/2025. However, there was no evidence that an initial Social Work assessment or initial Chaplain assessment was completed following admission to hospice services. A review of the 12/30/2025 Interdisciplinary Group (IDG) meeting documentation did not identify any discussion or documentation indicating that Social Work and Chaplain services had been declined or that assessments were not completed based on patient preference. During a joint clinical record review and interview conducted with the Administrator/Alternate Director of Nursing (Personnel Record 2) on 07/02/2026, the findings that initial comprehensive assessment components were not completed within the required timeframe and lacked supporting documentation explaining a delay or a patient/representative’s declination of services were discussed. The Administrator was unable to provide documentation of the reasons for the delay in the assessments.”

“It is required that the documented comprehensive assessment include a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, and herbal remedies. The medication review process includes identifying the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure 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, document review, and interview. In 8 of 14 (57%) clinical records reviewed revealed that the agency did not ensure that the patient’s medication profile was updated. HOSPICE POLICY: The hospice’s policy, “Assessment and Reassessment Guidelines (9.5) last revised June 2019 read in part that “...Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking...to identify: drug effectiveness, side effects, actual or potential drug interactions, noncompliance with medications, duplicate therapy, ineffective therapy, potential adverse reactions, drug therapy associated with lab monitoring...” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/25/2025. The patient’s plans of care (POC) for the benefit periods 03/19/2026 to 05/16/2026 and 05/17/2026 to 07/15/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 03/24/2026, 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment; For the benefit periods reviewed, the only Registered Nurse (RN) visits occurred on 04/30/2026 and 05/06/2026. Documentation from those visits indicated medications were reviewed with the patient and/or caregiver Additional medication profile reviews signed by the RN or Nurse Practitioner (NP), were documented on 03/03/2026, 03/04/2026, 06/23/2026, and 06/29/2026. This review identified a 111-day interval between the documented medication profile reviews dated 03/04/2026 and 06/23/2026, during which six comprehensive assessment updates were completed without documented evidence that all medications were reviewed as required. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/19/2025. The patient’s plans of care (POC) for the benefit periods 04/15/2026 to 06/13/2026 and 06/14/2026 to 08/12/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment; Medication profile reviews signed by the Registered Nurse (RN) and/or Nurse Practitioner (NP) were documented on 03/10/2026, 04/03/2026, and 06/02/2026. The only documented RN visits during the reviewed benefit periods occurred on 04/17/2026, 05/01/2026, 05/06/2026, and 06/06/2026. Documentation for each of those visits indicated that medications were reviewed with the patient and/or caregiver; This review identified a 60-day interval between the documented medication profile reviews dated 04/03/2026 and 06/02/2026, during which comprehensive assessment updates were completed without documented evidence that all medications were reviewed as required. CLINICAL RECORD 4: The patient elected the hospice benefit on SOC: 12/05/2025. Review of the patient’s plans of care (POC) for the benefit periods 03/31/2026 to 05/29/2026 and 05/30/2026 to 07/28/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment; Medication profile reviews signed by the Registered Nurse (RN) and/or Nurse Practitioner (NP) were documented on 12/31/2025, 01/15/2026, 02/02/2026, 03/07/2026, 03/19/2026, and 04/27/2026. The only documented RN visits during the reviewed benefit periods occurred on 05/01/2026, 05/06/2026, 05/28/2026, and 06/26/2026. Documentation for each of those visits indicated that medications were reviewed with the patient and/or caregiver. This review identified a 69-day interval between the documented medication profile review dated 04/27/2026 and the survey review date 06/30/3036, during which comprehensive assessment updates were completed on 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 without documented evidence that all medications were reviewed as required. