Franciscan Hospice Care

“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 9 (11%) clinical records reviewed, it was revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 5: The hospice election of benefit was 03/31/2026 with a primary diagnosis of congestive heart failure and secondary of diabetes. The initial comprehensive assessment completed 03/31/2026 identified that the patient was using a long acting dose of Lantus insulin and three times a day a Novolog dose plus a sliding scale with meals. The medication profile documented that diabetes was managed. The nursing assessment visit documented on 04/02/206 and 04/07/2026 documented that the husband, who was managing the diabetic medications, was adjusting both doses of insulin as he felt the patient was having too many hypoglycemic episodes and stated that she was a ‘brittle diabetic’. He was checking blood sugars that were over 200 but slowly came back to 180. Each visit the nurse assessed the blood sugars and provided education for blood sugar control. The initial plan of care dated 03/31/2026 - 06/28/2026, and plans of care updated every two weeks did not include interventions for diabetic management or monitoring of blood sugars. During joint record review with the director of education on 04/24/2026, it was stated there were no interventions related to blood sugars or diabetes.”

“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 5 (20%) clinical records reviewed, in which a hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 2: The hospice election of benefit was 04/01/2026 with a primary diagnosis of end stage renal disease. A Foley catheter was inserted by the nurse on 04/07/2026 and attached to large bag drainage. The catheter remained patent and in place as of review 04/24/2026. The hospice aide provided care 2 times a week with an assigned task for bathing, which was a bed bath each visit. The hospice aide plan of care was not updated for a task of foley catheter care as of review 04/24/2026. During joint record review with the director of education, it was stated that the task for foley care was not assigned to the hospice aide.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, personnel record review, observation, and interview with the Administrator and Hospice Educator. The hospice failed to ensure the following: Failed to ensure that skills and competencies of all individuals providing care, including volunteers providing services, were documented as assessed [HSRM. 14.I/L663/418.100(g)(3)]; Failed to ensure that each employee received initial orientation that addressed the employee’s specific job duties [HSRM.15.I/L662/418.100(g)(2)]; and Failed to ensure that each employee received initial orientation, including hospice philosophy [HSRM.15.I/L661/418.100(g)(1)]. 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 418.100: Organization and administration of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation; act only within the scope of their state license or state certification or registration; keep their qualifications current at all times. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record review, clinical record review, and interview with the Administrator, which revealed the following findings: Failure to ensure that all hospice professionals who provided direct care had a personnel record that included their qualifications, license, and or certification [HSRM.3.I/L 784/418.114(a)]. 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 418.114: Personnel qualifications. The collective deficient practice illustrated systemic process failures that could affect all patients receiving hospice services from the agency.”

“It is required that a hospice that provides inpatient care directly in its own facility must demonstrate compliance with all of the following standards: restraint or seclusion in a hospice inpatient facility is used when less restrictive interventions are determined to be ineffective to protect the patient, a staff member, or others from harm. The hospice policy and procedure defines when restraint and seclusion is used and who may order such in the inpatient facility in accordance with state law and regulation. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, personnel record review, observation, and interview with the Hospice Manager and Hospice Educator. The hospice failed to ensure the following: Failed to ensure that the inpatient unit (IPU) had an eyewash station available for staff use in the event of an occupational exposure to injurious corrosive materials [HSIC.8.I/L825/ 418.110(c)(1)]; Failed to ensure that meals provided to patients were served at the proper temperature [HSIC.28.I/L 838/418.110(m)(2)]; Failed to ensure that the restraint policy included documentation of when restraint and seclusion are used and who may order such in the inpatient facility in accordance with state law and regulation [HSIC.35.D/L844/ 418.110(n)(4)]; and Failed to ensure that the use of restraints in the IPU was in accordance with an order of a physician authorized to order restraint per state law and regulation [HSIC.36.I/L843/418.110(n)(3)]. The cumulative effect of these systemic problems has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42CFR: 418.110: Hospices that provide inpatient care directly must demonstrate compliance with all of the following standards: The collective 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 2 of 22 (10%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/06/2026. A review of the clinical record revealed that the initial spiritual assessment was completed on 01/14/2026, eight (8) days after the election of the hospice benefit. CLINICAL RECORD 9:The patient elected the hospice benefit on 02/05/2026. A review of the clinical record revealed that the initial spiritual assessment was completed on 02/11/2026, six (6) days after the election of the hospice benefit. During an interview and joint record review, the Hospice Educator/RN confirmed that spiritual assessments were not completed in a timely manner. During an interview, the SCC stated they were unaware that the assessment needed to be completed within 5 days of the election of the benefit date.”

