Bridginglife, Inc.

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. Patient Room: During an observation in a patient room, the water temperature was measured by staff maintenance personnel. The water temperature read 112.9 degrees Fahrenheit and intermittently rose to 113 degrees Fahrenheit. The maintenance lead reported on 07/22/2026 that hospital regulations are for the water temperature to be between 110 and 120 degrees Fahrenheit. The maintenance lead stated they can place regulators on the six (6) patient rooms prior to hospice moving patients into them.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. CONTINUING PRIOR REQUIRED ACTION This standard was not reviewed as this agency implemented the plan of correction on 04/20/2026. Previous Evidence: “It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 33 (9%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/19/2025 with a primary diagnosis of colon cancer. The Skilled Nursing (SN) assessment dated 01/29/2026 documented that the patient took Diflucan. Diflucan was not documented in the agency’s medication profile, and there was no evidence that it was reviewed as part of the patient’s medication regimen. CLINICAL RECORD 28/HOME VISIT 7: The patient elected the hospice benefit on 03/02/2026 with a primary diagnosis of brain cancer. The medication profile documented the following medications to be administered intravenously: morphine 10mg/ml, inject 4 mg every 4 hour as need for severe pain; lorazepam 2mg/ml; inject 2 mg intravenously every hour as needed for anxiety; morphine 2 mg/ml, inject 4mg/ ml intravenously every 4 hours for pain or (SOB) shortness of breath; Keppra 100mg/ml, inject 2 times a day for seizures; haloperidol 5 mg/ml, inject 1 mg every hour as needed for paranoia/agitation; glycopyrrolate 0,2mg/ml inject every hours as needed for congestion; and dexamethasone 10mg/ml, inject 4 mg every 12 hours for cerebral swelling. During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 03/10/2026, the patient had one (1) heparin lock and two subcutaneous accesses. Medication delivery observed included Keppra, morphine, and lorazepam, and the heparin lock was flushed with normal saline between each medication. The normal saline (NS) flush was not on the medication profile, and NS flushes were not documented in the interventions section of the plan of care. CLINICAL RECORD 30: The hospice benefit of election was 03/10/2026 with a primary diagnosis of pneumonia. The medication profile included medications to be administered intravenously: glycopyrrolate 0.2mg/ml, inject 0.2 mg every hour as needed for congestion, lorazepam 2mg/ml, inject 2 mg every 15 minutes as necessary for anxiety, morphine 10mg/5ml, inject 5 milligrams every 4 hours for pain, dyspnea, and tachypnea. The medication profile did not include the normal saline flush, and NS flushes were not documented in the interventions section of the plan of care. During an interview and a joint record review on 03/12/2026, the Quality Director, the Clinical Director, and the Compliance Director confirmed the findings, stating the medication profiles did not document all medications as they were supposed to.” During an interview on on 04/21/2026, the Manager of Compliance stated , “The Manager of Education sent out information through (name) yesterday to educate the nurses so the plan of correction is not fully implemented to see changes yet.” THIS IS CONTINUED REQUIRED ACTION”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 04/19/2026 with a diagnosis of senile degeneration of the brain. The plan of care documented the patient’s goal for Chaplain services: “Patient and family will have spiritual needs met.” “Will have spiritual needs met” is not a measurable outcome. CLINICAL RECORD 2: The patient elected hospice care on 04/20/2026 with a diagnosis of malignant neoplasm of the lung. The plan of care documented the patient’s goal for Chaplain services: “Patient and family will have spiritual needs met.” “Will have spiritual needs met” is not a measurable outcome. CLINICAL RECORD 3: The patient elected hospice care on 04/20/2026 with diagnoses of calculus of Bile duct and acute and chronic respiratory failure. The plan of care documented the patient’s goal for Chaplain services: “Patient and family will have spiritual needs met.” “Will have spiritual needs met” is not a measurable outcome. CLINICAL RECORD 4: The patient elected hospice care on 04/16/2026 with a diagnosis of malignant neoplasm of the breast. The plan of care documented the patient’s goal for Chaplain services: “Patient and family will have spiritual needs met.” “Will have spiritual needs met” is not a measurable outcome. CLINICAL RECORD 5: The patient elected hospice care on 04/20/2026 with a diagnosis of heart failure. The plan of care documented the patient’s goal for Chaplain services: “Patient and family will have spiritual needs met.” “Will have spiritual needs met” is not a measurable outcome. During an interview on 04/21/2026, the Manager of Compliance stated that the team had been working on developing measurable goals and the new language will be entered into the computer system by 05/01/2026.”