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/22/2026. The patient’s plans of care (POC) for the benefit periods 01/22/2026 to 04/21/2026 and 04/22/2026 to 07/20/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 01/27/2026, 02/10/2026, 02/24/2026, 03/10/2026, 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment. For the benefit periods under review, only one medication profile review was documented on 03/03/2026 and signed by the Registered Nurse (RN). The only documented RN visits during the reviewed benefit periods occurred on 03/11/2026, 04/20/2026, 04/30/2026, and 05/04/2026. Documentation from the visit dated 03/11/2026 noted review of new and/or changed medications and indicated, “SN conferred with an individual with education and training in drug management - facility staff.” Documentation from the remaining visits indicated that medications were reviewed with the patient and/or caregiver. This review identified a 105-day interval between the documented medication profile review dated 03/03/2026 and the last comprehensive assessment update reviewed on 06/16/2026. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/02/2026. Review of the patient’s plan of care (POC) for the benefit period 04/02/2026 to 06/30/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment. Medication profile reviews were documented on 04/01/2026, 06/02/2026, and 06/08/2026. The only documented RN visits during the reviewed benefit period occurred on 04/15/2026, 04/17/2026, 04/21/2026, 04/29/2026, 05/01/2026, and 06/17/2026. Documentation from the visit dated 04/15/2026 indicated the RN conferred with an individual with education and training in drug management, specifically the Medical Director. Documentation from the remaining visits reflected that medications were reviewed with the patient and/or caregiver. This review identified a 62-day interval between the documented medication profile reviews dated 04/01/2026 and 06/02/2026, during which comprehensive assessment updates were completed on 04/07/2026, 05/05/2026, and 05/19/2026 without documented evidence that all medications were reviewed as required. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/10/2026. Review of the patient’s plans of care (POC) for the benefit periods 03/10/2026 to 06/07/2026 and 06/08/2026 to 09/05/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 03/10/2026, 03/24/2026, 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment. Medication profile reviews signed by the Registered Nurse (RN) and/or Nurse Practitioner (NP) were documented on 03/17/2026, 04/03/2026, 05/01/2026, and 05/27/2026. The documented RN visits during the reviewed benefit periods occurred on 03/19/2026, 04/03/2026, 04/30/2026, 05/06/2026, 05/13/2026, and 05/27/2026. Documentation for these visits indicated that medications were reviewed with the patient and/or caregiver. This review identified a 17-day gap between a medication profile review with the comprehensive assessment update from 03/17/2026 to 04/03/2026. A 28-day gap between 04/03/2026 and 05/01/2026, a 26-day gap between 05/01/2026 and 05/27/2026 and a 20-day gap 05/27/2026 and the next documented comprehensive assessment/IDG update on 06/16/2026. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/31/2025. Review of the patient’s plans of care (POC) for the benefit periods from 03/31/2026 to 05/29/2026 and 05/30/3036 to 07/28/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment. There was on medication profile review dated 04/27/2026 was signed by the Registered Nurse. The documented RN visits during the reviewed benefit periods occurred on 04/15/2026, 04/17/2026, 04/19/2026, 05/13/2026, and 05/27/2026. Documentation for these visits indicated that medications were reviewed with the patient and/or caregiver. Following the medication profile review dated 04/27/2026, there was a 50-day interval through the comprehensive assessment update conducted on 06/16/2026 with no subsequent documented medication profile review. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/19/2025. Review of the patient’s plans of care (POC) for the benefit periods 03/19/2026 to 06/16/2026 and 06/17/2026 to 08/15/2026 identified multiple comprehensive assessment updates completed through Interdisciplinary Group (IDG) review. Documentation of IDG meetings dated 03/24/2026, 04/07/2026, 05/05/2026, 05/19/2026, 06/02/2026, and 06/16/2026 reflected updates to the patient’s comprehensive assessment; Medication profile reviews were documented on 12/22/2025, 01/16/2026, 03/03/2026 (signed by the Nurse Practitioner), and 05/15/2026. The documented Registered Nurse (RN) visits during the reviewed benefit periods occurred on 05/01/2026 and 06/04/2026. Documentation for these visits indicated that medications were reviewed with the patient and/or caregiver. Following the medication profile review dated 03/03/2026, there was a 73-day interval until the next documented medication profile review on 05/15/2026, Following the medication profile review dated 05/15/2026, there was a 32-day interval through the comprehensive assessment update conducted on 06/16/2026 with no subsequent documented medication profile review. During a review of the clinical record and related documentation on 07/01/2026, the absence of documented medication profile reviews as part of the patient’s comprehensive assessment updates was discussed with the Administrator/Alternate Director of Nursing (RN) (Personnel Record 2). The Administrator was unable to provide evidence of a current agency-standardized process for conducting, documenting, and tracking medication profile reviews.”

