Willow Ridge Hospice, LLC

“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; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. 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; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice population 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, document review, interview, and observation. In 4 of 14 (29%) clinical records reviewed and home visit observations, the agency did not ensure that the documented comprehensive assessment included a drug profile that contained the patient’s current medications. POLICY AND PROCEDURES: Agency Policy PC.M60 titled, Medications-Profile, read in part, “A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient’s prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy. The patient’s medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every fifteen days.” CLINICAL RECORD 1: The patient elected the hospice benefit on 04/07/2026. During a home visit with the Chaplain (Personnel Record 1) on 07/28/2026, the patient’s medication record from the skilled nursing facility was compared to the medication profile from the last comprehensive assessment dated 07/20/2026. The agency medication profile included: “Morphine Solution 5mg every 2 hours as needed for pain; Naloxone 4mg/0.1ml give 0.1ml as needed for signs of overdose; and Ondansetron 4mg give one tablet by mouth as needed for nausea”. The Morphine, Naloxone, and Ondansetron were not included in the skilled nursing facility’s medication list. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/08/2026. During a home visit with the Hospice Aide (Personnel Record 7) on 07/28/2026, the patient’s current medications in the home were reviewed with the patient. A bottle labeled “Calcium with Vitamin D tablets” was found during the medication review. The patient stated, “I have been taking this medication since last month”. The comprehensive assessment and medication profile dated 07/06/2026 did not include Calcium with Vitamin D tablets. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/29/2025. During a home visit with the Administrator (Personnel Record 9) on 07/28/2026, the patient’s medication record from the assisted living facility was compared to the medication profile from the last comprehensive assessment dated 07/23/2026. The agency medication profile included “Morphine Solution 5mg every 2 hours as needed for pain; and Levsin 0.125mg tablet every 6 hours as needed for increased oral secretions”. The Morphine and Levsin were not included in the assisted living facility medication list. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/19/2026. The plan of care dated 06/19/2026 through 09/16/2026 ordered “Oxygen 2-4 liters via nasal cannula as needed for shortness of breath”. The initial nursing assessment dated 06/19/2026 did not include oxygen in the medication profile. During joint record review and an interview on 07/28/2026, the Administrator confirmed that the medication profiles did not include oxygen or Calcium with Vitamin D tablets. The Administrator also confirmed that the medication profiles did not match the facility medication lists.”

“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 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/08/2026. The initial nursing assessment dated 04/08/2026 read in part, “Patient has a history of seizures. Patient is diabetic and takes insulin”. The plans of care dated 04/08/2026-07/06/2026 and 07/07/2026-10/04/2026 did not include interventions related to seizure precautions or diabetes education and management. During a joint record review and interview on 07/28/2026, the Administrator confirmed that the plan of care did not include interventions related to seizure precautions or diabetes.”

“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; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated in accordance with the agency’s policy. POLICY AND PROCEDURES: Agency Policy PC.I25 titled, Infection Control-Hand Hygiene, read in part, “Hospice staff must wash hands: Before touching a patient; Before performing clean/aseptic procedures; After performing tasks that involve risk of exposure to body fluids; After touching a patient; Before and after wearing gloves; and after any activity involving physical contact with a patient’s immediate environment”. HOME VISIT 2: The patient elected the hospice benefit on 04/07/2026. During a home visit with the Hospice Aide (Personnel Record 7) on 07/28/2026, the Hospice Aide was observed donning gloves without first performing hand hygiene. The Hospice Aide assisted the patient with removing the patient’s brief so that the patient could use the toilet. The Hospice Aide then provided hair care without performing hand hygiene and changing gloves. The Hospice Aide provided peri-care with the same gloves on and then removed the gloves and donned a new pair of gloves without performing hand hygiene. The Hospice Aide assisted the patient into a wheelchair and put away clean laundry. The Hospice Aide then emptied a urinal in the toilet and rinsed the urinal in the shower. The Hospice Aide removed gloves and proceeded to perform hand hygiene by washing with soap and water in the kitchen sink. When the Hospice Aide finished washing her hands, the Hospice Aide turned off the faucet with her bare hands and dried her hands with a hand towel by the kitchen sink. HOME VISIT 3: The patient elected the hospice benefit on 11/29/2025. During a home visit with the Registered Nurse/Administrator (Personnel Record 9) on 07/28/2026, the nurse performed hand hygiene and donned gloves, then performed the patient’s physical assessment. The nurse then removed the gloves and donned a new pair of gloves without performing hand hygiene. The nurse then cleaned the vital sign equipment. During a review of the home visit observations on 07/28/2026, the Administrator confirmed that the agency hand hygiene policy was not followed. The Administrator also stated, “We will be doing re-education with our staff this week on infection control, including hand hygiene.””