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas, and include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. CONTINUING PRIOR REQUIRED ACTION This standard was not reviewed as the agency’s changes to the QAPI plan will be implemented as of 06/01/2026. During an interview on April 21, 2026, the Manager of Compliance stated, “We have not implemented any change yet because it scheduled for June 1, 2026. Previous Evidence: It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas, and include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met as evidenced by document review and interview. A review of the agency’s Quality Assurance and Program Improvement (QAPI) program revealed that infection control metrics were not included in the QAPI tracking processes and were not reported to the Board of Directors. A review of the agency’s QAPI dashboard on 03/09/2026 revealed no documented evidence that key metrics related to the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases were tracked in the agency’s performance improvement activities. On 03/11/2026, a review of the agency’s Board of Directors meeting minutes from mid-2023 through 2026 revealed no evidence that infection control metrics were reported to or reviewed by the Board. During an interview on 03/09/2026, the agency’s Director of Quality and Education confirmed that they did not include infection control metrics on their quality dashboard or in their reports to the agency’s Board of Directors.” This a continued required action.”

“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 IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with wounds and Hospice Aide (HA) services, the agency did not ensure that the HA care plan included written instructions to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 04/19/2026 with a diagnosis of senile degeneration of the brain. The plan of care dated 04/19/2026 ordered wound care for the right (R) hip surgical incision, application of Xeroform, and covering with a foam dressing. The HA care plan dated 04/19/2026 did not include instructions for the HA in the event the dressing becomes wet, soiled, or dislodged during bathing. CLINICAL RECORD 3: The patient elected hospice care on 04/20/2026. The plan of care ordered wound care and dressings for a 5 x5 cm sacral wound and wound care with dressing changes for a 5.5 x10 cm wound on the left lower extremity. The HA care plan did not include instructions for the HA in the event the dressing becomes wet, soiled, or dislodged during bathing. The Manager of Accreditation stated in an interview on 04/21/2026, “The plan of care did not cover the wound instruction. The education for the inpatient team is actually scheduled for next week.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. CONTINUING PRIOR REQUIRED ACTION This standard was not reviewed as the agency implemented a new system to track competency and has scheduled to complete competencies for all disciplines by 06/30/2026. Previous Evidence: “It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review, document review, and interview. In 5 of 16 (31%) personnel records reviewed for individuals providing care, the agency did not ensure that competencies were assessed in accordance with the agency’s policy. Agency policy #1669 “Associate Competency” (effective date 08/29/2023) stated in part, “The supervisor is responsible for ... completing and documenting competency assessments within the first 90 days and annually thereafter.” PERSONNEL RECORD 2: The Registered Nurse (RN) was hired on 05/23/2005. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/23/2023 and 10/30/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 3: The RN was hired on 07/14/2003. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/23/2023 and 10/28/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 8: The RN, who provided care in the agency’s free-standing inpatient unit (IPU 2), was hired on 11/14/2022. A review of the personnel record on 03/11/2026 revealed a documented competency assessment dated 12/22/2022. There was no evidence of an annual competency for 2024, 2025, or 2026 to date. PERSONNEL RECORD 14: The Physical Therapist (PT) was hired on 11/09/2020. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/28/2023 and 11/21/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 17: The Volunteer was hired on 04/13/2015. A review of the personnel record on 03/11/2026 revealed no evidence of an annual competency for 2024, 2025, or 2026 to date. During an interview and a joint record review on 03/11/2026, the agency’s Chief People Officer confirmed that no additional documented evidence of competency assessments was available. During an interview and a joint record review on 03/11/2026, the agency’s Volunteer Coordinator confirmed that no additional documented evidence of competency assessments was available.”