“It is required that the comprehensive assessment be updated by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have occurred since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as often as the patient’s condition requires, but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review, and interview. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure the Registered Nurse (RN) performed visits to the patient in order to update the comprehensive assessment at least every 15 days. HOSPICE POLICY: The agency policy titled, Nursing Services (9.22), revised June 2019, read in part, “Professional nursing services will be provided in accordance with the patient’s IDG plan of care, under the supervision of a registered nurse. Professional nursing services will be provided by a registered nurse and include initial and ongoing comprehensive assessments of the patient’s needs. The Licensed Practical Nurse or Licensed Vocational Nurse (LPN/LVN) will supplement the nursing care needs of the patient as provided by the Registered Nurse and include: preparing clinical and progress notes, assisting the Registered Nurse in carrying out the IDG plan of care. The LPN/LVN will be supervised by the RN at least monthly.” HOSPICE POLICY: The hospice policy titled, “Reassessments/Update to the Comprehensive Assessment (9.8), revised May 2023, stated in part: “The update of the comprehensive assessment must be accomplished by the IDG...no less frequently than every 15 days.” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/25/2025. Review of the clinical record for the benefit periods 03/19/2026 to 05/16/2026 and 05/17/2026 to 07/15/2026 revealed that ongoing skilled nursing visits were provided predominantly by a Licensed Practical Nurse (LPN). LPN visits were documented on 03/23/2026, 03/27/2026, 03/30/2026, 04/03/2026, 04/06/2026, 04/10/2026, 04/13/2026, 04/17/2026, 04/20/2026, 04/24/2026, 04/27/2026, 05/08/2026, 05/11/2026, 05/15/2026, 05/18/2026, 05/22/2026, 05/26/2026, 05/29/2026, 06/01/2026, 06/04/2026, 06/08/2026, 06/11/2026, 06/16/2026, 06/24/2026, 06/25/2026, and 06/26/2026. Two Registered Nurse (RN) visits were documented during the review period, on 04/30/2026 and 05/06/2026. Nurse Practitioner (NP) visits were documented on 04/18/2026 and 06/21/2026. Following the RN visit on 05/06/2026, no additional RN visits were documented through the remainder of the review period, despite continued patient contact and assessment activities performed by the LPN through 06/26/2026. This resulted in a period of more than 50 days without a documented RN reassessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/19/2025. Review of the clinical record for the benefit periods 04/15/2026 to 06/13/2026 and 06/14/2026 to 08/12/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered frequency of nursing visits. The clinical record documented a Registered Nurse (RN) visit on 05/06/2026, and a subsequent Nurse Practitioner (NP) visit on 05/30/2026. Following the RN visit on 05/06/2026, the next documented clinical assessment was performed by the NP on 05/30/2026, resulting in a 24-day interval without documented RN involvement. CLINICAL RECORD 4: The patient elected the hospice benefit on 12/05/2025. Review of the clinical record for the benefit periods 03/31/2026 to 05/29/2026 and 05/30/2026 to 07/28/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered nursing visit frequency. The clinical record reflected Nurse Practitioner (NP) visits on 03/17/2026 and 05/02/2026, and Registered Nurse (RN) visits on 05/01/2026, 05/06/2026, 05/27/2026, 06/09/2026 (PRN), and 06/26/2026. Following the RN visit on 05/06/2026, the next scheduled RN visit did not occur until 05/27/2026, resulting in a 21-day interval between RN assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/22/2026. Review of the clinical record for the benefit periods from 01/22/2026 to 04/21/2026 and from 04/22/2026 to 07/20/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered nursing visit frequency. Registered Nurse (RN) visits were documented on 03/11/2026, 04/20/2026, 04/23/2026, 04/30/2026, and 05/04/2026. Nurse Practitioner (NP) visits were documented on 04/22/2026 and 06/28/2026. Following the RN visit on 03/11/2026, the next documented RN visit did not occur until 04/20/2026, resulting in a 40-day interval between RN assessments. Following the RN visit on 05/04/2026, no additional RN visits were documented through the remainder of the review period. Although an NP visit was documented on 06/28/2026, the record lacked evidence that an RN reassessed the patient, evaluated changes in condition, and updated the comprehensive assessment during the 55-day period between 05/04/2026 and 06/28/2026. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/02/2026. Review of the clinical record for the benefit period 04/02/2026 to 06/30/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered nursing visit frequency; Registered Nurse (RN) visits were documented on 05/01/2026, 05/27/2026, and 06/17/2026. From the start of the benefit period on 04/02/2026 until the next documented RN visit on 05/01/2026, there was a 29-day period without evidence of an RN reassessment. Following the RN visit on 05/01/2026, the next documented RN visit did not occur until 05/27/2026, resulting in a 26-day interval between RN assessments. Subsequently, the next RN visit was documented on 06/17/2026, creating an additional 21-day interval between RN assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/10/2026. Review of the clinical record for the benefit periods 03/10/2026 to 06/07/2026 and 06/08/2026 to 09/05/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered nursing visit frequency. Registered Nurse (RN) visits were documented on 03/10/2026, 05/27/2026, and 06/30/2026. Following the RN admission assessment on 03/10/2026, the next documented RN visit did not occur until 05/27/2026, resulting in a 78-day interval between RN assessments. The next RN visit was documented on 06/30/2026, creating an additional 34-day interval between RN assessments. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/31/2025. Review of the clinical record for the benefit periods 03/31/2026 to 05/29/2026 and 05/30/2026 to 07/28/2026 revealed that ongoing skilled nursing visits were provided primarily by a Licensed Practical Nurse (LPN) in accordance with the ordered nursing visit frequency. Registered Nurse (RN) visits were documented on 03/19/2026, 04/15/2026, 04/17/2026, 04/30/2026, 05/13/2026, and 05/27/2026. A Nurse Practitioner (NP) visit was documented on 04/26/2026. Following the RN visit on 03/19/2026, the next documented RN visit did not occur until 04/15/2026, resulting in a 27-day interval between RN assessments. During a joint clinical record review and interview conducted with the Administrator/Alternate Director of Nursing (RN) (Personnel Record 2) on 07/01/2026, the Administrator acknowledged the gaps in RN visit documentation and agreed that the records reflected extended periods without documented RN reassessment.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s plan of care was reviewed as required at least every 15 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/19/2025. The patient was reviewed for the first time by the Interdisciplinary Group (IDG) Meeting on 07/01/2026 and again on 07/15/2026. There was a 28-day gap in the patient’s plan of care review between 07/15/2026 and 08/12/2026. During a joint clinical record review and interview with the Administrator/Alternate Clinical Director (RN) on 07/02/2026 she confirmed the missing IDG review but could provide no evidence or reason as to why there was a 28-day gap. No evidence of review during that period of time was provided.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains service coordination and documents the exchange of information. The policies and procedures ensure that the sharing of information occurs between all disciplines providing care and services in all settings and is ongoing, whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s pain was communicated to the patient’s nurse and that the communication and follow-up were documented. HOSPICE POLICY: The hospice policy titled, Assessment and Reassessment Guidelines (9.5), revised June 2019, stated in part, “Communication: Pertinent assessment and reassessment data will be communicated to team members, the IDG... by IDG meetings, case conference, telephone.” CLINICAL RECORD 14: The election of the hospice benefit form was dated 09/12/2025 with a diagnosis of Malignant Neoplasm of Bronchus/Lung. A Social Work visit note dated 09/17/2025 documented that the patient was “in great pain”; however, there was no documented evidence that the Social Worker communicated this finding to the nursing staff, the physician, or other members of the interdisciplinary group (IDG). The next documented nursing visit occurred on 09/19/2025, when an LPN recorded a pain level of 4/10 and noted the patient reported significant intermittent back pain managed with scheduled Hydrocodone and additional doses available for breakthrough pain. There was no documented information that the Social Worker notified nursing staff or that a nurse completed a telephone or in-person assessment in response to the reported pain. During a joint clinical record review on 07/02/2026, the Administrator/Alternate Director of Nursing (RN) (Personnel Record 2) reviewed the Social Work note. She acknowledged that the Social Worker should have notified the nurse and documented the communication.”

“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 and use of gloves. This standard was not met as evidenced by document review, interview, and observation. In 1of 3 (33%) home visit observations the agency did not ensure personnel followed agency policy on hand hygiene. HOSPICE POLICY: The hospice policy titled, Hand Hygiene Policy and Compliance Program (5.7), revised July 2021, read in part, “Hand hygiene will be done by all employees... to reduce the transfer of microbes to patients. Indications for hand hygiene are: Before and after direct patient care, indications for handwashing and hand antisepsis...after removing gloves...moving from contaminated patient body site to clean site during patient care; after contact with inanimate objects or medical equipment close to patient...Use of gloves...remove gloves after contact with each patient...change or remove gloves if moving from a contaminated to a clean patient site or the environment.” HOME VISIT 3: During the home visit with the RN/Administrator/Alternate Director of Nursing (Personnel Record 2) on 07/01/2026, the RN washed her hands and donned gloves before providing patient care. After obtaining vital signs, assessing the patient’s feet, and evaluating skin integrity in the back and brief/buttocks area, she proceeded to disinfect patient care equipment, including a thermometer, pulse oximeter, blood pressure cuff, and stethoscope, without removing gloves, performing hand hygiene, or changing gloves. The same gloves used for direct patient care and contact with potentially contaminated body areas were used to clean the equipment. During an interview immediately following the visit on 07/01/2026, the Administrator/Alternate Director of Nursing acknowledged she had not performed appropriate hand hygiene before disinfecting the equipment and recognized that the same gloves had been worn throughout the patient assessment and cleaning process. She stated she was nervous due to being observed during the survey.”