“It is required that the hospice provides nursing care under the supervision of a Registered Nurse. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed with Licensed Practical Nursing services provided, the agency did not ensure that Licensed Practical Nurse supervisory visits were completed by a Registered Nurse no less frequently than every 30 days per agency policy. POLICY AND PROCEDURES: Agency Policy PC.N15 titled, Nursing Services, read in part, “Nursing care and services are provided to hospice patients by or under the supervision of a registered nurse. When nursing services are delegated to a licensed practical/vocational nurse, the LPN/LVN is supervised by an RN who is available at least by phone during the hours the LPN/LVN is providing services or is on-call and the RN makes at least monthly home visits and documents that the LPN/LVN is routinely providing nursing services in accordance with the patient’s plan of care and the LPN’s/LVN’s scope of practice”. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/29/2025. The plans of care dated 02/27/2026 through 05/27/2026 and 05/28/2026 through 07/26/2026 ordered “Skilled Nurse 2wk13”. Licensed Practical Nurse (LPN) visits were dated 03/13/2026, 03/20/2026, 04/03/2026, 04/06/2026, 05/19/2026, 05/25/2026, 06/01/2026, 06/22/2026, 06/26/2026 and 07/02/2026. LPN supervisory visits were dated 03/05/2026, 03/16/2026, 03/19/2026, and 04/03/2026. The record lacked documentation of LPN supervisory visits after 04/03/2026, 86 days outstanding as of 07/28/2026. CLINICAL RECORD 8: The patient elected the hospice benefit on 02/17/2026. The plan of care dated 05/18/2026 through 08/15/2026 ordered “Skilled Nurse 2wk13”. LPN visits were dated 05/19/2026, 05/25/2026, 06/01/2026, 06/08/2026, 06/15/2026, 06/30/2026, 07/06/2026, 07/09/2026, 07/13/2026, 07/20/2026. An LPN supervisory visit was dated 06/18/2026. The record lacked documentation of Licensed Practical Nurse supervisory visits after 06/18/2026, 10 days outstanding as of 07/28/2026. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/03/2025. The plan of care dated 07/03/2025 through 10/01/2025 ordered “Skilled Nurse 2wk13”. LPN visits were dated 07/07/2025, 07/14/2025, 07/21/2025, 07/30/2025, and 08/15/2025. The clinical record did not have documented evidence of any LPN supervisory visits. During joint record reviews and interviews on 07/28/2026 and 07/29/2026, the Administrator confirmed that Licensed Practical Nurse supervisory visits were not completed per agency policy.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of deceased patients, the agency did not ensure that a bereavement plan of care was included in the clinical record. POLICY AND PROCEDURES: Agency Policy PC.B10 titled, Bereavement Care Planning, read in part, “A bereavement care plan is developed for identified family members and other involved individuals after the patient’s death”. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/24/2026. The patient passed away on 04/08/2026. The clinical record did not have documented evidence of a bereavement plan of care. During a joint record review and interview on 07/29/2026, the Bereavement Coordinator confirmed that a bereavement plan of care was not documented.”

“It is required that Hospice Aides are 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The Hospice Aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that Hospice Aides were supervised by a Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/08/2026. The plan of care dated 04/08/2026 through 07/06/2026 and 07/07/2026 through 10/04/2026 ordered “Hospice Aide 1wk1 and 3wk12”. The first Hospice Aide visit was dated 04/10/2026. Hospice Aide supervisory visits were dated 04/14/2026, 04/28/2026, 05/06/2026, 05/12/2026, 05/15/2026, 05/18/2026, 05/26/2026 and 06/02/2026. The record lacked documentation of Hospice Aide supervisory visits after 06/02/2026, which made Hospice Aide supervisory visits 42 days outstanding as of 07/27/2026. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/07/2026. The plan of care dated 04/07/2026 through 07/05/2026 ordered “Hospice Aide 3wk1 and 5wk12”. The plan of care dated 07/06/2026 through 10/03/2026 ordered “Hospice Aide 5wk13”. The first Hospice Aide visit was dated 04/08/2026. Hospice Aide supervisory visits were dated 04/09/2026, 04/20/2026, 04/27/2026, and 05/04/2026. The next Hospice Aide supervisory visit was dated 05/19/2026, a total of 15 days later and 1 day outstanding. The next Hospice Aide supervisory visit was dated 06/12/2026, a total of 24 days later and 10 days outstanding. A Hospice Aide supervisory visit was dated 06/15/2026. The next Hospice Aide supervisory visit was dated 07/06/2026, a total of 21 days later and 7 days outstanding. CLINICAL RECORD 3: The patient elected the hospice benefit on 11/29/2025. The plan of care dated 11/29/2025 through 02/27/2026 and 02/28/2026 through 05/28/2026 ordered “Hospice Aide 3wk13”. The first Hospice Aide visit was dated 12/01/2025. Hospice Aide supervisory visits were dated 12/03/2025, 12/10/2025, and 12/17/2025. The next Hospice Aide supervisory visit was dated 01/02/2026, a total of 16 days later and 2 days outstanding. The next Hospice Aide supervisory visit was dated 03/05/2026, a total of 63 days later and 49 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/19/2026. The plan of care dated 06/19/2026 through 09/16/2026 ordered “Hospice Aide 2wk13”. The first Hospice Aide visit was dated 06/22/2026. The first Hospice Aide supervisory visit was dated 07/01/2026. The next Hospice Aide supervisory visit was dated 07/16/2026, a total of 15 days later and 1 day outstanding. CLINICAL RECORD 8: The patient elected the hospice benefit on 02/17/2026. The plan of care dated 05/18/2026 through 08/15/2026 ordered “Hospice Aide 3wk13”. The first Hospice Aide visit was dated 05/18/2026. The first Hospice Aide supervisory visit was dated 05/21/2026. The next Hospice Aide supervisory visit was dated 06/11/2026, a total of 21 days later and 7 days outstanding. The next Hospice Aide supervisory visit was dated 06/18/2026. The record lacked documentation of Hospice Aide supervisory visits after 06/18/2026, 26 days outstanding as of 07/28/2026. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/24/2026. The plan of care dated 02/24/2026 through 05/22/2026 ordered “Hospice Aide 3wk13”. The first Hospice Aide visit was dated 02/25/2026. The first Hospice Aide supervisory visit was dated 03/13/2026, a total of 16 days later and 2 days outstanding. The next Hospice Aide supervisory visit was dated 04/07/2026, a total of 25 days later and 11 days outstanding. During joint record reviews and interviews on 07/28/2026 and 07/29/2026, the Administrator confirmed that Hospice Aide supervisory visits were completed less frequently than every 14 days. The Administrator also stated, “We have a performance improvement plan that we started last year for supervisory visits. I will make sure that we do more education on completing supervisory visits timely”.”