“It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by document review, interview, and observation. The OSHA requirements for emergency eyewashes and showers, found at 29 CFR 1910.151(c), specify that “where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.” A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure an eyewash station was available for staff use in the event of an occupational exposure to injurious corrosive materials. During a tour on 04/21/2026 of the agency’s free-standing IPU (IPU 2), no eye wash station or other provision for the flushing of eyes in the case of occupational exposure to injurious corrosive materials was present. In an interview on 04/21/2026, the Manager of Compliance and Accreditation stated, “It is purchased and scheduled to be installed on April 30, 2026.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by document review and interview. The agency did not ensure that quarterly fire drills were conducted and documented for each shift in the hospital-based inpatient unit (IPU). The agency did not ensure that fire drills were completed quarterly on each shift. Additionally, this references K712 “Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift....” During an interview on 04/21/2026, the Manager of Compliance stated in part, “The agency has changed processes and will take over fire drills themselves versus relying on the hospital, effective 04/30/2026. A review of the agency’s plan of correction revealed that the changes would be implemented by 04/30/2026. The agency did not ensure that fire drills were completed quarterly on each shft.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, clinical record review, observation, and interviews with the Compliance Director, Quality Director, and the Facility Director, which revealed the hospice failed to ensure the following: Failed to ensure that the patient’s clinical record contained all physician orders for infusion site care in 8 of 13 (62%) clinical records reviewed and home visits observed for patients who received care in the agency’s inpatient unit (IPU). The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The deficient practice illustrated a process failure that could affect all patients receiving hospice care and services from the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 33 (9%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/19/2025 with a primary diagnosis of colon cancer. The Skilled Nursing (SN) assessment dated 01/29/2026 documented that the patient took Diflucan. Diflucan was not documented in the agency’s medication profile, and there was no evidence that it was reviewed as part of the patient’s medication regimen. CLINICAL RECORD 28/HOME VISIT 7: The patient elected the hospice benefit on 03/02/2026 with a primary diagnosis of brain cancer. The medication profile documented the following medications to be administered intravenously: morphine 10mg/ml, inject 4 mg every 4 hour as need for severe pain; lorazepam 2mg/ml; inject 2 mg intravenously every hour as needed for anxiety; morphine 2 mg/ml, inject 4mg/ ml intravenously every 4 hours for pain or (SOB) shortness of breath; Keppra 100mg/ml, inject 2 times a day for seizures; haloperidol 5 mg/ml, inject 1 mg every hour as needed for paranoia/agitation; glycopyrrolate 0,2mg/ml inject every hours as needed for congestion; and dexamethasone 10mg/ml, inject 4 mg every 12 hours for cerebral swelling. During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 03/10/2026, the patient had one (1) heparin lock and two subcutaneous accesses. Medication delivery observed included Keppra, morphine, and lorazepam, and the heparin lock was flushed with normal saline between each medication. The normal saline (NS) flush was not on the medication profile, and NS flushes were not documented in the interventions section of the plan of care. CLINICAL RECORD 30: The hospice benefit of election was 03/10/2026 with a primary diagnosis of pneumonia. The medication profile included medications to be administered intravenously: glycopyrrolate 0.2mg/ml, inject 0.2 mg every hour as needed for congestion, lorazepam 2mg/ml, inject 2 mg every 15 minutes as necessary for anxiety, morphine 10mg/5ml, inject 5 milligrams every 4 hours for pain, dyspnea, and tachypnea. The medication profile did not include the normal saline flush, and NS flushes were not documented in the interventions section of the plan of care. During an interview and a joint record review on 03/12/2026, the Quality Director, the Clinical Director, and the Compliance Director confirmed the findings, stating the medication profiles did not document all medications as they were supposed to.