“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 1 of 12 (8%) clinical records reviewed of patients receiving hospice aide services it was revealed that the agency did not ensure that the hospice aide was provided patient-specific instructions by the Registered Nurse (RN) to safely and effectively meet the needs of the patient. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/25/2026. The Plan of Care (POC) dated 06/25/2026 to 09/22/2026 included hospice aide visits twice weekly, with instructions to provide a chair bath at each visit . The Registered Nurse (RN) admission assessment dated 06/25/2026 documented three wounds. The hospice aide care plan did not include instructions for protecting wounds during bathing and personal care, precautions for wound dressings, or guidance on reporting wet, loose, displaced, or soiled dressings to the RN. During a joint clinical record review and interview conducted on 07/02/2026, the Administrator/Alternate Director of Nursing (RN) (Personnel Record 2) reviewed the patient’s documented wounds, the ordered hospice aide visits, and the hospice aide care plan. she confirmed the omission and said, “That’s a good idea.” she reported the patient had not yet allowed the aide to provide bathing assistance, however she could not provide evidence that the aide had received written or verbal instructions regarding wound protection, dressing management, or reporting of wound-related concerns.”

“It is required that hospice aides report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed of patients receiving hospice aide services it was revealed that the hospice did not ensure the hospice aide communicated changes in the patient’s condition. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/12/2025 and died on 10/06/2025. The Plan of Care (POC) included hospice aide visits twice weekly with a shower using a chair at each visit. On 09/24/2025, the hospice aide documented, “The client has a new sore on her bottom.” On 09/26/2025, the aide documented the patient refused a shower and was “extremely tired” and could “barely move.” On 10/01/2025, the aide documented refusal of the ordered shower and noted the patient was “very lethargic,” sleeping throughout care and awakening only when turned. There was no documented evidence that the aide reported the new skin impairment, increasing weakness, lethargy, or functional decline to the Registered Nurse (RN). During a joint clinical record review and interview conducted on 07/02/2026, the Administrator/Alternate Director of Nursing (Personnel Record 2) confirmed that these findings represented changes in the patient’s condition that were not reported to the Registered Nurse (RN). She further stated that the hospice aide should have notified the RN of these observations and documented that the RN was notified.”

“It is required that hospice aides be supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 6 of 12 (50%) clinical records reviewed for patients receiving hospice aide services revealed the agency did not ensure that the registered nurse supervised the hospice aide no less frequently than every 14 days. HOSPICE POLICY: The hospice policy titled, Hospice Aide Supervision (4.21), revised February 2022, stated in part, “Hospice will conduct the 14-day supervisory visit during an on-site visit, in-person visit. At least every 14 days, the Registered Nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met.” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/25/2025. A review of the patient’s benefit periods and plans of care (POC) dated 03/19/2026 to 05/16/2026 and 05/17/2026 to 07/15/2026 revealed orders for Hospice Aide (HA) visits. RN visits were documented on 04/30/2026 and 05/06/2026; these were the only on-site visits documented by the RN, and HA Supervisory visits were documented on 03/30/2026, 04/27/2026, 05/11/2026, 06/0/2026, and 06/23/2026. Following the RN visit on 05/06/2026, no additional RN visits were documented through 06/30/2026, resulting in a gap of more than 48 days between 05/06/2026 and 06/23/2026. The HA Supervisory visit conducted on 06/08/2026 occurred 33 days after the last documented RN visit on 05/06/2026, and the subsequent hospice aide supervisory visit on 06/23/2026 occurred 48 days after the last documented RN visit. Additionally, the period between the HA Supervisory visits on 06/08/2026 and 06/23/2026 was 15 days, CLINICAL RECORD 3: The patient elected the hospice benefit on 06/19/2025. A review of the patient’s benefit periods/plans of care (POC) for 04/15/2026 to 06/13/2026 and 06/14/2026 to 08/12/2026 revealed documented RN visit on 05/06/2026 and a Nurse Practitioner (NP) visit on 05/30/2026. Hospice Aide Supervisory visits were documented on 04/28/2026, 05/12/2026, 05/26/2026, and 06/06/2026. Following the RN visit on 05/06/2026, the next documented RN visit was performed by an NP (Nurse Practitioner) on 05/30/2026, creating a 24-day gap without documented RN involvement. During this interval, HA supervisory visits occurred on 05/12/2026 and 05/26/2026. The HA supervisory visit on 