Breeze Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4: The election of benefits form was dated 07/25/2026 with a primary diagnosis of peripheral vascular disease with comorbidities of Type 1 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene, Polyneuropathy, Anemia, Chronic Pain, and Hypertension. The initial nursing assessment dated 07/25/2026 documented that the patient had comorbidities of Type 1 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene. The right leg had several unresolved clots and a poor prognosis even with the use of thrombolytic therapy, and the patient had severe uncontrolled intermittent pain and an open wound at the amputation site. The nursing note documented a right upper leg amputation site with wound care that included wound cleanser, polymem, adaptic, ABD, Kerlix, and tape to be changed daily and PRN (as needed). The medication record was reviewed on 08/24/2026 which revealed Bactrim DS 800 mg-160 mg oral tablet take 1 tab(s) oral 2 times a day for 7 day(s) for infection started on 07/27/2026, and Levofloxacin 750 mg oral tablet take 1 tab(s) orally every 24 hours started on 07/27/2026. The initial plan of care dated 07/27/2026 lacked documentation of problems, interventions, and goals related to infection and wounds. During a joint review of the record and an interview on 08/24/2026, the Administrator/Director of Nursing confirmed that there was no documented evidence that the plan of care included problems, goals, and interventions for infection and wounds.”

“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. 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. CONTINUING PRIOR REQUIRED ACTION This standard was not reviewed as the agency had not acquired any volunteer hours as of 08/24/2026. During an interview on 08/24/2026, the Administrator/Director of Nursing and the Volunteer Coordinator stated that the Volunteer Coordinator had been out on leave but returned to work full time on 07/22/2026. All staff had received education regarding the volunteer program on 07/17/2026. They stated that the agency had onboarded 2 volunteers as of 07/31/2026. The agency has scheduled an all-staff volunteer orientation and training for 09/04/2026. Previous Evidence: 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. The hospice documents the cost savings achieved through volunteers. 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 with the Interim Volunteer Coordinator (Personnel Record 11) and Administrator (Personnel Record 1) on 07/15/2026, revealed they did not have any current volunteers on staff and did not have documented cost savings reports for the years 2023, 2024, and 2025. The Administrator stated, “They had a Performance Improvement Plan (PIP) which needs revision to address the current situation”. If patients request volunteer service, they are sending current staff and paying them. She further stated that none of the staff have received volunteer training. CONTINUING PRIOR REQUIRED ACTION This standard was not reviewed as the agency had not acquired any volunteer hours as of 08/24/2026. During an interview on 08/24/2026, the Administrator/Director of Nursing and the Volunteer Coordinator stated that the Volunteer Coordinator had been out on leave, but returned to work full time on 07/22/2026. All staff had received education regarding the volunteer program on 07/17/2026. They stated that the agency had onboarded 2 volunteers as of 07/31/2026. The agency has scheduled an all-staff volunteer orientation and training for 09/04/2026. Previous Evidence: 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. The hospice documents the cost savings achieved through volunteers. 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 with the Interim Volunteer Coordinator (Personnel Record 11) and Administrator (Personnel Record 1) on 07/15/2026, revealed they did not have any current volunteers on staff and did not have documented cost savings reports for the years 2023, 2024, and 2025. The Administrator stated, “They had a Performance Improvement Plan (PIP) which needs revision to address the current situation”. If patients request volunteer service, they are sending current staff and paying them. She further stated that none of the staff have received volunteer training.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the organization did not ensure the patient’s record included all physician’s orders. CLINICAL RECORD 4: The election of benefits form was dated 07/25/2026 with a primary diagnosis of peripheral vascular disease. The initial nursing assessment dated 07/25/2026 documented a right upper leg amputation site with wound care, including wound cleanser, polymem, adaptic, ABD, Kerlix, and tape to be changed daily and PRN (as needed). The registered nurse (RN) hospice comprehensive assessment dated 07/30/2026 documented that the wound care treatment included a wound cleanser, a composite dressing, dry Kerlix, a non-adherent dressing, and tape. The record lacked documentation of wound care orders in the initial plan of care dated 07/25/2026. The record lacked documentation of the physician’s orders for wound care for the nursing visits on 07/27/2026 or 07/30/2026. During a joint review of the record and an interview on 08/24/2026, the Administrator agreed that there was no documented evidence of the physician’s orders for the wound care.”

“It is required that a hospice must routinely provide substantially all core services directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by review of the agency’s clinical records and interviews which revealed the following issues: Failed to ensure that medical social services were provided in person according to plan of care and per the patient and family [HCDT.9.I/L594/418.64(c); and Failed to ensure a counselor was available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process {HCDT.10. I/L595/ 418.64(d)}. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice services from the agency.”