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 15 of 27 (56%) clinical records reviewed of community program patients, the agency did not ensure that the patient’s plan of care included measurable outcomes. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/17/2025 with a primary diagnosis of senile degeneration of the brain. The plans of care updated on 12/04/2025, 12/18/2025, 01/02/2026, 01/09/2026, 01/21/2026, 01/23/2026, 02/06/2026, and 02/20/2026 documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/28/2026 with a primary diagnosis of dissection of the aorta. The plans of care updated on 02/04/2026, 02/11/2026, 02/19/2026, and 03/05/2026 documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/16/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). All updates to the plan of care documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. In addition, the plan of care documented the skilled nursing (SN) goal: “patient passes soft, formed stool at a frequency that is ‘normal for patient.’ “Normal” for the patient was not defined and is not a measurable outcome. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/06/2026 with a primary diagnosis of heart disease. All updates to the plan of care documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 8:The patient elected the hospice benefit on 09/30/2025 with a primary diagnosis of senile degeneration of the brain. All updates to the plan of care documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/29/2025 with a primary diagnosis of benign neoplasm of cerebral meninges. All updates to the plan of care documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. Additionally, the plan of care documented the patient’s social work goal: “Patient/Caregiver will minimize effects of abnormal grief.” “Minimize effects of abnormal grief” is not a measurable outcome. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/18/2026 with a primary diagnosis of pancreatic cancer. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 12: The patient elected the hospice benefit on 12/30/2025 with a primary diagnosis of senile degeneration of the brain. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 13: The patient elected the hospice benefit on 11/03/2025 with a primary diagnosis of breast cancer. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 15: The patient elected the hospice benefit on 02/03/2026 with a primary diagnosis of fracture of the left femur. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. The POC update on 02/14/2026 documented the SN patient goal: “Patient will maintain normal bowel pattern.” Normal for the patient was not defined and is not a measurable outcome. CLINICAL RECORD 16: The patient elected the hospice benefit on 09/12/2025 with a primary diagnosis of Alzheimer’s Disease. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 17: The patient elected the hospice benefit on 10/27/2025 with a primary diagnosis of congestive heart failure (CHF). The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. CLINICAL RECORD 18: The patient elected the hospice benefit on 12/16/2025 with a primary diagnosis of breast cancer. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. The plan of care, updated 02/09/2026, documented the patient’s goal for coping: “Patient will maintain optimal coping through hospice care. “Will maintain optimal coping” is not a measurable outcome. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/29/2025 with a primary diagnosis of benign neoplasm of cerebral meninges. The plan of care update documented the patient’s spiritual goals: “Patient achieves feeling of spiritual comfort” and “Patient and family will have spiritual needs met.” “Achieves feeling of spiritual comfort” and “will have spiritual needs met” are not measurable outcomes. CLINICAL RECORD 24: The patient elected the hospice benefit on 12/28/2025 with a primary diagnosis of senile degeneration of the brain. The plan of care update documented the patient’s spiritual goal: “Patient achieves feeling of spiritual comfort.” “Achieves feeling of spiritual comfort” is not a measurable outcome. During an interview on 03/12/2026, the Compliance Director and the Director of Quality confirmed the findings and stated that the goals were not measurable.”