05/26/2026 occurred 20 days after the last documented RN visit on 05/06/2026. The HA supervisory visit documented on 06/06/2026 occurred 31 days after the last documented RN visit on 05/06/2026. CLINICAL RECORD 4: The patient elected the hospice benefit on 12/05/2025. A review of the patient’s benefit periods/plans of care (POC) for 03/31/2026 to 05/29/2026 and 05/30/2026 to 07/28/2026 revealed documented RN visits on 05/01/2026, 05/06/2026, 05/27/2026, 06/09/2026 (PRN), and 06/26/2026. Nurse Practitioner (NP) visits were documented on 03/17/2026 and 05/02/2026. Hospice Aide Supervisory visits were documented on 03/17/2026, 03/31/2026, 04/14/2026, 04/28/2026, 05/12/2026, 05/27/2026, 06/09/2026, and 06/23/2026. Between the RN visit on 05/06/2026 and the subsequent visit on 05/27/2026, there was a 21-day gap with no documented RN involvement. During this interval, an HA supervisory visit was completed on 05/12/2026, six days after the last documented RN visit; however, no RN visit was documented within the following 14 days The next HA supervisory visit on 05/27/2026 occurred 21 days after the previous RN visit on 05/06/2026. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/22/2026. A review of the patient’s benefit periods/plans of care (POC) for 01/22/2026 to 04/21/2026 (review beginning 03/01/2026) and 04/22/2026 to 07/20/2026 revealed documented RN visits on 03/11/2026, 04/20/2026, 04/23/2026, 04/30/2026, and 05/04/2026. Nurse Practitioner (NP) visits were documented on 04/22/2026 and 06/28/2026. Hospice Aide Supervisory visits were documented on 03/17/2026, 03/31/2026, 04/14/2026, 04/29/2026, 05/12/2026, 05/26/2026, 06/09/2026, and 06/23/2026. Following the RN visit on 03/11/2026, the next documented RN visit did not occur until 04/20/2026, creating a 40-day gap without documented RN involvement. During this interval, HA supervisory visits were completed on 03/17/2026, 03/31/2026, and 04/14/2026. The HA supervisory visit on 03/31/2026 occurred 20 days after the last documented RN visit on 03/11/2026, The subsequent HA supervisory visit on 04/14/2026 occurred 34 days after the last documented RN visit, Further review identified that the last documented RN visit occurred on 05/04/2026. Following that visit, HA supervisory visits were conducted on 05/12/2026, 05/26/2026, 06/09/2026, and 06/23/2026, with no documented RN visits during that timeframe. The HA supervisory visit on 05/26/2026 occurred 22 days after the last documented RN visit on 05/04/2026, The HA supervisory visits on 06/09/2026 and 06/23/2026 occurred 36 and 50 days after the last documented RN visit, respectively. Although an NP visit was documented on 06/28/2026, the record lacked evidence that an RN was onsite with the patient to assess and document hospice aide performance at least every 14 days as required. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/10/2026. A review of the patient’s benefit periods/plans of care (POC) for 03/10/2026 to 06/07/2026 (review beginning 05/01/2026) and 06/08/2026 to 09/05/2026 revealed documented RN visits on 05/27/2026 and 06/30/2026. Hospice Aide Supervisory visits were documented on 05/08/2026, 05/22/2026, and 06/19/2026. Prior to the RN visit on 05/27/2026, Hospice Aide Supervisory visits were conducted on 05/08/2026 and 05/22/2026; however, no RN visits were documented to evidence onsite supervisory oversight of hospice aide services during that timeframe. The HA Supervisory visit on 05/22/2026 occurred without evidence of an RN onsite supervisory visit within the preceding 14 days. Further review identified a 34-day gap between the documented RN visits of 05/27/2026 and 06/30/2026. During this interval, an HA Supervisory visit was completed on 06/19/2026, 23 days after the last documented RN visit on 05/27/2026, The record lacked evidence of ongoing RN supervisory oversight of hospice aide services at intervals of no more than 14 days throughout the review period. Specifically, the absence of documented RN supervisory visits associated with the HA Supervisory visits on 05/22/2026 and 06/19/2026, as well as the 34-day gap between RN visits from 05/27/2026 through 06/30/2026, . CLINICAL RECORD 9: The patient elected the hospice benefit on 12/31/2025. A review of the patient’s benefit periods/plans of care (POC) for 03/31/2026 to 05/29/2026 and 05/30/2026 to 07/28/2026 revealed documented RN visits on 03/19/2026, 04/15/2026, 04/17/2026, 04/30/2026, 05/13/2026, and 05/27/2026. A Nurse Practitioner (NP) visit was documented on 04/26/2026. Hospice Aide Supervisory visits were documented on 03/20/2026, 04/03/2026, 04/17/2026, 05/15/2026, 06/12/2026, and 06/26/2026. Following the RN visit on 03/19/2026, an HA Supervisory visit was completed on 04/03/2026, 15 days later. the RN visit on 05/27/2026 and the next documented HA Supervisory visit on 06/12/2026. The HA Supervisory visit on 06/12/2026 occurred 16 days after the last documented RN visit, , the HA Supervisory visit on 06/26/2026 occurred 30 days after the last documented RN visit on 05/27/2026, with no intervening RN visit documented. During a joint clinical record review and interview conducted with the Administrator (RN) (Personnel Record 2) on 07/01/2026. The Administrator reviewed the evidence and agreed that the record reflected HA supervisory visits during weeks in which no RN visit documentation was present. The Administrator stated that the RN had been on-site during those supervisory visits; however, when asked to identify documentation in the clinical record demonstrating the RN’s on-site presence and supervisory observation of the hospice aide, she stated that such documentation was not present.