Compassionate Care Hospice

“Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care for 10 patients (#3, #4, #6, #8, #9, #19, #1, #2, #17 and #18), out of total sample of 19 patients.Findings include: 7. Patient #1 was admitted to the agency in June 2026 with a diagnosis of Parkinson’s disease (slow brain disorder that changes how you move) and required hospice services.Review of the physician ordered Hospice POC, dated 6/24/26 through 9/21/26, indicated the following:-HHAV: effective 6/24/26, 2 times a week x 13 weeks, once a week x 1 week.-HHAV: effective 6/28/26, 5 times a week x 12 weeks then once a week x 1 week.Review of the clinical record for the weeks of 6/28/26 through 7/4/26, 7/19/25 through 7/25/26 and 7/26/26 through 8/1/26 did not indicate HHAVs were provided per the physician ordered POC.During an interview on 8/6/26 at 8:45 A.M., the Administrator said HHAVs were not provided on 7/3/26, 7/22/26, 7/24/26, 7/28/26, 7/30/26 and 7/31/26 and said there was no documentation of the reasons for the missed visits. She said the physician ordered POC for HHAVs was not followed, as required.8. Patient #2 was admitted to the agency in July 2025 with a diagnosis of traumatic brain injury (TBI-damage to the brain caused by an external physical force) and required hospice services.Review of the physician ordered Hospice POC, dated 5/26/26 through 7/24/26, indicated the following:-HHAV: 4 times a week x 1 week then 5 times a week x 8 weeksReview of the clinical record for the week of 6/7/26 through 6/13/26, 6/28/26 through 7/4/26, and 7/12/26 through 7/18/26 did not indicate HHAVs were provided per the physician ordered POC.During an interview on 8/5/26 at 3:08 P.M., the Administrator said HHAVs were not provided on 6/11/26, 7/3/26, 7/13/26, and 7/14/26 and said there was no documentation of the reasons for the missed visits. She said the physician ordered POC was not followed for HHAVs, as required.9. Patient #17 was admitted to the agency in February 2026 with a diagnosis of senile degeneration of the brain and required hospice services.Review of the physician ordered Hospice POC, dated 5/17/26 through 8/14/26, indicated the following:-SN visits: 2 times a week x 1 week with 8 visits as needed During an interview on 8/6/26 at 9:13 A.M., the Administrator and Area Vice President of Clinical said the POC had a typo on it and the correct order for SN visits was 2 times a week x 13 weeks with 8 visits as needed.Review of the clinical record for the week of 6/28/26 through 7/4/26 did not indicate a second SN visit.During an interview on 8/6/26 at 9:13 A.M., the Administrator said SN visits were not provided as ordered by the physician and said there was no documentation of the reasons for the missed visits.10. Patient #18 was admitted to the agency in August 2021 with a diagnosis of Parkinsonism (a clinical syndrome defined by core movement signs including slowed movement, resting tremors, muscle stiffness, and balance issues).Review of the physician ordered Hospice POC, dated 5/19/26 through 7/17/26, indicated the following:-HHAV: 4 times a week x 1 week then 5 times a week x 8 weeksReview of the clinical record for the weeks of 6/7/26 through 6/13/26, 6/28/26 through 7/4/26, and 7/12/26 through 7/17/26 did not indicate HHAVs were provided per the physician ordered POC.During an interview on 8/6/26 at 9:56 A.M., the Administrator said HHAVs were not provided on 6/11/26, 7/3/26, 7/13/26, and 7/18/26 and said there was no documentation of the reasons for the missed visits. She said the physician ordered POC for HHAVs was not followed, as required. Review of the agency policy entitled, Hospice Plan of Care, dated 10/1/25, included the following: *All hospice care and services must follow an individualized written plan of care (POC) that meets the patient’s and their family’s needs. *The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including but not limited to: a. Interventions to manage pain and symptoms, b. Scope and frequency of all services necessary to meet the needs of the patient, c. Patient/caregiver goals for hospice services........ 1. Patient #3 was admitted to the agency in June 2026 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure (long term high blood pressure damages both the heart and kidneys). Review of the physician ordered Hospice POC, dated 5/1/26 through 6/29/26, indicated the following: -Home Health Aide Visit (HHAV): effective 5/3/26, 2 times a week for 8 weeks, and 1 time a week for 1 week. Review of the clinical record indicated no HHAVs were provided the week of 6/21/26. During an interview on 8/6/26 at 11:00 A.M., the Administrator said HHAVs were not provided the week of 6/21/26 and the POC was not followed, as required. 2. Patient #4 was admitted to the agency in May 2026 with a diagnosis of Alzheimer’s Disease (a progressive brain disorder that damages nerve cells, causing a slow decline in memory, thinking, and daily living skills). Review of the physician ordered Hospice POC, dated 5/8/26 through 8/5/26, indicated the following: -HHAV: effective 5/10/26, 5 times a week for 12 weeks, and 3 times a week for 1 week. Review of the clinical record indicated 3 HHAVs were provided the week of 7/26/26 and not 5, as ordered. During an interview on 8/6/26 at 8:00 A.M., the Administrator said the POC was not followed for HHAVs for the week of 7/26/26, as required. 3. Patient #6 was admitted to the agency in June 2026 with a diagnosis of multiple sclerosis (MS-a chronic autoimmune disease of the central nervous system that causes fatigue, vision problems, and muscle weakness). Review of the physician order, dated 6/22/26, indicated to increase HHAVs to 5 times a week. Review of the clinical record for the week of 7/19/26 through 7/26/26, indicated 3 HHAVs were provided. Review of the clinical record for the week of 7/26/26 through 8/1/26, indicated 2 HHAVs were provided. During an interview on 8/6/26 at 12:00 P.M., the Administrator said the POC was not followed for HHAVs for the weeks of 7/19/26 and 7/26/26, as ordered. 4. Patient #8 was admitted to the agency in April 2026 with a diagnosis of senile degeneration of the brain (mental deterioration of intellectual ability). Review of the physician ordered Hospice POC, dated 7/21/26 through 10/18/26, indicated the following: -HHAVs: effective 7/21/26, 4 times a week for 1 week, and 5 times a week for 12 weeks. Review of the clinical record indicated 1 HHAV was not provided the week of 7/19/26 and no HHAVs were provided for the week of 7/26/26. During an interview on 8/6/26 at 3:30 P.M., the Administrator said the POC was not followed for HHAVs for the weeks of 7/19/26 and 7/26/26, as ordered. 5. Patient #9 was admitted to the agency in January 2026 with a diagnosis of progressive supranuclear ophthalmoplegia (a brain disorder that damages brain cells). Review of the physician ordered Hospice POC, dated 4/23/26 through 7/21/26, indicated the following: -HHAVs: 2 times a week for 1 week, and 5 times a week for 12 weeks. Review of the clinical record indicated one HHAV was not provided the week of 6/14/26 and no HHAVs were provided for the week of 6/21/26. During an interview on 8/6/26 at 3:35 P.M., the Administrator said the POC was not followed for HHAVs for the weeks of 6/14/26 and 6/21/26, as ordered. 6. Patient #19 was admitted to the agency in September 2024 with a diagnosis of cerebral atherosclerosis (build up of plaque in the blood vessels of the brain). Review of the physician ordered Hospice POC, dated 6/25/26 through 8/23/26, indicated the following: -Skilled Nurse Visit (SNV): effective 6/25/26, 1 time a week for 8 weeks, and 8 as needed (PRN) for medical needs. -HHAV: effective 6/25/26, 1 time a week for 1 week, and 3 times a week for 8 weeks. Review of the clinical record indicated a SNV was not provided the week of 6/21/26. Further review of the clinical record indicated 2 HHAVs were provided the week of 6/28/26, not 3, as ordered. During an interview on 8/6/26 at 8:00 A.M., the Administrator said the POC was not followed for the week of 6/21/26 for missed SN visit, and the week of 6/28/26 as only 2 HHAVs were provided, and not 3, as ordered.”