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of: operations. This standard was not met as evidenced by document review and interview. A review of the agency’s Quality Assurance and Program Improvement (QAPI) program revealed that the agency did not ensure that operational and non-clinical aspects of the agency’s functions were represented in the QAPI program. A review of the agency’s QAPI program reports, including the QAPI dashboard on 03/09/2026, found no documented evidence of audits, reviews, or tracking of operational performance metrics. In addition, there was no documented evidence of program improvement efforts related to the agency’s non-clinical operations. A review of the agency’s Board of Directors meeting minutes for mid-2023 through 2026 on 03/09/2026 revealed no evidence that operational metrics were reported to or reviewed by the Board of Directors. During an interview on 03/09/2026 with the agency’s Director of Quality and Education, who was present for the QAPI review, she confirmed that operational metrics or program improvement efforts were not currently included in the agency’s QAPI program. A review of the agency’s Quality Assurance and Program Improvement (QAPI) program revealed that the agency did not ensure that operational and non-clinical aspects of the agency’s functions were represented in the QAPI program.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; This standard was not met as evidenced by document review, interview, and observation. In 1 of 9 (11%) home visits observed, the agency did not ensure that hand hygiene was performed as indicated per policy. Agency policy “Home Care Infection Preventions and Control Program - Hand Hygiene” stated in part, “Perform hand hygiene with an alcohol-based hand sanitizer as the preferred method when soap and water are not indicated... Perform hand hygiene: Immediately after removing gloves.” HOME VISIT 2: During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 03/09/2026, the RN performed wound care on the patient’s left leg. After completing wound care on the two wounds on the patient’s left leg, the RN removed and disposed of the soiled barriers from the bed and removed their gloves. Clean supplies were obtained from the box, and new gloves were applied without hand sanitization. Another wound was cared for, and equipment was cleaned, except for the pen, which was used four (4) times during care to write down measurements; it was left on the patient’s hearth. During the interview on 03/09/2026, the Clinical Director, who was present for the home visit, confirmed that the RN’s hands were not sanitized at the glove change.”

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas, and include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met as evidenced by document review and interview. A review of the agency’s Quality Assurance and Program Improvement (QAPI) program revealed that infection control metrics were not included in the QAPI tracking processes and were not reported to the Board of Directors. A review of the agency’s QAPI dashboard on 03/09/2026 revealed no documented evidence that key metrics related to the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases were tracked in the agency’s performance improvement activities. On 03/11/2026, a review of the agency’s Board of Directors meeting minutes from mid-2023 through 2026 revealed no evidence that infection control metrics were reported to or reviewed by the Board. During an interview on 03/09/2026, the agency’s Director of Quality and Education confirmed that they did not include infection control metrics on their quality dashboard or in their reports to the agency’s Board of Directors. A review of the agency’s Quality Assurance and Program Improvement (QAPI) program revealed that infection control metrics were not included in the QAPI tracking processes and that infection control metrics were not reported to the Board of Directors.”

“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 and interview. In 2 of 26 (7%) clinical records reviewed of community program patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written instructions to meet the patient’s needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/30/2025 with a primary diagnosis of lung cancer. The POC dated 12/30/2025 to 03/29/2026 ordered HA services two (2) times per week, effective 12/31/2025. The Skilled Nursing (SN) comprehensive assessment dated 01/20/2026 documented that the patient had a fall with a skin tear on the left hand with orders for a dressing change that included cleaning with normal saline, covering with xeroform, kerlix, and Coban. The HA care plan dated 12/31/2025 assigned the HA the tasks of shampoo, perineal care, oral care, bed bath, and skin care. The HA care plan was not updated to include instructions regarding the dressing on the patient’s left lower arm (through 02/20/2026), should the dressing become wet, soiled, or dislodged during care. CLINICAL RECORD 15: The patient elected the hospice benefit on 02/03/2026 with a primary diagnosis of unspecified fracture of the left femur. The initial plan of care ordered HA services two (2) times a week. The SN comprehensive assessment dated 03/05/2025 documented that the patient’s Foley catheter was removed. The HA task assigned for catheter care remains on the HA care plan as of 03/11/2026, six (6) days later. During an interview and a joint record review on 03/11/2026, the Quality Director and the Director of Clinical Services stated that the tasks were unclear.