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Review of the agency volunteer documentation that revealed the agency did not ensure to document activities that demonstrated ongoing efforts to recruit and retain volunteers. During the interview on 07/01/2026, the Administrator/Volunteer Coordinator (Personnel Record 2) stated that an employee responsible for maintaining volunteer records had been terminated on 02/03/2026, which led to the creation of a new 2026 volunteer binder. There was no documented evidence of volunteer recruitment, retention, outreach, engagement, or program oversight activities conducted prior to 01/2026. The agency could not demonstrate that an active, ongoing volunteer program was maintained or that volunteer services were available to meet patient and family needs in accordance with hospice requirements. During a review of the Volunteer Program documentation and an interview on 07/01/2026, the Administrator/Volunteer Coordinator (Personnel Record 2) stated that an employee responsible for maintaining volunteer records had been terminated on 02/03/2026 after being found shredding documentation, which led to the creation of a new 2026 volunteer binder. However, the hospice remained unable to provide documentation demonstrating volunteer recruitment, retention, outreach, engagement, or program oversight activities conducted prior to 01/2026. As a result, the agency could not demonstrate that an active, ongoing volunteer program was maintained or that volunteer services were available to meet patient and family needs in accordance with hospice requirements.”

“It is required that the hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Review of the Volunteer Program documentation provided revealed that the organization did not demonstrate that it maintained and utilized an active volunteer program sufficient to meet hospice volunteer requirements. Documentation provided for review reflected only 3.88 volunteer hours during the first quarter of 2026 and 5.42 volunteer hours during the second quarter of 2026. No information was provided for the calendar years 2023, 2024, and 2025. During interview, the Administrator/Volunteer Coordinator stated that an employee responsible for assisting with the maintenance and tracking of volunteer records was terminated on 02/03/2026. She further stated that a new volunteer record book was established in 2026 following the loss of documentation. Review of the hospice’s volunteer program records and interview revealed that the organization could not demonstrate that it maintained and utilized an active volunteer program sufficient to meet hospice volunteer requirements. A review of the agency’s Volunteer Program documentation, together with an interview conducted on 07/01/2026 with the Administrator/Volunteer Coordinator (Personnel Record 2), identified that the hospice was unable to provide complete records supporting the recruitment, retention, management, and utilization of volunteers. Documentation provided for review reflected only 3.88 volunteer hours during the first quarter of 2026 and 5.42 volunteer hours during the second quarter of 2026. In addition, the organization could not provide documentation of volunteer recruitment or retention activities conducted prior to January 2026. During interview, the Administrator/Volunteer Coordinator stated that an employee responsible for assisting with the maintenance and tracking of volunteer records was discovered shredding documentation and was subsequently terminated on 02/03/2026 for willful destruction of company property. She further stated that a new volunteer record book was established in 2026 following the loss of documentation. Despite this explanation, the hospice was unable to produce records demonstrating ongoing volunteer recruitment efforts, retention activities, volunteer utilization, or effective oversight of the volunteer program for the period under review. As a result, the hospice lacked sufficient documentation to demonstrate the ongoing operation and management of an organized volunteer program. The absence of documentation related to volunteer recruitment, retention, and service utilization had the potential to limit the availability of volunteer support for patients and families, reduce opportunities for companionship and supportive services, impair the hospice’s ability to evaluate the effectiveness of its volunteer program, and hinder the organization’s ability to demonstrate compliance with hospice volunteer program requirements.”

