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“Based on record review and interview, the hospice failed to take immediate action, investigate nor document when notified of alleged verbal abuse to prevent further violation while the violation was being verified in 1 of 1 hospice aide disciplinary form reviewed (Hospice Aide 1).Findings include: 1.An undated policy, titled, “Patient Rights and Responsibilities,” indicated patients were provided with a written notice of the patient’s rights and responsibilities in advance of furnishing care and would include to be free from mistreatment, neglect, or verbal, mental, sexual and physical abuse. 2.An undated policy, titled, “Complaint Resolution,” indicated complaints are to be brought to the attention of the clinical director, conduct a documented investigation of complaints within 5 days, the person filing the complaint would be provided information as to the status of the complaint investigation process within 10 days, corrective action would be implemented in response to a substantiated complaint, and complaints are tracked and reviewed to identify trends and performance improvement opportunities. 3.A Hospice Admission Packet indicated Patients’ Rights the right to lodge complaints and the hospice would document the complaint and resolution of the complaint. The Patients’ Rights indicated a patient had a right to be free from verbal abuse. The Patients’ Rights indicated all mistreatment, verbal abuse, by anyone furnishing service on behalf of the hospice would be investigated and all verified violations would be reported to appropriate agencies including to the state survey and certification agency within 5 working days of becoming aware of the violation. 4.A Hospice Aide 1 Employee Discipline Form, dated 01/16/2026, completed by the Former Administrator, Administrative Staff 3, indicated a written warning was provided to Former Hospice Aide 1 for unprofessional behavior and language with Patient #2. The Form indicated while providing care to the patient Hospice Aide 1 stated, “get the fuck up off the toilet,” to the patient, a facility staff member overheard this statement and reported it to the facility’s supervisor, the facility advised Hospice Aide 1 to admit to the patient’s family member that this was said to the patient, or the facility was going to inform the family member. The Form indicated action taken included education on professional language, staying calm, and stepping away, and Hospice Aide 1 was apologetic and indicated it would not happen again. A Former Employee List indicated: Hospice Aide 1 termination date of 04/16/2026, Administrative Staff 2 confirmed Hospice Aide 1 was terminated; Former Hospice Administrator, Administrative Staff 4 end of employment date of 05/12/2026, and Former Director of Nursing, Administrative Staff 5, unable to obtain end of employment date, Administrative Staff 2 confirmed the Former Director of Nursing resigned from the position and no longer worked for the hospice, as of survey date of 06/19/2026. A Quality Improvement Report (Complaint Log), for 06/19/2025 to 06/19/2026, failed to evidence documentation of a complaint investigation related to Hospice Aide 1’s unprofessional behavior with Patient #2. During an interview, on 06/23/2026, beginning at 2:00 PM, Administrative Staff 2 indicated a complaint related to Hospice Aide 1 should have been and was not documented in the complaint log.During an interview, on 06/23/2026, beginning at 1:30 PM, the Interim Administrator, Administrative Staff 1, indicated complaints could be initiated by field staff, would go to the Director of Nursing for documentation of investigation, resolution and follow up, and Hospice Aide 1, the Former Administrator, and the Former Director of Nursing were no longer employed with the hospice.”

“Based on record review and interview, the hospice failed to ensure verified patient’s rights violations were reported to the state within 5 business days of becoming aware of the violation in 1 of 1 hospice aide with a disciplinary form reviewed (Hospice Aide 1).Findings include: A Hospice Admission Packet indicated Patients’ Rights indicated all mistreatment, verbal abuse, by anyone furnishing service on behalf of the hospice would be investigated and all verified violations would be reported to appropriate agencies including to the state survey and certification agency within 5 working days of becoming aware of the violation.A Hospice Aide 1 Employee Discipline Form, dated 01/16/2026, completed by the Former Administrator, Administrative Staff 3, indicated a written warning was provided to Former Hospice Aide 1 for unprofessional behavior and language with Patient #2. The Form indicated while providing care to the patient Hospice Aide 1 stated, “get the fuck up off the toilet,” to the patient, a facility staff member overheard this statement and reported it to the facility’s supervisor, the facility advised Hospice Aide 1 to admit to the patient’s family member that this was said to the patient, or the facility was going to inform the family member. The Form indicated action taken included education on professional language, staying calm, and stepping away, and Hospice Aide 1 was apologetic and indicated it would not happen again. A Former Employee List indicated: Hospice Aide 1 termination date of 04/16/2026, Administrative Staff 2 confirmed Hospice Aide 1 was terminated; Former Hospice Administrator, Administrative Staff 4 end of employment date of 05/12/2026, and Former Director of Nursing, Administrative Staff 5, unable to obtain end of employment date, Administrative Staff 2 confirmed the Former Director of Nursing resigned from the position and no longer worked for the hospice, as of survey date of 06/19/2026. During an interview, on 06/23/2026, beginning at 2:00 PM, Administrative Staff 2 indicated the hospice did not have documentation of Hospice Aide 1’s documentation of verbal abuse being reported to the state agency.”