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 5 of 26 (19%) clinical records reviewed of community program patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes to the Registered Nurse (RN) as they related to changes in the care provided and what had been ordered on the plan of care CLINICAL RECORD 1: The patient elected the hospice benefit on 11/17/2025 with a primary diagnosis of senile degeneration of the brain. The HA care plan assigned the HA tasks for each visit: bed bath, partial bath, oral care, foot care, perineal care, and incontinence care. The HA visit note dated 12/29/2025 documented “N/A - not applicable for incontinent care, bed bath, partial bath, foot care, and oral care.” The HA visit note dated 11/22/2025 documented “N/A - not applicable for oral care.” The HA visit note dated 01/12/2026 documented that the patient “refused bed bath, partial bath, and oral care. The HA visit note dated 01/20/2026 documented that the patient refused perineal care, foot care, and bath. The HA summary note documented that the facility aide was notified. There was no documentation indicating that the hospice RN was notified of the changes in the patient’s needs. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/11/2026 with a primary diagnosis of pathological fracture. The HA care plan assigned the HA tasks for each visit: shampoo, oral care, back rub, assist with dressing, perineal care, and bed bath. The HA visit note dated 02/17/2026 documented “not applicable” for shampoo, oral care, perineal care, and bed bath. There was no documentation indicating that the hospice RN was notified of the changes in the patient’s needs. CLINICAL RECORD 12: The patient elected the hospice benefit on 12/30/2025 with a primary diagnosis of congestive heart failure (CHF). The HA care plan assigned the HA tasks for each visit: shampoo, oral care, back rub, perineal care, and bed bath. The HA visit note dated 03/09/2026 documented “not applicable” for perineal care and bed bath. There was no documentation indicating that the hospice RN was notified of the changes in the patient’s needs. CLINICAL RECORD 18: The patient elected the hospice benefit on 12/16/2025 with a primary diagnosis of breast cancer. The HA care plan assigned the HA tasks for each visit: shampoo, oral care, and shower. The HA visit notes dated 01/29/2026, 02/11/2026, and 02/28/2026 documented that the tasks were refused. There was no documentation indicating that the hospice RN was notified of the changes in the patient’s needs. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/19/2025 with a primary diagnosis of colon cancer. The initial plan of care ordered HA services two (2) times a week. The HA care plan assigned the HA tasks for each visit: bed bath, shower, oral care, and shampoo. The HA visit notes dated 01/29/2026 and 02/03/2026 documented that the care was refused. The HA visit notes dated 02/26/2026 and 03/03/2026 documented that the tasks were “not applicable.” There was no documentation indicating that the hospice RN was notified of the changes in the patient’s needs. During an interview and joint record review on 03/11/2026, the Quality Director, the Compliance Director, and the Clinical Director confirmed the findings and stated that the RN notification was not documented.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review, document review, and interview. In 5 of 16 (31%) personnel records reviewed for individuals providing care, the agency did not ensure that competencies were assessed in accordance with the agency’s policy. Agency policy #1669 “Associate Competency” (effective date 08/29/2023) stated in part, “The supervisor is responsible for ... completing and documenting competency assessments within the first 90 days and annually thereafter.” PERSONNEL RECORD 2: The Registered Nurse (RN) was hired on 05/23/2005. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/23/2023 and 10/30/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 3: The RN was hired on 07/14/2003. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/23/2023 and 10/28/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 8: The RN, who provided care in the agency’s free-standing inpatient unit (IPU 2), was hired on 11/14/2022. A review of the personnel record on 03/11/2026 revealed a documented competency assessment dated 12/22/2022. There was no evidence of an annual competency for 2024, 2025, or 2026 to date. PERSONNEL RECORD 14: The Physical Therapist (PT) was hired on 11/09/2020. A review of the personnel record on 03/11/2026 revealed documented competency assessments dated 03/28/2023 and 11/21/2025. There was no evidence of an annual competency for 2024. PERSONNEL RECORD 17: The Volunteer was hired on 04/13/2015. A review of the personnel record on 03/11/2026 revealed no evidence of an annual competency for 2024, 2025, or 2026 to date. During an interview and a joint record review on 03/11/2026, the agency’s Chief People Officer confirmed that no additional documented evidence of competency assessments was available. During an interview and a joint record review on 03/11/2026, the agency’s Volunteer Coordinator confirmed that no additional documented evidence of competency assessments was available.