“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. The agency did not ensure that hospice volunteers 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 hospice employees and contract staff. VOLUNTEER COST SAVINGS REPORT: The agency Volunteer Cost Savings Reports for 2024 and 2025 were reviewed. The report revealed that the agency’s total percentage of volunteer hours was 3.5% for 2024 and 3.27% for 2025. During an interview with the Volunteer Coordinator on 07/28/2026, the Volunteer Coordinator confirmed that the agency’s volunteer hours for 2024 and 2025 were less than 5%. The Volunteer Coordinator also stated, “We started a Performance Improvement Plan in 2025 to help increase our hours. Unfortunately, our hours are still below 5%.” The agency did not ensure that hospice 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 hospice employees and contract staff.”

“It is required the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by interview and observation. Review of the agency supply room revealed the agency did not ensure that medical supplies and appliances to be used in the palliation and management of the patient’s terminal illness were not expired. SUPPLY ROOM: A tour and review of the medical supplies in the agency’s supply room was conducted with the Administrator on 07/29/2026. Several packets of adhesive remover pads were found with an expiration date of 05/01/2026. During review of the medical supplies in the agency supply room the Administrator confirmed that the adhesive remover pads were expired. The Administrator disposed of the expired adhesive remover pads. The agency did not ensure that medical supplies and appliances related to the palliation and management of the patient’s terminal illness were checked for expiration dates.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care; and the hospice election form; and any advance directives. This standard was not met as evidenced by interview and observation. In 2 of 2 (100%) home visit observations at a skilled nursing or assisted living facility, the agency did not ensure that the facility was provided with the most recent hospice plan of care and the hospice election of benefit form. HOME VISIT 1: The patient elected the hospice benefit on 04/08/2026. During a home visit at a skilled nursing facility with the Chaplain (Personnel Record 1), the agency-provided hospice binder was reviewed. The binder did not include a hospice election of benefit form. A Registered Nurse at the facility reviewed the binder and all electronic records from the facility and stated, “I do not see a hospice election of benefit form or hospice consent”. HOME VISIT 3: The patient elected the hospice benefit on 11/29/2025. During a home visit at an assisted living facility with the Registered Nurse/Administrator (Personnel Record 9), the hospice binder was reviewed at the assisted living facility. The binder did not include a hospice election of benefit form or a copy of the patient’s current plan of care. The nurse reviewed the hospice binder and stated, “I don’t see a hospice consent form or the current plan of care”. During a review of the home visit observations on 07/28/2026, the Administrator confirmed the above finding that the facilities providing care did not have all required documents.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care; and the hospice election form; and any advance directives. This standard was not met as evidenced by interview and observation. In 2 of 2 (100%) home visit observations at a skilled nursing or assisted living facility, the agency did not ensure that the facility was provided with the most recent hospice plan of care and the hospice election of benefit form. HOME VISIT 1: The patient elected the hospice benefit on 04/08/2026. During a home visit at a skilled nursing facility with the Chaplain (Personnel Record 1), the agency-provided hospice binder was reviewed. The binder did not include a hospice election of benefit form. A Registered Nurse at the facility reviewed the binder and all electronic records from the facility and stated, “I do not see a hospice election of benefit form or hospice consent”. HOME VISIT 3: The patient elected the hospice benefit on 11/29/2025. During a home visit at an assisted living facility with the Registered Nurse/Administrator (Personnel Record 9), the hospice binder was reviewed at the assisted living facility. The binder did not include a hospice election of benefit form or a copy of the patient’s current plan of care. The nurse reviewed the hospice binder and stated, “I don’t see a hospice consent form or the current plan of care”. During a review of the home visit observations on 07/28/2026, the Administrator confirmed the above finding that the facilities providing care did not have all required documents.”