“Based on record review and interview, the hospice failed to ensure ongoing sharing of information between all disciplines in 1 of 1 active clinical record reviewed with a terminal diagnosis of congestive heart failure (weakness of the heart muscle) (Patient #4), and in 1 of 1 discharged clinical record reviewed with a terminal diagnosis of congestive heart failure (Patient #2).Findings include: 1.An undated policy, titled, “Plan Of Care,” indicated revisions to the plan of care are based on information from the patient’s updated comprehensive assessment, and review of and changes to the plan of care were to be documented and communicated to members of the IDG. 2.An Interdisciplinary Group (IDG) Summary Report, dated 02/26/2026, for Patient #4, indicated a hospice election date of 11/26/2025, a hospice diagnosis of congestive heart failure and hospice aide visit frequency of 1 time per week.An IDG Summary Report, dated 03/12/2026, indicated hospice aide visit frequency of 2 times per week. IDG Summary Reports, dated 03/26/2026 and 04/09/2026, indicated hospice aide visit frequency of 1 time per week. A Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 04/23/2026, indicated hospice aide frequency 1 time per week. Hospice IDG Comprehensive Assessment and Plan of Care Update Reports, dated 05/07/2026, 05/21/2026, 06/04/2026, and 06/18/2026 failed to evidence a hospice aide frequency of visits, and failed to evidence the IDG provided assessment nor interventions of the multiple missed hospice aide visits.A RN Visit Note Report, dated 06/05/2026, indicated no supervisory visit was completed due to no hospice aide. A RN Visit Note Report, dated 06/12/2026, indicated a supervisory visit was completed, the hospice aide followed the plan of care, and the hospice aide had the ability to perform tasks.An Aide Care Plan Report, for 02/24/2026 to 05/24/2026, indicated hospice aide 1 time per week for 1 week and then 2 times per week for 12 weeks. A Hospice Aide Visit Note Report, dated 12/30/2025, indicated a hospice aide visit was completed. A review of the clinical record failed to evidence a hospice aide visit after 12/30/2025. A Missed Visit Report, indicated hospice aide visits were missed on 11/27/2025, 12/05/2025, 12/16/2025, 12/23/2025, 12/24/2025, 01/01/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/20/2026, 01/22/2026, 01/27/2026, 01/29/2026, 02/03/2026, 02/05/2026, 02/10/2026, 02/12/2026, 02/17/2026, 02/19/2026, 02/24/2026, 02/26/2026, 03/03/2026, 03/05/2026, 03/10/2026, 03/12/2026, 03/17/2026, 03/19/2026, 03/24/2026, 03/26/2026, 03/26/2026, 03/31/2026, 04/02/2026, 04/07/2026, 04/09/2026, 04/14/2026, 04/21/2026, and 04/23/2026 with 41 missed visits noted. 3.A Plan of Care (POC) for the initial benefit period, 11/25/2025 to 02/22/2026, for Patient #2 indicated Hospice Aide 3 times per week for 9 weeks, 2 times a week for 2 weeks, and 3 times per week for 1 week. Hospice Aide Visit Notes, dated 12/02/2025, 12/03/2025, 12/09/2025, 12/10/2025, 12/12/2025, 12/17/2025, 12/22/2025, 12/24/2025, 12/29/2025, 03/12/2026, 03/19/2026, 03/26/2026, 04/02/2026, 04/23/2026, and 04/28/2026 indicated patient refused visits or care was provided. A Missed Visit Report, indicated 12/31/2026, 01/01/2026, 01/05/2026, 01/28/2026, 03/13/2026, 03/17/2026, 03/23/2026, 03/24/2026, 03/31/2026, 04/07/2026, 04/09/2026, 04/14/2026, 04/16/2026, 04/30/2026, 05/05/2026, 05/19/2026, 05/26/2026, 05/27/2026, and 06/04/2026 indicated hospice aide visits were missed. A Hospice Physician Order, dated 03/10/2026, indicated hospice aide 1 time a week for 1 week, then 2 times per week for 5 weeks.A RN Hospice Recertification Assessment, dated 05/08/2026, indicated the plan of care was to be updated to reflect that the patient no longer wanted to hospice aide visits. A Clinical Record reviewed failed to evidence hospice aide visits from 12/29/2025 to 03/12/2026, 04/19/2026 to 04/23/2026, 05/19/2026 to 06/12/2026, and failed to evidence the IDG provided assessment nor interventions of the multiple missed hospice aide visits.During an interview, on 06/23/2026, beginning at 9:30 AM, Entity B’s Director of Nursing (DON), indicated Patient #2’s first hospice aide stopped providing care due to the patient and the aide did not get along, and no hospice aide was provided for a period of time after the first hospice aide stopped providing care to the patient.4.During an interview, on 06/23/2026, beginning at 1:30 PM, the Interim Administrator indicated a director of nursing was responsible for reviewing missed visits, and patient’s declining hospice aide visits should have been addressed by assessing reason for missed visit to provide interventions, and Patient #4 did not have updates to the POC for change in hospice aide visits nor orders of frequency change. 5.During an interview, on 06/23/2026, beginning at 12:30 PM, Registered Nurse (RN) 1 indicated a plan of care should be updated with the frequency of discipline visits and an order written if frequency was changed or discontinued.”