“It is required that the hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles 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 that the agency had volunteers to provide volunteer services {HSLG.7. I/L646/ 418.78(d)}; and Failed to ensure that volunteers provided 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 for 2023, 2024, and 2025{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 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 1 of 19 (5%) clinical records reviewed it was revealed that the agency did not ensure the initial comprehensive assessments were completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/02/2026. The RN completed the patient’s initial assessment on 06/02/2026. The clinical record did not provide evidence of a psychosocial assessment within 5 days of admission. The Medical Social Worker (MSW) did a telephonic psychosocial assessment on 06/18/26. There was no documented evidence in the clinical record for the reason for the delay. During a joint record review and interview with the Administrator (Personnel Record 1) on 06/15/2026, the Administrator confirmed that there was no documented evidence that an initial psychosocial assessment was completed within (5) calendar days after the election of hospice care.”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 07/02/2026. A review of the clinical record revealed that the RN documented on the initial assessment dated 07/02/2026 that the patient and family were considering discontinuing dialysis. The clinical record did not provide evidence of documented education delivered to the patient/family regarding discontinuing dialysis during the subsequent RN visit on 07/05/2026. CLINICAL RECORD 15: The patient elected the hospice benefit on 07/14/2025. A review of the clinical record revealed that there was no evidence of documentation of education on the plan of care of 11/12/2025, and the LPN visit note of 11/12/25. There was no documented evidence in the clinical record of education related to the signs and symptoms of impending death. The patient expired on 11/18/2025. During a joint record review and interview with the Administrator (Personnel Record 1) on 07/15/2026, the Administrator confirmed that there was no documented evidence of required education being provided to the patients as appropriate to their responsibilities for care as stated in the plan of care. The Administrator stated, “They are delivering education but not documenting it.””

“It is required that medical social services are provided by a qualified social worker per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed for patients who had social worker services ordered it was revealed that the agency did not ensure the social worker provided services per the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/18/2023. The Medical Social Worker (MSW) visits were ordered monthly. There was no documented evidence that the MSW provided a visit in June 2026. The last documented in-person MSW visit was dated 05/11/2026. A telehealth MSW visit was documented on 07/08/2026. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/27/2026. The MSW visits were ordered monthly. There was a MSW visit dated 05/06/2026. There was no documented evidence of an MSW visit for June 2026. There was also no documented evidence of the reason for the missed visit. During a joint record review and interview with the Administrator (Personnel Record 1) on 07/15/2026, the Administrator confirmed that there was no documented evidence that MSW provided the services as ordered.”

“It is required that counseling services are available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. This standard was not met as evidenced by personnel record review and interview. The agency did not ensure a counselor was available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. There was no documented evidence of a personnel record for a chaplain/counselor for counseling services. The agency did not have a chaplain, effective 07/10/2026. During a joint record review and interview with the Administrator Personnel Record 1) on 07/14/2026 and 07/15/2026, the Administrator stated that the Chaplain quit on Friday and they were putting a temporary plan in place using community resources to ensure the patient’s needs would continue to be addressed while they recruit for a new counselor/chaplain.”

“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 19 (5%) clinical records reviewed it was revealed that the agency did not ensure the written patient care instructions for a hospice aide were prepared by the RN who was responsible for the supervision of the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/18/2023. A review of the clinical record revealed that the aide plan of care dated 12/18/2023 did not include documented evidence of the frequency of the aide assigned task for baths and shampoo. During a joint record review and interview with the Administrator (Personnel Record 1) on 07/14/2026, the Administrator confirmed there was no documented evidence specifying the frequency of bathing and shampooing to be completed by the Aide.”

“It is required that the hospice documentation includes: The identification of each position that is occupied by a volunteer and the work time spent by volunteers occupying those positions. This standard was not met as evidence by personnel record review and interview. There was no documented evidence of a personnel record for a volunteer. The hospice did not ensure the agency had volunteers to provide volunteer services. The Administrator stated, “They had a Performance Improvement Plan (PIP) which needs revision to address the current situation. If patients request volunteer service, they are sending current staff and paying them.” She further stated that none of the staff have received volunteer training.”

“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. 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 with the Interim Volunteer Coordinator (Personnel Record 11) and Administrator (Personnel Record 1) on 07/15/2026, revealed they did not have any current volunteers on staff and did not have documented cost savings reports for the years 2023, 2024, and 2025. The Administrator stated, “They had a Performance Improvement Plan (PIP) which needs revision to address the current situation”. If patients request volunteer service, they are sending current staff and paying them. She further stated that none of the staff have received volunteer training. This standard was not met as evidenced by the document review and interview. A joint review of the volunteer program was conducted with the Interim Volunteer Coordinator (Personnel Record 11) and Administrator (Personnel Record 1) on 07/15/2026, which confirmed that they do not have any volunteers on service and do not have cost savings reports for 2023, 2024, and 2025. The Administrator stated, “They had a Performance Improvement Plan (PIP) which needs revision to address the current situation”. If patients request volunteer service, they are sending current staff and paying them. She further stated that none of the staff have received volunteer training.”