Compassus - Grand Blanc

“It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure that the patient’s right to receive effective pain and symptom management. HOSPICE POLICY: The hospice policy “Pain Management (HOS-C_08A),” effective 01/01/2024, last revised 02/25/2026, last reviewed 03/19/2026, included in part that “...At every nursing visit, fully assess and document the patient’s pain, pain interventions, and outcomes...Self-Identified Threshold (SIT) for Pain: The SIT is the level of pain severity at which the person experiencing the pain requires additional intervention to bring the pain under control...At the admission nursing visit, the nurse completes the comprehensive pain assessment and then establishes with the patient the level of pain severity which will require a change in current pain management strategy....If the patient has pain above his/her SIT...the nurse will contact the physician, obtain orders, and implement the intervention. The nurse will ensure that the patient is at or below his/her SIT before leaving the patient...The nurse will notify the physician if the intervention is ineffective and obtain revised orders... CLINICAL RECORD 3: A review of the admission visit on 02/13/2026, the nurse documented severe pain manifested by labored breathing, repeated calling out, loud moaning, crying, facial grimacing, tense body language, agitation, anxiety, possible hallucinations, and recent episodes of screaming, restlessness, and crying out. The patient’s wife identified the most important goal of care as the patient being “comfortable and not agitated.” The record further reflected that pain was an active problem occurring daily, anxiety and agitation had a severe impact on the patient, and the patient was assigned an Acuity Level 3 indicating a heightened need for symptom management and support. The record did not have documented evidence that the physician was contacted for new interventions, medication orders, or physician-directed measures implemented to address the documented pain, agitation, and anxiety. On 02/14/2026, the patient’s condition remained symptomatic with severe pain documented at 7/10 on the PAINAD scale. The nurse observed yelling, loud moaning, groaning, crying, facial grimacing, clenched fists, knees pulled to the chest, striking out, and agitation. The record identified severe impact from pain, anxiety, and agitation, and documented that the patient’s pain exceeded his established pain threshold of 4/10 noted at admission. The patient’s pain was noted to affect appetite, concentration, emotions, mobility, sleep, functional status, and relationships. The patient exhibited pain, and the nurse noted that no breakthrough pain medication was ordered; there was no documentation that the nurse contacted the physician for any additional interventions. The patient’s acuity Level was documented as a 1, indicating the highest level of support was needed. There was no additional nursing visit or phone call documented after the 02/14/2026 visit, and the patient died on 02/16/2026 at 12:20 a.m. The death was not attended by the on-call nurse. A joint review of the clinical information and an interview with the Director of Clinical Services (DCS) (Personnel Record 4) were conducted on 08/25/2026 at 12:26 p.m. The DCS acknowledged that the medical record indicated that the patient’s pain and symptoms had not been treated effectively to bring him to a comfortable level prior to his death. She stated that staff should have contacted the attending physician or hospice Medical Director to pursue further interventions for the patient’s pain and agitation and increase follow-up to ensure the patient’s comfort, and noted that this was not their normal practice and did not meet their expectations for hospice care. Of the two nurse visits documented, the admission nurse was new to their agency and new to hospice care, and the weekend on-call nurse was no longer employed. A phone interview was conducted on 08/25/2026 at 1:05 p.m. with the Registered Nurse (RN) (Personnel Record 1) who performed the admission visit. She stated that she was new to hospice at the time of this visit, and this was one of her first admissions to perform. She stated that she remembered the patient appearing very anxious. She added that “Looking back now, I recognize that he was likely experiencing terminal restlessness.” While she remembered getting the approval from the Hospice Medical Director for the admission, she did not remember contacting any other physician or Nurse Practitioner regarding symptom management. She stated that the RNCM at that facility was present off and on during the admission visit, and she felt the RNCM would likely have done the follow-up.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure the patient’s plan of care included planned interventions aligned with patient and family goals for problems identified in the initial and updated comprehensive assessments. HOSPICE POLICY: The agency’s policy, “Pain Management (HOS-C_08A),” effective 01/01/2024, last revised 02/25/2026, last reviewed 03/19/2026, included in part that”...At the admission nursing visit, the nurse completes the comprehensive pain assessment and then establishes with the patient the level of pain severity which will require a change in current pain management strategy. If the patient is unable to communicate, the Non-Verbal Pain Score of 3 is the assigned “SIT” unless the patient’s caregiver/representative identifies a different SIT number on behalf of the patient....If the patient has pain above his/her SIT...the nurse will contact the physician, obtain orders, and implement the intervention. The nurse will ensure that the patient is at or below his/her SIT before leaving the patient...The nurse will notify the physician if the intervention is ineffective and obtain revised orders...” HOSPICE POLICY: The policy entitled “Individualized Plan of Care (HOS-C_90A),” effective 01/01/2024, last revised 10/17/2025, and last reviewed 10/17/2025, reads in part that “...The RN performing the initial assessment...identifies the immediate physical...needs to provide a safe POC for the immediate support of the patient...The RN reviews these findings and recommendations with the patient’s attending physician...the hospice physician, the patient and/or their representative/caregiver, if appropriate, the facility team caring for the patient...The RN incorporates any additional recommendations, orders, or POC interventions after this discussion and completes the initial POC...” CLINICAL RECORD 3: During the admission visit on Friday, 02/13/2026, the nurse noted that the patient had severe pain, evidenced by labored breathing, repeated troubled calling out, loud moaning and crying, and facial grimacing, with tense body language. Pain was noted as an active problem, with the patient unable to contribute any further