“Based on record review and interview, the hospice failed to ensure ongoing sharing of information with non-hospice providers in 1 of 1 active clinical record reviewed of a patient that resided in Entity B, a skilled nursing facility (Patient #1), and in 1 of 1 discharged clinical record reviewed of a patient that resided in Entity B (Patient #2). Findings include: 1.An undated policy, titled, “Hospice Care For Nursing Facility Residents, Coordination Of Services,” indicated the hospice would provide overall coordination of the hospice care with facility representatives, the hospice IDG would ensure communication to coordinate the hospice care. 2.An undated policy, titled, “Medications – Administration,” indicated the RN Case Manager would provide instructions on when and how to administer medications included in the plan of care. 3.An undated policy, titled, “Medications – Profile,” indicated a patient specific medication profile was maintained for each patient and reviewed at least every fifteen days, and the patient’s medication profiled would include determining accuracy and completeness of the profile. 4.A Hospice Interdisciplinary (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 06/18/2026, indicated Patient #1 resided in Entity B, a skilled nursing facility that administered medications. A Hospice Client Medication Report, received on 06/23/2026, for Patient #1 reviewed by RN 1 on 06/15/2026, and the hospice medical director on 06/18/2026, indicated medications to included but not limited to Amlodipine (lowers blood pressure) 10 mg one tablet daily start date of 02/10/2025, Aricept (dementia) 10mg one tablet daily start date of 02/10/2025, Baclofen (muscle relaxer) 5 mg one tablet twice a day start date of 05/28/2026, Buspirone (antianxiety) 7.5mg one tablet every 6 hours start date of 02/10/2025, Lisinopril (lowers blood pressure) 5mg one tablet daily start date of 02/10/2025, Sertraline (antidepressant) 10mg one tablet daily start date of 02/10/2025, Ibuprofen (pain reliever) 800 mg one tablet twice per day start date of 06/15/2025, Pravastatin (cholesterol lowering) 40mg one tablet daily start date of 02/10/2025, and Xarelto (blood thinner) was discontinued on 06/15/2026. An Entity B Physician Report, dated 06/23/2026, indicated Patient #1 was on medications to include but not limited to Amlodipine 5mg one tablet daily start date of 11/04/2025, Baclofen 5mg one tablet three times per day start date of 05/15/2026, Lisinopril 10mg one tablet daily start date of 11/04/2025, Sertraline 75mg one tablet daily start date of 05/20/2026, Xarelto 20mg one tablet daily start date of 06/25/2025, and acetaminophen (pain reliever) 325mg two tablets every 6 hours as needed start date of 03/02/2026. The review of patient’s medications indicated a discrepancy between the hospice and Entity B’s medication list of the following: the Lisinopril, Baclofen, Lisinopril, and Sertraline dose, the patient continued to be Xarelto that was discontinued on the hospice medication report, Aricept, Buspirone, and Pravastatin were on the hospice’s medication report and were not on Entity B’s medication report. During an interview, on 06/23/2026, beginning at 12:30 PM, RN 1, the case manager for Patient #1 indicated she did not know when medication reconciliation was to occur, should be at the start of care, every 2 to 3 weeks, and RN 1 indicated during the patient’s last visit at Entity B, she asked if there were any changes to patient’s medications, the facility’s director of nursing indicated different doses of medications were noted, RN 1 indicated there was a care plan meeting at Entity B next week and she would review Entity B’s patient’s medications at that time to update. RN 1 indicated she does not document when medications are reconciled with a skilled nursing facility. 5.An IDG Comprehensive Assessment and POC Update Report, dated 06/04/2026, indicated Patient #2 resided in Entity B. A Hospice Client Medication Report indicated Patient #2 medications included but not limited to scheduled Ativan 1mg one tablet 4 times per day start date of 02/15/2026, and Quetiapine 150mgs one tablet every PM start date of 11/25/2025, and Quetiapine 50mgs one tablet every AM start date of 11/25/2025. The Report indicated the hospice medical director reviewed the medications on 06/04/2026 and 06/18/2026 to review adverse effects, ineffective drug therapy, duplicate drug therapy, and non-compliance with drug therapy. An Entity B Medication Report, dated 06/12/2026, the date of discharge from hospice, indicated Patient #2 medications included but not limited to scheduled Ativan 1 milligram (mg) 3 times per day start date of 03/25/2026, Quetiapine 150 mgs one tablet every AM start date of 06/29/2025, and Quetiapine 50 mgs one tablet every PM start date of 06/28/2025. During an interview, on 06/23/2026, beginning at 12:30 PM, RN 1 indicated she did not know when medications were to be reconciled with a skilled nursing facility, and does not document when medication reconciliations are completed. RN 1 indicated during skilled nursing facility’s care plan meetings medications are to be reviewed. During an interview, on 06/23/2026, beginning at 1:30 PM, the Interim Administrator indicated medication reconciliation should be completed and documented at every nurse visit.”