“Based on record review, policy review and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for 2 patients (#6 and #17), out of a total sample of 19 patients.Findings include: 2. Patient #17 was admitted to the agency in February 2026 with a diagnosis of senile degeneration of the brain (age-related cognitive decline and brain tissue loss) and required hospice services.During an interview on 8/6/26 at 9:13 A.M., the Administrator and Area Vice President of Clinical said the physician ordered Plan of Care (POC) for Skilled Nursing (SN) visits was 2 times a week x 13 weeks with 8 visits as needed.Review of the clinical record for the week of 6/28/26 through 7/4/26 did not indicate a second SN visit, as ordered, or that the physician was notified of the missed visit.During an interview on 8/6/26 at 9:13 A.M., the Administrator said the physician was not notified of the missed SN visit as required. Review of the agency policy entitled, Clinical Records Maintenance and Confidentiality, dated 5/7/26, indicated the following: *Missed Visits: A missed visit is defined as a visit that is not made as scheduled and cannot be rescheduled within the patient’s Medicare treatment week. *If an ordered visit cannot be made, *Although a verbal order for the missed visit is not required, the physician must be notified of the missed visit. 1. Patient #6 was admitted to the agency in June 2026 with a diagnosis of multiple sclerosis (MS-a chronic autoimmune disease of the central nervous system that causes fatigue, vision problems, and muscle weakness). Review of the physician order, dated 6/22/26, indicated to increase hospice aide visits to 5 times a week. Review of the clinical record for the week of 7/19/26 through 7/26/26, indicated 2 hospice aide visits were not provided, and there was no documentation to indicate the physician had been notified. Review of the clinical record for the week of 7/26/26 through 8/1/26, indicated 3 hospice aide visit were not provided, and there was no documentation to indicate the physician had been notified. During an interview on 8/6/26 at 12:00 P.M., the Administrator said the physician was not notified of the missed hospice aide visits, as required.”

“Based on document review and staff interview, the agency failed to provide volunteers in a day-to-day administrative and/or direct patient care service position in an amount that, at a minimum, equals five (5) percent (%) of the total patient care hours of all paid hospice employees and contract staff. Findings include: Review of the Hospice Volunteer Requirement Report for cost savings between August 2025 through July 2026 indicated the following:8/2025-Cost Savings 0.15%9/2025-Cost Savings 0.16%10/2025-Cost Savings 0.08%11/2025-Cost Savings 0.37%12/2025-Cost Savings 0.32%1/2026-Cost Savings 0.61%2/2026-Cost Savings 0.51%3/2026-Cost Savings 1.34%4/2026-Cost Savings 1.34%5/2026-Cost Savings 1.60%6/2026-Cost Savings 1.18%7/2026-Cost Savings 1.25%Total Cost Savings last 12 months: 0.74%.During an interview on 8/4/26 at 12:50 P.M., the Volunteer Coordinator said she is aware of the low Volunteer Savings Program percentage and is actively recruiting to try to increase the savings.During an interview on 8/5/26 at 11:40 A.M., the Director of Operations and Area Vice President of Clinical Services said they are aware of the Volunteer Cost Savings being less that 5%. They said the agency is actively recruiting volunteers. They could not provide any additional information.”