Transitions Crown Point, LLC

“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, interview, and observation. In 1 of 16 (6%) clinical records reviewed for patients receiving hospice aide services revealed the agency did not ensure that the aide plan of care included all instructions for the hospice aide. CLINICAL RECORD 3: A home visit observation was conducted with the Hospice Aide (HA) (Personnel Record 4) on 10/08/2025. The patient had a Kerlex wrap on her left lower leg. The hospice aide placed a plastic bag over the dressing when she assisted the patient in the shower. The current aide plan of care dated 06/26/2025 did not include instructions for the aide to cover the leg dressing with a plastic bag or to keep the dressing dry. A review of the clinical record revealed that the patient sustained a skin tear to the left leg on 09/30/2025, requiring an emergency room visit, sutures, and twice-weekly wound care by the Registered Nurse. The aide plan of care was not updated after the patient sustained the injury. The Administrator (Personnel Record 1) was interviewed on 10/08/2025 and stated, “The aide plan of care should have been updated.””

“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 need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical record reviewed where the patient received hospice aide services revealed the agency did not ensure that the Registered Nurse (RN) documented an aide supervision no less frequently than every 14 days. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice on 01/17/2025. The Plan of Care dated 08/12/2025 included orders for hospice aide services with a frequency of twice weekly. There were documented aide supervisions on 08/25/2025, 08/31/2025, 09/08/2025, 09/14/2025, and 10/01/2025 (17 days). The Administrator (Personnel Record 1) was interviewed on 10/06/2025 and stated, “There was no documented aide supervision between 09/14/2025 and 10/01/2025. The visits for the nurse were switched and the aide supervision was missed.” CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice on 08/07/2025. The Plan of Care (POC) dated 08/07/2025 included orders for hospice aide services with a frequency of five visits weekly. The HA was provided as ordered on the (POC). There was aide supervision documented by a Registered Nurse (RN) on 08/11/2025, 09/01/2025, and 09/09/2025. There was no further documented HA supervision through 10/05/2025. Documented aide supervision was greater than fourteen days from 09/09/2025 to 10/05/2025 (26 days). The Administrator (Personnel Record 1) was interviewed on 10/08/2025 and stated, “The RN’s who visited the patient on 09/12/2025 and 09/26/2025 should have documented aide supervision.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients with orders for volunteer services included on the Plan of Care revealed the agency did not ensure that services were provided as ordered by the interdisciplinary group. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 03/19/2025. The Plan of Care (POC) dated 03/19/2025 included an order for Volunteer services. There was no further documentation in the record that the Volunteer Coordinator contacted the patient to arrange for Volunteer services, nor was a Volunteer Plan of Care present in the clinical record. The Volunteer services were not provided as ordered. The Volunteer Coordinator (VC) (Personnel Record 8) and the Administrator (Personnel Record 1) were interviewed on 10/09/2025. The VC stated, “I did contact the patient, and she declined Volunteer services. The patient thought the volunteer would be able to assist more with personal care needs. I did not document the conversation in the notes.””

“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 which revealed the agency did not ensure that volunteer services were utilized for 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. Volunteer Program: The agency’s volunteer program was reviewed, as well as the agency’s documentation of volunteer cost savings. The agency’s documented percentage of volunteer utilization was 0.86% in 2024. The agency has not utilized volunteer services for 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 Alternate Administrator (Personnel Record 11) was interviewed on 10/08/2025 and stated, “We recently started a PIP to work on increasing the use of volunteers.” The Volunteer Coordinator (Personnel Record 8) was interviewed on 10/09/2025 and stated, “I am working on getting more volunteers who would be able to visit patients.” The agency did not ensure that volunteer services were utilized for 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.”

“Based on record review and interview, the agency failed to evidence they had a written agreement for the services provided by Entity 1 and failed to evidence administrative oversight of services provided by Entity1. The findings include: 1.The personnel record for Registered Nurse (RN) 1 indicated their criminal history was ordered by Entity 1 on 5/28/2024. 2. The personnel record for RN 2 indicated their background check was ordered by Entity 1 on 12/10/2020. 3.The personnel record for Social Worker 1 indicated their background check was ordered by Entity 1 on 8/7/2023. 4.On 12/13/2024, beginning at 1:44 PM, the Administrator indicated the personnel files were maintained by their corporate office, indicated the hospice did not maintain the personnel files of their employees. The Administrator indicated Corporate Person 2, from Entity 1, completed the criminal history backgrounds for agency personnel and indicated she does not receive a copy of the agencys personnel criminal history report. The Administrator indicated if there was a criminal infraction on the criminal history report, Corporate Person 2, not the Administrator, makes the decision if an applicant could be hired. 5. On 12/13/2024, at 11:52 AM, during the entrance conference, the Administrator indicated Entity 1 had a call center where the agencys incoming phone calls were answered and triaged. The Administrator indicated Entity 1 answers the phone calls for the hospice via their call center. 6. A review of a contract with Entity 1 dated 3/12/2022 failed to evidence services were provided under written agreement for the answering and triaging of the agencys phone calls, nor conducting the agencys personnel criminal history checks, and maintenance of the agencys personnel files.”