“Based on observation, record review, and interview, the hospice failed to ensure the hospice plan of care identified the care and services that were needed and specifically identify which provider was responsible for performing the respective functions in 1 of 1 active clinical record reviewed of a patient that resided in Entity B, a skilled nursing facility (Patient #1), and in 1 of 1 discharged clinical record reviewed of a patient that resided in Entity B (Patient #2). 1.An undated policy, titled, “Hospice Care For Nursing Facility Residents, Coordination Of Services,” indicated the hospice would provide overall coordination of the hospice care with facility representatives, and the hospice’s plan of care would identify the care and services that were needed and specifically identify which provider was responsible for performing the respective functions. 2.A Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 06/18/2026, indicated Patient #1 resided in Entity B that administered medications. The Report indicated skilled nurse and hospice aide 1 time per week visits, skilled nurse to educate facility staff to educate staff to assess and document fluid and food intake, and provide pain management, Chaplain frequency was 4 times per month and social worker provided visits. The Report failed to evidence a delineation of care between Entity B and hospice. A Plan of Care for the initial benefit period, 11/25/2025 to 02/22/2026, indicated skilled nursing visits 1 time per week, Hospice Aide 3 times per week for 9 weeks, 2 times a week for 2 weeks, and 3 times per week for 1 week.During an observation of a facility visit on 06/22/2026, beginning at 9:00 AM, the facility’s hospice provided binder failed to evidence a delineation of care between Entity B and hospice. During an interview, on 06/23/2026, beginning at 9:30 AM, Entity B’s Director of Nursing (DON), indicated Entity B was not provided with a delineation of care from hospice.3.A IDG Comprehensive Assessment and POC Update Report, dated 05/21/2026, and 06/04/2026, indicated Patient #2 resided in Entity B, received skilled nursing visits, had wounds, and failed to evidence a delineation of care between Entity B and hospice. A Hospice Order, dated 04/15/2026, indicated to cleans wound with wound cleaner and apply foam dressing every 3 days, and start Bactrim (antibiotic) daily for 10 days for skin infection.An Entity B Physician Order Report, dated 04/15/2026, indicated to clean wound with wound cleaner or normal saline, pat day, apply skin prep to peri-wound and cover with a border dressing 3 times per week. 4.During an interview, on 06/23/2026, beginning at 1:30 PM, the Interim Administrator indicated there was not a delineation of care on hospice’s plan of care between hospice and Entity B for Patient #1 nor Patient #2.”

“Based on observation, record review, and interview, the hospice failed to ensure Entity B, a skilled nursing facility was provided with the most recent hospice plan of care, and advanced directives in 1 of 1 facility visit completed (Patient #1).Findings include: An undated policy, titled, “Hospice Care For Nursing Facility Residents, Coordination Of Services,” indicated the hospice would provide overall coordination of the hospice care with facility representatives, the hospice IDG would ensure communication to coordinate the hospice care. The policy indicated hospice would provide the facility with the most recent plan of care, hospice election form, advanced directives, physician certification of terminal illness, and hospice medication information. The policy indicated the hospice’s plan of care would identify the care and services that were needed and specifically identify which provider was responsible for performing the respective functions.A Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 06/18/2026, indicated Patient #1 resided in a skilled nursing facility, the patient’s had an advanced directive of do not resuscitate, and the advanced directive was located in the fridge.A clinical record review indicated an Out of Hospital Do Not Resuscitate Declaration and Order, dated 06/15/2025. During an observation of an Entity B’s visit, on 06/23/2026, beginning at 9:00 AM, the hospice provided facility binder failed to contain the patient’s advanced directives nor a hospice plan of care.During an interview, on 06/23/2026, beginning at 9:30 AM, Entity B’s Director of Nursing indicated Entity B was not provided with the patient’s advanced directive by hospice.During an interview, on 06/23/2026, beginning at 1:30 PM, the Interim Administrator, Administrative Staff 1, indicated a skilled nursing facility hospice provided binder should contain Interdisciplinary Group Notes, Plan of Care and Updates to the Plan of Care, Advanced Directives, and visit notes.”

