Frederick Health Hospice
A hospice in Frederick, Maryland 21702
1 Frederick Health Way, Frederick, Maryland 21702. (240) 566-3030.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 6 deficiencies cited in the last three years
- 3of 5 family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean4
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
6 deficiencies cited in the last three years
The middle of the 5 hospices serving ZIP code 21702 had 7.
The last inspection on record was on Jan 17, 2024: a follow-up inspection by The Joint Commission.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
6 deficiencies in 1 month of the last 36. Last cited Dec 2023. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Dec 8, 2023: initial inspection by The Joint Commission6 deficiencies
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Quality assessment & performance improvement (42 CFR 418.58)
“Observed in Tracer Activities. Upon interview, the Hospice Director confirmed that the Hospice QAPI bereavement and volunteer services had several data collection monitors and outcomes completed. However, information was reviewed by the Hospice Leadership but had not been sent to Senior Leadership at the Hospital - the Governing Board”
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Timeframe for completion of assessment (42 CFR 418.54(b))
“Observed in Record Review. In 1 of 16 patient records reviewed, It was noted by the hospice surveyor that the bereavement, spiritual and social work assessments were not completed in 5 calendar days after the election of Hospice program by the patient. These assessment were completed 8 days after the Hospice Benefit. This was confirmed by the leadership accompanying the surveyor .”
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Content of plan of care (42 CFR 418.56(c)(4))
“Observed in Infection Control System Tracer. In 1 of 18 patient records reviewed, It was noted that one physician order was not clarified The order stated wound care X 1/ day . There was no specificity of the what the wound required, if the wound needed a cleansing agent a cleansing agent or a specific dressing.”
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Prevention (42 CFR 418.60(a))
“Observed in Tracer Activities. Upon interview, the Hospice clinical manager confirmed that the multi-patient use INR monitor found at the Hospice House was disinfected with a different product (but effective against BBP) than what the manufacturer instructions specify for use for disinfection of the device.”
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Content (42 CFR 418.104(a)(3))
The inspectors’ words, 204 words
“Observed in Individual Tracer. In 2 of 20 patient records reviewed, It was also noted by the Hospice Surveyor that the dose of the Trazadone given to the patient was 25mg. However, the medication profile listed that 50 mg of Trazadone was ordered, and there was no explanation of why the dose was changed. Also this patient wound note was not complete, there were no measurements listed for the two wounds the patient had one on the sacrum and one on the gluteal fold. Also the note says the wound was cleansed but there is no documented cleanser agent. And the there is a notation that the wound was dressed but no indication of a specific dressing for this wound. Observed in Tracer Visit. In 2 of 20 patient records reviewed, It was noted by the hospice surveyor that the medication reconciliation was inaccurate. The medication profiles in the medical record in the LTC facility and the medication profile in the hospice’s record did not match. Hyoscyamine was on the LTC medication profile but not included in the hospice’s medication list. The frequencies for acetaminophen were different for the two medication profiles. These issues were confirmed by the RN and leadership accompanying the surveyor”
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Coordination of services (42 CFR 418.112(e)(3)(i))
“Observed in Individual Tracer. In 1 of 16 patient records reviewed, It was noted by the hospice surveyor that there was no hospice plan of care provided to the contracted Skilled Nursing Facility for this patient. This was confirmed by the leadership accompanying the surveyor.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 17, 2024 | Follow-up inspection by The Joint Commission | No deficiencies cited |
| Dec 8, 2023 | Initial inspection by The Joint Commission | 6 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jul 26, 1990.
- Ownership: non-profit.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 12.4 nurse care minutes per routine home care day, 11.8% of skilled nursing minutes at weekends and a visit near death for 91.4% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 62% at home, 25% in assisted living, 12% in a skilled nursing facility, 1% in a hospital.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 12.4 min |
| Skilled nursing minutes at weekends | 11.8% |
| Visits near death | 91.4% of patients who died |
Who owns it?
- 9 owners or officers are people: Carlos Tomas Graveran (managing employee (on the payroll), 100%); Elizabeth B Pakenas (corporate director, 0%); Gordon M Cooley (corporate director, 0%); Michelle Mahan (corporate director); James Frederick Manning (corporate director, 0%); Thomas Kleinhanzl (corporate director); Jennifer Teeter (managing employee (on the payroll)); Shelby Boggs (managing employee (on the payroll), 0%); Stephen L Johnson (corporate director, 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- Family caregivers rate it 3 of 5 in CMS’s survey (Oct 1, 2023 to Sep 30, 2025): 81% rated it 9 or 10 out of 10, and 86% would definitely recommend it.
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 99.69% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 61.5% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | 3 of 5 |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 5 hospices CMS’s data show serving patients in ZIP code 21702, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 7; this one had 6.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Frederick Health Hospice This hospice | 6 |
| Holy Cross Home Care and Hospice | 13 |
| Montgomery Hospice & Prince Georges Hospice | 5 |
| Bridginglife, Inc. | 21 |
| Amedisys Hospice of Greater Chesapeake | 7 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.