“It is required that each patient’s plan of care include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 7 (14%) home visits observed, the agency did not ensure that the plan of care included all treatments to meet the patient’s needs. HOME VISIT 2/CLINICAL RECORD 2: Patient was admitted to hospice on 03/02/2026. The skilled nurse (SN) comprehensive assessment documented that the patient had a Foley catheter in place. During the home visit with the Registered Nurse (RN) on 03/11/2026, the patient had an indwelling Foley catheter. The plan of care dated 03/02/2026 did not include orders to manage the Foley catheter or specify its size. During an interview and joint record review on 03/13/2026, the Hospice Educator/RN confirmed the clinical record did not include the Foley catheter or balloon size.”

“It is required that hospice aides be assigned to a specific patient by a registered nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an 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 2 of 8 (25%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2/ HOME VISIT 2: The patient elected hospice care on 03/02/2026 with a diagnosis of congestive heart failure (CHF). During a home visit with the Registered Nurse (RN) [Personnel Record 2] on 03/11/2026, the patient was using oxygen. Oxygen and oxygen precautions were not documented on the HA care plan. CLINICAL RECORD 5: The patient was admitted to hospice on 12/29/2025 with a diagnosis of bladder cancer metastasized to intra-abdominal lymph nodes. The plan of care dated 12/29/2025 ordered Warfarin and documented safety precautions: bleeding precautions. The HA care plan dated 12/29/2025 assigned the HA the relevant tasks: shaving the patient’s face and head with an electric razor. The HA care plan did not alert the HA of the bleeding precautions. During an interview and a joint clinical record review on 03/11/2026, the Hospice Educator/RN confirmed that the HA care plan did not include bleeding precautions.”

“It is required that a hospice aide provide services as ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services as ordered by the Interdisciplinary Group. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/05/2026 with a terminal diagnosis of high-grade serous carcinoma of the ovary. The plan of care ordered HA services 2W13 effective 02/08/2026. A review of the clinical record revealed documented missed visits dated 02/09/2026, 02/11/2026, and 02/16/2026. No visits or missed visits were documented by the HA after 02/16/2026. There was no evidence of a change in the HA frequency or evidence of a physician’s order to discontinue HA services. During an interview on 03/10/2026, the Hospice Educator/Registered Nurse (RN) confirmed that there were no physician orders to discontinue HA services, but that HA services had been removed from the schedule.”

“It is required that the hospice provide an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies, and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 1 of 20 (5%) personnel records reviewed, the agency did not ensure that each employee received initial orientation, including hospice philosophy. PERSONNEL RECORD 14: The contracted Music Therapist’s (MT) hire date was not documented. The agency did not provide a personnel record for the MT or evidence of orientation to the hospice philosophy. During an interview, the Administrator stated, “We don’t have a file on her, and we are not going to be able to get one. We have tried to contact her multiple times.””

“It is required that the hospice provide an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies, and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness, and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 1 of 20 (5%) personnel records reviewed, the agency did not ensure that each employee received initial orientation that addressed the employee’s specific job duties. PERSONNEL RECORD 14: The contracted Music Therapist’s hire date was not documented. The agency did not provide a personnel record for the MT or evidence of orientation to the employee’s specific job duties. During an interview, the Administrator stated, “We don’t have a file on her, and we are not going to be able to get one. We have tried to contact her multiple times.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met as evidenced by clinical record review, personnel record review, observation, and interview. In 1 of 20 (5%) personnel records reviewed, the agency did not ensure that skills and competencies of all individuals providing care, including volunteers providing services, were documented as assessed. PERSONNEL RECORD 2: The Registered Nurse (RN) was hired on 08/10/2025. A personnel record review included documentation of a nursing skills competency assessment initiated by the Hospice Educator on 08/12/2025. Wound care was not documented as addressed and checked off as complete. During the home visit (HOME VISIT 2) on 03/11/2026, the RN was observed providing wound care. During an interview, the Hospice Educator confirmed that wound care was not checked off and documented on the skills competency checklist. During an interview on 03/13/2026, the Hospice Educator confirmed that wound care was not checked off and documented on the skills competency checklist.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice: are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation; act only within the scope of their state license or state certification or registration; [and] keep their qualifications current at all times. This standard was not met as evidenced by clinical record review, interview, and personnel record review. In 1 of 2 (50%) personnel records reviewed for contracted alternate care delivery professions, the agency did not ensure that all hospice professionals who provided direct care had a personnel record that included their qualifications, license, and or certification. PERSONNEL RECORD 14: The contracted Music Therapist’s (MT) hire date was not documented. The agency did not provide a personnel record for the MT or evidence of the MT’s qualifications or certification. A clinical record review revealed the MT provided music therapy services to patient’s clinical record 3 and clinical record 4. During an interview, the Administrator stated, “We don’t have a file on her, and we are not going to be able to get one. We have tried to contact her multiple times.””