“Based on record review and interview, the hospice failed to ensure a contract was in place to triage and manage the hospice after-hours triage answering service in 1 of 1 agency. Findings include: An undated policy titled, “On Call Services,” indicated patients would have access to hospice services 24 hours per day, 7 days per week and would receive a prompt response when accessing the on-call services. The policy indicated patients and families would receive written information at the time of admission regarding how and when to access care after normal business hours. The Hospice After Hours Triage Call Logs, dated 02/20/2025 to 03/19/2025 and 02/16/2026 to 03/16/2026, included Patient and Family Members names, phone numbers, and reason for call. An Admission Packet included a phone number for patients and family members to call for emergencies; the number was called on 03/16/2026, at 7:20 PM, and an answering service answered the call and directly connected call to hospice RN 3. During an interview, on 03/17/2026, beginning at 9:30 AM, the Administrator indicated hospice did not have a contract with Entity A, the hospice’s after-hours triage answering service.”

“Based on record review and interview, the hospice failed to evidence they provided a copy of the policy for safe use and disposal of controlled drugs (substances regulated by law due to their potential for abuse and harm) to their patient and or their primary caregiver, when controlled drugs were first ordered in 4 of 4 active clinical records reviewed (Patient #1, Patient #2, Patient #3, and Patient #5) and in 1 of 1 discharged clinical record reviewed (Patient #4). Findings include: 1.An undated policy, titled, “Destruction of Medication,” indicated the hospice maintained a systematic process for the identification, handling, and destruction of medications that are no longer needed by hospice patients. The policy indicated medications identified for destruction would include when a medication was discontinued or replaced, medication was expired, the patient was discharged from the hospice services or the patient dies. The policy indicated the patient and or responsible caregiver would be educated on safe medication storage and disposal practices, and education and involvement would be documented in the clinical record. The policy indicated medication destruction would be documented in the patient’s clinical record. 2.An Admission Packet review failed to evidence a medication disposal policy for patient review.3.A Comfort Pack Formulary Covered Medication List indicated Ativan (controlled anti-anxiety medication), Morphine (control pain reliever), Bisacodyl Suppository, Acetaminophen Suppository, Haldol (controlled anti-anxiety medication), Hyoscyamine (secretion reducer) and Prochlorperazine (anti-nausea medication) were provided in the agency’s comfort pack provided upon admission if facility and patient and or caregiver agree. 4.An Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report, dated 02/12/2026, indicated Patient #1, start of care 06/30/2025, was prescribed Ativan on 08/02/2025, and Morphine on 08/01/2025.A Start of Care RN Hospice Note, dated 06/30/2025, indicated Patient was on Oxycodone (controlled pain medication), and failed to evidence documentation the agency’s policy for safe use and disposal of controlled drugs was provided or discussed with patient or caregiver. 5.A Plan of Care, for benefit period 10/07/2025 to 01/04/2026, indicated Patient #2 had a start of care date of 10/07/2025, and Ativan twice per day was initiated. A Start of Care RN Hospice Note, dated 10/07/2025, failed to evidence documentation the agency’s policy for safe use and disposal of controlled drugs was provided or discussed with Patient or caregiver. 6.A Start of Care RN Visit Note, dated 02/06/2026, indicated Patient #3 was prescribed Ativan and Morphine; the record failed to evidence documentation the agency’s policy for safe use and disposal of controlled drugs was provided or discussed with Patient or caregiver. 7. A Start of Care RN Visit Note, dated 08/23/2025, indicated Patient #4 was on hydrocodone (controlled pain medication); the record failed to evidence documentation the agency’s policy for safe use and disposal of controlled drugs was provided or discussed with Patient or caregiver. 8. A Interdisciplinary Comprehensive Assessment and Plan of Care Update Report, dated 02/12/2026, indicated Patient #5 was provided with a comfort medication kit on 02/06/2026, and indicated Patient was on Lyrica and Tramadol (controlled pain-relieving medications). The record failed to evidence documentation the agency’s policy for safe use and disposal of controlled drugs was provided or discussed with Patient or caregiver. 9.During an interview, on 02/16/2026, beginning a 1:50 PM, the Administrator indicated the hospice staff does not document discussion of the hospice’s policy for medication disposal with the patient or family, patients are not provided with a copy of the hospice’s medication disposal policy when comfort kits are ordered, upon admission, or when controlled medications are initiated. 10. During an interview, on 02/16/2026, beginning at 1:00 PM, RN 1 indicated education should be provided to patient and caregiver related to proper medication disposal.”

