Constellation Hospice

“Based on document review and interview, the hospice agency failed to ensure that the initial comprehensive social work assessment was completed no later than 5 calendar days from the election of hospice care for one patient (#8), out of a total sample of 19 patients. Specifically, for Patient #8, the initial social work comprehensive assessment was completed 15 days after admission to hospice care services.Findings include: Review of the Agency policy, titled, Interdisciplinary Group Membership and Responsibilities, revised November 2023, included the following:The interdisciplinary group responsibilities include but are not limited to: A. Consulting with the patient’s attending physician (if any), completes the initial comprehensive assessments within (5) calendar days after the election of hospice care.Patient #8 was admitted to hospice care in May 2025, with the diagnosis of chronic obstructive pulmonary disease with acute exacerbation.Review of Patient #8’s clinical record indicated the MSW (Master of Social Work) Hospice Initial Assessment as dated 5/24/25, 15 days after hospice services were elected. The MSW Hospice Initial Assessment was completed 10 days after the required 5 calendar days. Further review of the clinical record failed to indicate any documentation as to why the initial assessment was not completed timely. During an interview on 11/19/25 at 3:20 P.M., the Director of Clinical Services said the initial Social Work assessment was not completed within 5 days as required, and there was no documentation to support why the Social Work assessment was not completed.”

“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 Agency policy, titled, Volunteer Services, revised November 2023, included the following: The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel.Review of the Hospice Volunteer Hours/Cost Savings Report for cost savings between November 2024 through October 2025 indicated the following:11/2024-Cost Savings 6%12/2024-Cost Savings 3%1/2025-Cost Savings 4%2/2025-Cost Savings 2%3/2025-Cost Savings 1%4/2025-Cost Savings 1%5/2025-Cost Savings 1%6/2025-Cost Savings 1%7/2025-Cost Savings 1%8/2025-Cost Savings 1%9/2025-Cost Savings 1%10/2025-Cost Savings 1%Total Cost Savings last 12 months: 1.91%During an interview on 11/19/25 at 10:45 A.M., the Volunteer Coordinator said that there was a decrease in volunteer cost savings over the last year due to some of the volunteers moving away. She said it has been a challenge recruiting new volunteers.During an interview on 11/19/25 at 11:30 A.M., the Administrator said she meets with the Volunteer Coordinator weekly to discuss getting the percentage up. She said it has been a challenge and some potential volunteers lose interest during the onboarding process.”

“Based on document review and staff interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 3 patients (#1, #4, and #5), out of a total sample of 19 patients.Findings include: Review of the agency policy, titled Clinical/Service Data Collection, revised November 2023, indicated the following:*Policy: Home care personnel providing patient care and supervisor functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. *Entries into the clinical/service record will be made on the day of care/services provided to the patient. All documentation will be turned into the office at the end of the workday.1. Patient #1 was admitted to the agency in August 2025 with a diagnosis of senile degeneration of the brain.Review of the physician ordered Plan of Care (POC) for certification period 8/18/25 through 11/15/25 indicated the following:-Skilled Nursing (SN) visits: 1-2 times a week for 13 weeks, and 5 PRN (as needed) visits.-Chaplain: 1-2 times a month, and 3 PRN visitsReview of the clinical record indicated the following:-9/24/25 Registered Nurse (RN) visit note was signed on 9/26/25.-10/8/25 RN visit note was signed on 10/10/25.-10/29/25 RN visit note was signed on 10/31/25.-10/16/25 Chaplain visit note was signed on 10/18/25.-11/6/25 Chaplain visit note was signed on 11/8/25.2. Patient #4 was admitted to the agency in December 2024 with a diagnosis of Alzheimer’s Disease.Review of the physician ordered POC for certification periods 8/10/25 through 10/8/25 and 10/9/25 through 12/7/25 indicated the following:-SN visits: 1-2 times a week for 3 months and 10 PRN visits for pain and symptoms management.-Home Health Aide (HHA) visits: 2-3 times a week for 3 months, and 10 PRN visits for care and comfort.Review of the clinical record indicated the following:-10/27/25 HHA visit note was signed on 11/2/25.-10/29/25 HHA visit note was signed on 11/2/25.-10/31/25 HHA visit note was signed on 11/2/25.-11/5/25 HHA visit note was signed on 11/7/25.-11/10/25 HHA visit note was signed on 11/14/25.-11/12/25 HHA visit note was signed on 11/14/25.-11/14/25 HHA visit note was signed on 11/17/25.-10/4/25 RN visit note was signed on 10/6/25.-10/5/25 RN visit was signed on 10/7/25.3. Patient #5 was admitted to the agency in February 2025 with a diagnosis of mild protein malnutrition.Review of the physician ordered POC for certification period 2/14/25 through 5/14/25 indicated the following:-SN visits: 1-2 times a week for 3 months and 6 PRN visits for pain and symptoms management-HHA visits: 1-2 times a week for 10 weeks.Review of the clinical record indicated the following:-2/19/25 HHA visit note was signed on 2/23/25.-2/22/25 HHA visit note was signed on 2/26/25.-3/6/25 HHA visit note was signed on 3/8/25.-3/7/25 HHA visit note was signed on 3/9/25.-3/11/25 HHA visit note was signed on 3/14/25.-3/18/25 HHA visit note was signed on 3/20/25.-3/20/25 HHA visit note was signed on 3/23/25.-2/18/25 RN visit note was signed on 2/27/25.During an interview on 11/18/25 at 12:59 P.M., the Administrator said that documentation should be completed within 24 hours of the visit.During an interview on 11/19/25 at 12:09 P.M., the Director of Clinical Services said that all notes should be completed on the same day of the visit. She said that she could not find any documentation to indicate a reason why the notes were completed greater than 24 hours after the visit.”