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, observation, and interview. In 8 of 13 (62%) clinical records reviewed and home visits observed for patients who received care in the agency’s inpatient unit (IPU), the agency did not ensure that all physician orders for infusion site care were documented. Agency policy #3623 “Subcutaneous Catheters for Injections and Infusions” stated in part, “Procedure/Process/Guidelines - Physician orders must be obtained for each procedure.” CLINICAL RECORD 21: The patient elected the hospice benefit on 08/09/2025 with a primary diagnosis of ovarian cancer. During a stay at the IPU, the patient received medications via a Hickman line, as identified in the Skilled Nursing (SN) comprehensive assessment. The plan of care, dated 08/09/2025 and updated every two weeks, did not document any interventions for catheter care, including dressing changes and site care. A clinical record review revealed no physician order for site care and dressing changes for the Hickman catheter. CLINICAL RECORD 26: The patient elected the hospice benefit on 11/09/2025 with a primary diagnosis of cardiomyopathy. During a stay at the IPU, the SN comprehensive assessment documented a PICC line (peripherally inserted central line) and a subcutaneous line. The plan of care, dated 11/09/2025 and updated every two weeks, did not include interventions for care of the PICC line site or the subcutaneous site, nor did it specify whether the site should be rotated. A clinical record review revealed no physician order for PICC line site care, frequency of dressing changes, or for the subcutaneous line. CLINICAL RECORD 27: The patient elected the hospice benefit on 12/06/2025 with a primary diagnosis of unspecified sequelae of cerebral infarction. The SN comprehensive assessment dated 12/06/2025 (at the IPU) documented an intravenous site. The patient was an IPU patient who was provided with GIP care for symptoms of pain. There were no physician orders documented for the care of the infusion site or the frequency of dressing change. CLINICAL RECORD 28/HOME VISIT 7: The patient elected the hospice benefit on 03/02/2026 with a primary diagnosis of brain cancer. During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 03/10/2026, the patient was observed with three (3) heparin locks. Medication delivery observed included Keppra, morphine, and lorazepam, and the heparin lock was flushed between each medication. A clinical record review revealed no physician orders for the heparin lock flushes with normal saline or dressing changes. During an interview, the Registered Nurse (RN) [Personnel Record 7] stated that the lines were in place because the patient was difficult to access, so they had options if one line went bad. CLINICAL RECORD 30: The patient elected the hospice benefit on 03/09/2026 with a diagnosis of chronic obstructive pulmonary disease (COPD). The medication profile documented the administration of intravenously of glycopyrrolate 0.2mg/ml, inject 0.2 mg every hour as needed for congestion, lorazepam 2mg/ml, inject 2 mg every 15 minutes as necessary for anxiety, morphine 10mg/5ml, inject 5 milligrams every 4 hours for pain, dyspnea, and tachypnea. The SN comprehensive assessment dated 03/09/2026 documented a heparin lock for infusion. A clinical record review revealed no physician orders regarding flushing, site care, or the frequency of dressing changes for the heparin lock. CLINICAL RECORD 31: The patient elected the hospice benefit on 03/09/2026 with a primary diagnosis of kidney cancer. The SN comprehensive assessment documented medications provided through an IV (intravenous) route. The patient had a port and a heparin lock in place. The patient’s port was used for the administration of prn (as needed) morphine, lorazepam, Haldol, and glycopyrrolate. A clinical record review revealed no physician orders for site care or the frequency of dressing changes for the port or the heparin lock. CLINICAL RECORD 32: The patient elected the hospice benefit on 03/08/2026 with a primary diagnosis of lung cancer. The SN comprehensive assessment dated 03/08/2026 documented two subcutaneous IV sites, one in the right arm and one in the left arm, and a heparin lock in the right arm. A clinical record review revealed no physician orders documented for site care of the subcutaneous lines or the heparin lock, or for the frequency of dressing changes. CLINICAL RECORD 33: The patient elected the hospice benefit on 03/10/2026 with a primary diagnosis of pneumonia. The SN comprehensive assessment on 03/10/2026 documented an infusion site with a heparin lock. The patient received Haldol, morphine, Robinul, and lorazepam intravenously prn. A clinical record review revealed no physician orders for the site care or the frequency of dressing changes for the heparin lock. During an interview on 03/12/2026, the Compliance Director and the Quality Director stated that they should have physician orders for this care, but that the staff had all been competent in this care. During the interview on 03/12/2026, the Compliance Director and the Facility Director stated they were thinking of referring to the Lippincott manual for these.”