“Based on observation, record review, and interview, the hospice failed to investigate, resolve and document alleged or real violations of misappropriate of patient’s property in 1 of 1 complaints of misappropriation of patient property (Patient #2). Findings include: The undated policy titled, “Abuse, Neglect, Mistreatment and Exploitation,” indicated misappropriation of patient property was described as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient’s belongings or money without the patient’s consent. The policy indicated the Administrator would investigate alleged violations involving person providing services on behalf of the hospice and would document all activities and conversations during investigations related to an alleged violation. A Complaint Report, dated 07/02/2025, indicated caregiver for Patient #2 reported to the hospice, indicated their hospice aide, hospice aide 2, was arrested at Patient’s home for taking narcotics and money. The caller relayed family had placed cameras the night before, as family sensed the aide was acting suspiciously; the director of human resources was informed, the aide was immediately terminated, and the family was called to ensure their wellbeing. The Complaint Report failed to evidence other patients Hospice Aide 2 had provided care were contacted to evaluate if they had concerns with Hospice Aide 2 or other staff.A Police Report from Entity C, a County Sheriff’s office dated 07/02/2025, indicated $60.00 in cash was stolen, prescriptions stolen were recovered on 07/02/2025 at 3:20 PM at Patient #2’s private residence, and Hospice Aide 2 was transported to Entity C’s Jail and charged with theft. Video recording was provided for review, by the hospice, who relayed Patients family member [FM] 2, provided to hospice. The recordings evidenced an individual identified by the Administrator as Hospice Aide 2, in Patient’s kitchen, opening a cabinet, removing a bowl with a lid with medication bottles inside;Hospice aide 2 was observed removing medication from a prescription bottle and putting medications into her scrub top pocket. A Patient List, provided by hospice, indicated Hospice Aide 2 provided care to 27 patients between 04/23/2025 to 07/02/2025. During an interview on 09/02/2025, beginning at 5:05 PM, Administrative Staff 5 indicated the hospice did not have documentation of follow up with other patients Hospice Aide 2 had provided care to ensure patients, nor their family members, had care concerns or concerns of misappropriation.”

“Based on observation, record review, and interview, the hospice failed to report a verified violation of misappropriation of patient’s property to the state within 5 business days of becoming aware of the violation in 1 of 1 complaint received of a patient’s misappropriation of Patient property by a hospice employee. Findings include: The undated policy, titled, “Abuse, Neglect, Mistreatment and Exploitation,” indicated the hospice would follow all Federal and State requirements regarding alleged violations involving misappropriation of Patient property by anyone providing services on behalf of the hospice. The policy indicated misappropriation of patient property was the deliberate misplacement, exploitation, or wrongful, temporary of permanent use of patient’s belongings or money without the patient’s consent. The policy indicated if an alleged violation was verified the Administrator would ensure that verified violations were reported to State and local bodies having jurisdiction, including state survey and certification agency, within 5 days of becoming aware of the violation. The policy indicated all assessments, interventions, discussions and follow up with the State Agency would be documented and kept confidential. A Complaint Report, dated 07/02/2025, completed by the hospice Administrator, indicated caregiver for Patient #2 called the hospice and indicated the hospice aide was arrested at Patient’s home for taking narcotics and money and family had put in cameras the night before when the family felt the aide was acting suspiciously; the director of human resources and president of the company was informed, the aide was immediately terminated, and the president of the company called the family to ensure their wellbeing. An Email from the Administrator to the Director of Human Resources, dated 07/02/2025, indicated she spoke to FM A, indicated cameras were placed in the home the previous night because the family suspected something suspicious was happening with Hospice Aide 2; Hospice Aide 2 would immediately ask to use the bathroom upon arrival to the home, and Hospice Aide 2 would go into rooms that she didn’t need to be in. FM A informed the Administrator, Hospice Aide 2 went through FM A’s purse and took $70.00, Hospice Aide 2 took medication from a backstock of medication from a container in a cabinet and not from a container of medications in view on a counter, Hospice Aide 2 picked up a prescription on Monday and the aide immediately suggested the bottles be combined so there were not two different bottles. 