“It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by document review, interview, and observation. The OSHA requirements for emergency eyewashes and showers, found at 29 CFR 1910.151(c), specify that “where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.” The agency did not ensure that the inpatient unit (IPU) had an eyewash station available for staff use in the event of an occupational exposure to injurious corrosive materials. IPU Tour: During a tour of the agency’s IPU on 03/09/2026, no eyewash station or other provision for flushing eyes in the event of occupational exposure to injurious corrosive materials was present. The IPU facility housed cleaning and sanitation supplies. During an interview on 03/09/2026, the Hospice Manager, who was present for the IPU tour, confirmed that there was no eyewash station or other provision for flushing the eyes within the IPU. The agency did not ensure that there was an eyewash station anywhere within the facility.”

“It is required that the hospice inpatient facility provide meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview, and observation. The agency did not ensure that meals provided to patients were served at the proper temperature. IPU Tour: The agency received flash-frozen foods prepared by the hospital for its patients, which were then reheated in the microwave for IPU patients. During an interview on 03/11/2026, the Hospice Educator/RN reported that staff take the food’s temperature when they remove it from the microwave, but they have never logged it. There was no documentation to demonstrate the temperature at which food was served to IPU patients.”

“It is required that the use of restraint or seclusion in the hospice inpatient facility is in accordance with the order of a physician authorized to order restraint and seclusion per hospice policy and state law and regulation. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 3 (100%) home visits observed and clinical records reviewed of IPU patients, the agency did not ensure that the use of restraint in the IPU was in accordance with an order of a physician authorized to order restraint per state law and regulation. State Administrative Code 410 IAC 16.2-3.1-26 stated in part, “Resident behavior and facility practices...(b) Restraint or seclusion shall be employed only by order of a physician, and the type of restraint or seclusion shall be specified in the order. HOME VISIT 5/CLINICAL RECORD 20: The patient elected hospice care on 03/06/2026 with a diagnosis of acute myeloid leukemia, not having achieved remission. During the home visit to the patient in the IPU (room 3) with the Registered Nurse (RN) [Personnel Record 21] on 03/11/2026, the patient was awake, alert, and oriented, found lying in bed with all four side rails raised. A review of the clinical record revealed no evidence of a physician’s order for restraints. HOME VISIT 6/CLINICAL RECORD 21: The patient elected hospice care on 12/15/2025 with a diagnosis of cancer of the peritoneum. During the home visit to the patient in the IPU (room 8) with the Registered Nurse (RN) [Personnel Record 21] on 03/11/2026, the patient was awake, alert, and oriented, found lying in bed with all four side rails raised. A review of the clinical record revealed no evidence of a physician’s order for restraints. HOME VISIT 7/CLINICAL RECORD 22: The patient elected hospice care on 03/06/2026 with a diagnosis of acute infective endocarditis. During the home visit to the patient in the IPU (room 6) with the Registered Nurse (RN) [Personnel Record 21] on 03/11/2026, the patient was awake, alert, and oriented, found lying in bed with all four side rails raised. A review of the clinical record revealed no evidence of a physician’s order for restraints. During an interview on 03/11/2026, the Hospice Manager/RN stated that the hospice has a no-restraint policy. The Hospice Manager/RN was observed entering each patient’s room and lowering the bottom two side rails. Hospice Manager stated that staff were trained that 3 side rails up were ok but four were considered a restraint.”

“It is required that restraint or seclusion in a hospice inpatient facility be used when less restrictive interventions are determined to be ineffective to protect the patient, a staff member, or others from harm. The hospice policy and procedure define when restraint and seclusion are used and who may order such in the inpatient facility in accordance with state law and regulation. This standard was not met as evidenced by document review and interview. A review of the agency’s restraint policy revealed the policy did not include documentation of when restraint and seclusion are used and who may order such in the inpatient facility in accordance with state law and regulation. State Administrative Code 410 IAC 16.2-3.1-26 stated in part, “Resident behavior and facility practices...(b) Restraint or seclusion shall be employed only by order of a physician, and the type of restraint or seclusion shall be specified in the order. Agency policy #17586729 “Alternatives to Restraint Guidelines” (dated 03/20/2025) read in part, “Purpose: To provide staff care options in lieu of physical and chemical restraints at the hospice house. Patients receiving care at the hospice house will receive care. B. Patients who are at risk to themselves or others will be dealt with through appropriate measures without resorting to physical or chemical restraints.” During an interview on 03/11/2026, the Hospice Manager/RN stated that the hospice has a no-restraint policy.”