“It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property.. This standard was not met as evidenced by document review, interview, and observation. The OSHA requirements for emergency eyewashes and showers, found at 29 CFR 1910.151(c), specify that “where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.” A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure an eyewash station was available for staff use in the event of an occupational exposure to injurious corrosive materials. IPU TOUR 2: During a tour on 03/11/2026 of the agency’s free-standing IPU (IPU 2), no eye wash station or other provision for the flushing of eyes in the case of occupational exposure to injurious corrosive materials was present. During an interview on 03/11/2026, the agency’s IPU Manager, who was present for the IPU tour of the agency’s free-standing IPU (IPU 2), confirmed that there was no eyewash station or other provision for flushing the eyes within IPU 2. A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure that an eye wash station was present for use by staff in case of occupational exposure to bloodborne pathogens.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The agency did not ensure that quarterly fire drills were conducted and documented for each shift in the hospital-based inpatient unit (IPU). A review of the hospital’s fire drill logs revealed documented fire drills at the agency’s hospital-based inpatient unit (IPU 1) held on the following dates and shifts: 08/29/2023 at 12:45 am (night shift); 03/24/2024 at 4:45 pm (day shift); 06/20/2025 at 8:30 am (day shift). and 03/02/2026 at 12:15 pm (day shift). A review of documentation revealed no documented additional fire drills at the IPU during that time frame. Additionally, this references K712 “Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift....” During an interview on 03/10/2026, the agency’s Inpatient Manager stated that the fire drills in the hospital-based IPU (IPU 1) were organized and performed by the hospital staff, and documentation of the IPU’s fire drills was not maintained within the IPU. During an interview on 03/10/2026, the hospital’s Manager of Safety and Emergency Management, who oversees the fire drills for the hospital, including the IPU (IPU 1), confirmed that there was no documented evidence of additional fire drills held in the IPU, and they were unaware of the required frequency of fire drills for the IPU. A review of the agency’s fire drill logs revealed that the agency did not ensure that fire drills were conducted once per quarter per shift at their hospital-based inpatient unit (IPU).”

“It is required that the hospice inpatient facility provides meals to each patient that are: obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review, interview and observation. The agency did not ensure that everyone entering the kitchen used proper hair restraint procedures. The Food and Drug Administration (FDA) “Food Code 2022, Section 2-402.11(A) stated in part, “Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles.” IPU TOUR 2: During a tour of the agency’s free-standing IPU (IPU 2) on 03/11/2026, the agency’s cook was observed in the kitchen without a hair restraint in place. No provision for access to or use of any hair restraint was in place for staff entering the kitchen area. In addition, a refrigerator that was designated for staff use, as well as storage areas for staff use, were located within the kitchen, in the food preparation area. During an interview on 03/11/2026, the agency’s Accreditation Specialist (AS), who was present during the IPU tour, confirmed that there was no provision for staff to use hair restraints when entering the kitchen, including its food preparation areas. In addition, the AS confirmed that the cook had not been using hair restraints during the IPU tour. A tour of the agency’s free-standing inpatient unit (IPU) revealed that the agency did not ensure that everyone entering the kitchen used proper hair restraint procedures.”