8 Norco (narcotic pain medication with Hydrocodone) were found in Hospice Aide 2’s pocket on 07/02/2025, a total of 14 Norco tablets were missing from the last two days and camera footage would be sent to the hospice. An Email, dated 07/14/2025, to the Hospice Director of Human Resources from the Office of the Attorney General indicated the complaint was submitted and received by the Consumer Protection Division. An Office of the Attorney General Licensing Enforcement and HPU Complaint Form indicated the Director of Human Resources signed and submitted the complaint form on 07/14/2025 related to the 07/02/2025 misappropriation of patient’s property by Hospice Aide 2. The review failed to evidence the State Agency, The Dept. of Health [IDOH] and Centers for Medicare and Medicaid Services [CMS] were notified of the misappropriation of patient’s property by Hospice Aide 2 within 5 days of the violation or allegation. A Police Report from Entity C, a County Sheriff’s office, dated 07/02/2025, indicated $60.00 in cash was stolen, prescriptions stolen were recovered on 07/02/2025 at 3:20 PM at Patient #2’s private residence, and Hospice Aide 2 was transported to Entity C’s Jail and charged with theft. The Police Report indicated FM B dispatched police and had video proof of hospice stealing prescription pills that belonged to Patient #2, and indicated Hospice Aide 2 had been coming to the resident to provide care for Patient #2 for approximately 4 to 6 week. The Police Report indicated FM A indicated a Hydrocodone prescription was missing 8 tablets, FM B had installed security cameras in the home on 07/01/2025 and the video recordings evidenced Hospice Aide 2 in the kitchen retrieving Patient #2’s medication container from a cabinet, picking several pills out from a container and putting them into her pocket. The Police Report indicated Hospice Aide 2 indicated she had administered medication to Patient #2 one time due to the family had asked her to, indicated she knew where the medication was stored, and denied stealing anything. The Police Report indicated when the police officer notified Hospice Aide 2 the police officer had watched a security camera recording from 07/02/2025, of Hospice Aide 2 taking pills from Patient’s medication container and putting them into her pocket Hospice Aide 2 reached into her shirt pocket and retrieved 6 Hydrocodone pills and handed them to FM A, when asked where the other 2 outstanding pills were Hospice Aide 2 indicated she did not know, and then dug into her pocket again and was able to find the other 2 Hydrocodone pills. The Police Report indicated the police officer asked about stealing of money, to which Hospice Aide 2 denied taking money and then after further discussion Hospice Aide 2 admitted to stealing approximately $60.00 in cash and using it for gasoline for her personal vehicle. The Police Report indicated Hospice Aide 2 was placed in handcuffs and escorted to the patrol vehicle. The Police Report indicated Hospice Aide 2 was in jail and the police officer completed the remanding form and Hospice Aide 2 was charged with theft. The Police Report indicated a link was sent to FM B to upload the security camera recording, the police report was a summary of events, and the body camera footage would serve for exact dialogue and sequence of events.An observation of a video recorded by Patient #2, FM B provided by hospice, identified as person in the video by the Administrator as Hospice Aide 2, evidenced Hospice Aide 2 in Patient’s kitchen, opening a cabinet, removing a bowl with a lid with medication bottles inside. Hospice aide 2 was observed removing medication from a prescription bottle and putting medications into her scrub top pocket. During an interview on 09/02/2025, beginning at 11:45 AM, the Administrator indicated Patient #2’s family placed the cameras the night before the 07/02/2025 incident with Hospice Aide 2. The family had relayed Hospice Aide 2 was in rooms of the home where she should not have been. RN 3 as notified by Patients’ family of the police being called and provided the Hospice with the home video recordings. The Administrator indicated the hospice agency was not aware of any concerns by the family about Hospice Aide 2 until RN 3 was notified that the police were called and why on 07/02/2025. The Administrator indicated there were no other patients who reported complaints related to Hospice Aide 2; Hospice Aide 2 was terminated. The Administrator indicated she had not obtained the police report. The Administrator indicated she was unaware of the timeframe required to report to the State Agency regarding allegations or actual misappropriation of patient property.”