“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. Review of the hospice volunteer program records and interview revealed that the organization could not demonstrate that volunteer services were provided 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. A review of the agency Volunteer Program documentation, together with an interview conducted on 07/01/2026 with the Administrator/Volunteer Coordinator (Personnel Record 2), identified that the hospice was unable to provide complete records necessary to calculate and verify compliance with the 5-percent volunteer requirement. Documentation provided for review reflected only 3.88 volunteer hours during the first quarter of 2026 and 5.42 volunteer hours during the second quarter of 2026. The organization was unable to provide supporting documentation demonstrating the total number of patient care hours worked by paid hospice employees and contract staff or other records necessary to validate that volunteer services met the required minimum threshold. No information was provided for the calendar years 2023, 2024, and 2025. Review of the hospice’s volunteer program records and interview revealed that the organization could not demonstrate that volunteer services were provided 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. A review of the agency’s Volunteer Program documentation, together with an interview conducted on 07/01/2026 with the Administrator/Volunteer Coordinator (Personnel Record 2), identified that the hospice was unable to provide complete records necessary to calculate and verify compliance with the 5-percent volunteer requirement. Documentation provided for review reflected only 3.88 volunteer hours during the first quarter of 2026 and 5.42 volunteer hours during the second quarter of 2026. The organization was unable to provide supporting documentation demonstrating the total number of patient care hours worked by paid hospice employees and contract staff or other records necessary to validate that volunteer services met the required minimum threshold. Further review revealed the hospice could not provide documentation of volunteer recruitment or retention activities conducted prior to January 2026. During interview, the Administrator/Volunteer Coordinator stated that an employee responsible for assisting with the maintenance and tracking of volunteer records was discovered shredding documentation and was subsequently terminated on 02/03/2026 for the willful destruction of company property. The Administrator further stated that a new volunteer record book was created in 2026 following the loss of documentation. Despite this explanation, the hospice was unable to produce records demonstrating ongoing volunteer recruitment, retention, volunteer utilization, or compliance with the required volunteer hour calculations for the period under review. As a result, the organization lacked sufficient documentation to demonstrate compliance with the volunteer requirement and to evidence the effective operation of its volunteer program. The absence of complete volunteer program records and supporting documentation had the potential to limit oversight of volunteer program and impair the hospice’s ability to ensure compliance with hospice participation requirements.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator: Is an employee of the organization; Informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities; Has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidence by personnel record review and interview. During the personnel record review it was identified that the Alternate Administrator was out on medical leave. There was no other identified Alternate Administrator. PERSONNEL RECORD 2: The Administrator with a date of hire 10/16/2019 was also the Alternate Director of Nursing. PERSONNEL RECORD 3. The Director of Nursing (DON)with a hire date of 02/09/2026 was also the Alternate Administrator. The DON was noted to be out on medical leave effective 05/21/2026. During the interview with the Administrator(Personnel Record 2), he reported that the Alternate Administrator has been on medical leave since 05/21/2026.”

“It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment. Persons under contract with the hospice may instruct the patient and/or family, but the instruction must be documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG and the IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the hospice did not ensure the clinical record included documentation of caregiver education related to the safe use of durable medical equipment (DME) HOSPICE POLICY: The agency policy titled, Patient Equipment, (3.1) revised June 2019, stated in part, “Hospice will ensure that the patient, where appropriate, as well as the family and/or other caregiver(s), receive instruction in the safe use of home medical equipment and supplies. The patient, family and/or caregiver must be able to demonstrate the appropriate use of home medical equipment to the satisfaction of the IDG. The education given to the patient/family on the use of the equipment must be documented in the patient’s record, as well as the patient/family’s understanding of the safe use of the equipment and supplies.” HOSPICE POLICY: The hospice policy titled, Patient Record Content, (11.2) dated June 2019, read in part, “The patient record will contain documentation of all patient education regarding home medical equipment provided by hospice.” CLINICAL RECORD 2: The patient resided at home and elected the hospice benefit on 06/25/2026. Admission documentation dated 06/25/2026 identified the patient as chair-bound and dependent on assistance for all activities of daily living. The Plan of Care (POC), physician orders, and hospice aide plan of care included the use of a Hoyer lift for transfers. There was no documented evidence that family members or caregivers were educated on the Hoyer lift operation, transfer techniques, or equipment safety precautions as required by agency policy. CLINICAL RECORD 4: The patient resided at home and elected the hospice benefit on 12/05/2025. Review of the Plans of Care for the benefit periods 12/05/2025 to 03/30/2026, 03/31/2026 to 05/29/2026, and 05/30/2026 to 07/28/2026 identified physician orders for activity as tolerated using a Hoyer lift, with a Hoyer lift also included as ordered durable medical equipment (DME). During the admission visit on 12/05/2025, the Registered Nurse (RN) documented that the patient experienced pain with movement, ambulation, and Hoyer lift transfers. There was no documented evidence that family members or caregivers were educated on the Hoyer lift operation, transfer techniques, or equipment safety precautions as required by agency policy. During a joint clinical record review and interview conducted on 07/02/2026, with the Administrator/Alternate Director of Nursing (Personnel Record 2), she stated, that hospice staff were the only individuals utilizing the Hoyer lift for patient transfers, but she was unable to provide documentation supporting that hospice personnel exclusively performed all transfers or that family members and/or caregivers had been instructed not to operate the lift.”