“Based on record review and interview, the hospice failed to ensure hospice aides demonstrated their skills’ and their competency evaluation addressed the 12 subject areas, with a pseudo patient or patient, in 4 of 4 personnel records reviewed of hospice aides with patient contact (Hospice Aide 2, 4, 5, and 6). Findings include: The undated policy titled, “Hospice Aide Competency,” indicated an individual may furnish hospice aide service for the hospice after the individual had successfully completed a competency evaluation. The evaluation must assess communication skills, observation/reporting/documentation of patient care, reading/recording patient temperature, pulse and respiration rate, basic infection control procedures, basic elements of body functions, maintenance of a clean, safe environment, recognition of emergencies, physical/emotional needs of the patient/caregiver, demonstration of appropriate safe technique with bed bath/shower/skin care/oral care/toileting/elimination, safe ambulation and transfer techniques, normal range of motion, adequate nutrition and fluid intake, and any other tasks the hospice would choose to have an aide perform. The policy indicated the hospice would maintain documentation demonstrating the requirements of the policy were met. The Personnel record for Hospice Aide 2 indicated a date of hire [DOH] of 04/23/2025 and a first patient contact date of 05/01/2025; the record failed to evidence a skills competency evaluation was completed. During an interview on 09/02/2025, beginning at 2:04 PM, the Director of Human Resources indicated Home Health Aide 2 did not have a skills competency evaluation completed. The Personnel file for Hospice aide 4, indicated a DOH of 10/21/2024 and a first patient contact date of 10/25/2024; the record failed to evidence a competency evaluation was completed, before patient contact. The file included an Infection Control Observation Checklist, dated 08/18/2025, which indicated hospice aide 4 demonstrated competency in handwashing, bag technique, hazardous material/sharps handling and disposal, equipment cleaning, gait belts. A Personnel Review for Hospice Aide 5 indicated a date of hire of 03/16/2020 and a first patient contact date of 04/07/2020; the record failed to evidence a skills competency evaluation was completed to include 12 subject areas with a pseudo patient or patient, before patient contact. The record included an Infection Control Observation Checklist, dated 08/15/2025, which indicated Hospice Aide 5 demonstrated competency in handwashing, bag technique, hazardous material/sharps handling and disposal, equipment cleaning, gait belts. A Personnel Review for hospice aide 6 indicated a date of hire of 05/15/2023 and a first patient contact date of 05/22/2023; the record failed to evidence a skills competency evaluation was completed to include 12 subject areas with a pseudo patient or patient. The record included an Infection Control Observation Checklist, dated 08/18/2025, indicated CNA 6 demonstrated competency in handwashing, bag technique, hazardous material/sharps handling and disposal, equipment cleaning, gait belts. During an interview on 09/02/2025, beginning at 2:26 PM, the Director of Nursing indicated the hospice aides had not completed hands on skills competency evaluations with a pseudo patient or patient, and the infection control observation checklist was completed as a competency evaluation.”

“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 all problems identified in the initial comprehensive assessment were included in the plan of care with interventions and goals. Clinical Record 7: The patient was admitted to service on 2/9/2023 and the comprehensive assessment included a Foley catheter. The initial plan of care was documented on 02/09/2023. There were no interventions or goals for the catheter. The initial assessment also identified surgical dressings on a hip post-surgical wound, but no interventions or goals were identified on the plan of care. The patient died on 02/162023 During interview with the administrator on 12/14/2023 stated that the software has been problematic and confirmed that the interventions and goals were not on the plan of care.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as Hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure hand hygiene was followed per agency policy. Document 2: Agency policy 7-009 titled Hand Hygiene (reviewed November 2022) stated in part, “ Hand decontamination using an alcohol-based hand rub should be performed after contact with a patient’s intact skin. After contact with inanimate objects. Home Visit 2: During the home visit on12/12/2023 with the chaplain (Personnel Record 6), the visit started with a prayer holding the patient’s hands, and then the visit continued with conversation, with no hand sanitization from the entry into the home and the exit of the home. At the end of the visit, the chaplain held hands with the patient for prayer, put his coat on and exited the house, with no hand sanitization as the car was entered. During an interview with the administrator, she stated that hand hygiene was not performed correctly.”

“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 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 12 (17%) clinical records in which a hospice aide was accepted, the agency did not ensure that the plans of care were documented with clear directions for the aide to provide care. Clinical Record 7: The aide plan dated 02/09/2023 was for a facility patient receiving aide care two times a week. The aide’s plan of care did not document that the patient had a Foley catheter and instructions for catheter care. The nursing initial assessment identified that the patient had a Foley catheter. Clinical Record 10: The aide plan was dated 06/22/2021 and reviewed each benefit period but was not changed. The patient had a Foley catheter inserted on 11/13/2023. The catheter was not listed on the aide plan and did not provide instructions for care of the catheter. During interviews with the administrator on 12/13/2023 and 12/14/2023 stated that the software did not have a Foley option for the aide plan and no method to add it. The software contractor was able to correct this, and all aide plans were being corrected.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records in which a hospice aide was accepted, the agency did not ensure that the aide followed the documented aide plan of care. Clinical Record 8: The hospice aide plan of care was documented on 09/11/2022 and reviewed each benefit period. The task for bath was assigned as a bed bath. On the following dates, the aide documented a shower was provided and that the patient was transferred via Hoyer lift with 2 people assisting: 10/25/2022, 10/28/2022, 11/03/2022, 11/11/2022, 11/18/20222, 01/03/2023, and 02/03/2023. The documentation had a checkmark by case manager notified but not what the case manager was notified of. There was no direction for the use of a Hoyer lift documented on the aide plan or task of a shower. During an interview with the administrator on 12/13/2023, it was confirmed that the aide plan was not followed.”