information due to his cognitive deficit. The pain was noted to occur daily with activity, movement, exercise, and procedures/treatments exacerbating symptoms. The patient’s stated pain threshold (SIT) was documented as a 4/10. Neurologically, the patient was disoriented and confused and appeared agitated with hallucinations. The anxiety scale for cognitive impairment was used with observed guarding, and the nurse noted the patient was almost in tears, whining, whimpering, wincing, and frowning. Within the previous twelve hours, the nurse noted that the patient had been reported to have been screaming and crying out and was restless and agitated. The nurse noted, “Psych services have been initiated; will likely start Klonopin for anxiety/agitation…” Under the care coordination section of the visit note, the patient, caregiver, and healthcare personnel provided responses for the assessment. A section of the nurse visit note included: “Indicate if you communicated with other disciplines involved in this case: No.” The nurse noted all medications were reviewed for effectiveness, side effects, interactions, duplicative actions, and/or needed lab monitoring, and that the only medication changes consisted of the patient’s wife requesting that most supplements be discontinued. The patient’s acuity level was documented at Level 3, with the nurse indicating a heightened level of support was needed and that more frequent team contact was required to provide reassurance, training, and/or symptom management. The patient’s wife, the facility nurse, and the facility nurse practitioner participated in developing and reviewing the plan of care per the nurse note. When asked what was most important to the patient and the patient’s caregiver, she noted that the patient should be “comfortable and not agitated.” The nurse documented that during the visit, the patient’s agitation was discussed, with teaching provided to the family and caregiver to notify the facility nurse and to call hospice with symptoms, and that training was provided to notify hospice when PRN (as needed) usage of medication for any symptom changes from his baseline. The HOPE symptom assessment tool documented in the patient’s “Symptom Impact Screening,” pain was noted to have a “moderate impact,” and anxiety and agitation a “severe impact.” The nurse narrative included that “Patient is a 92-year-old male residing in (NF)...upon arrival, patient is in bed with wife (at bedside. Patient seems to be experiencing some agitation, anxiety, and possible hallucinations. Patient is crying out, but he is not well understood, as he is mumbling and unable to be directed or answer questions. Patient’s wife is his primary contact, with his daughter, who is very involved in his care...Patient is no longer able to answer orientation questions and seems to be in distress at the time of visit. Patient is also followed by Psych physician, who will be starting him on Klonopin after urine dip test was negative for UTI...Patient’s skin was assessed, except for the upper torso and extremities due to patient discomfort and agitation. Patient...cried out while being touched...Patient also received pain medication upon RN arrival. Patient does seem to be having moderate-severe pain, although he is unable to describe the pain or level of pain...RN spoke with facility NP and facility nurses...Patient’s wife signed POLST for comfort care only...The (hospice Medical Director) was notified of admission and agrees with terminal diagnosis of protein-calorie malnutrition.” On Saturday, 02/14/2026, the on-call nurse visited with the patient’s wife and daughter present. He exhibited pallor and was oriented only to person; at times, he was lethargic, yelled, and had an agitated mood and affect. He called out, moaned, and groaned loudly; he cried at times with facial grimacing. His body language was rigid, with clenched fists, knees pulled up, and striking out. The nurse documented the patient’s pain at a 7/10 on the PAINAD scale and labeled his pain as severe (= 7-10/10). She noted the patient utilized opioid medication and that the “patient’s current pain is greater than self-identified pain threshold or greater than mild intensity via observation of pain using PAINAD scale.” The caregiver noted the pain affected the patient’s quality of life: appetite, concentration, emotions, functional status, mobility, sleep/rest disturbance, and his relationship with others. When specifying how often breakthrough pain medication was needed, she documented “none ordered.” The Symptom Impact Screening put the impact of the patient’s pain, anxiety, and agitation as “severe.” She documented that the patient’s medications were reviewed for their effectiveness, side effects, interactions, and duplicative action; a medication reconciliation was performed with the facility LPN; and no changes were made. The patient’s Acuity Level was scored as Level 1, indicating the highest level of support was needed. The nurse documented that the patient’s spouse and the facility nurse participated in reviewing the patient’s plan of care. Lastly, she documented that the “Patient in bed with eyes closed occasionally yells out, spouse at bedside trying to redirect, face flushed, oral cavity dried with sores noted to lips, white spots to back of throat, pain 7/10 Tramadol in use, educated on agitation and pain control, spouse frustrated, coordinated care with facility nurse, the patient’s spouse, and daughter.” No visit was made on Sunday, 02/15/2026, and a visit “Hospice Unattended Death at Facility” was documented that included that the facility reported the death date and time of 02/16/2026 12:20 am. The nurse did not attend the death but noted that the “Patient died a peaceful death.” The patient’s plan of care and physician orders for the benefit period 02/13/2026 to 02/16/2026 were not updated to address the patient’s documented uncontrolled pain and anxiety, and no specific goals for the patient’s comfort were identified. During a joint review of the clinical record and an interview with the Director of Clinical Services (DCS) (Personnel Record 4) on 08/25/2026 at 12:26 p.m., it was confirmed that the clinical record lacked documented interventions and follow-up actions to address the patient’s ongoing symptoms in order for the patient to achieve comfort. The DCS acknowledged that a nurse new to hospice practice and to the agency completed the hospice admission assessment and that the on-call nurse involved was no longer employed by the agency. She further confirmed that, consistent with facility requirements, new hospice interventions and medications required physician or nurse practitioner orders from the facility’s practitioners; however, there was no evidence that the facility physician or nurse practitioner was contacted during either visit to obtain orders addressing the patient’s persistent symptoms. The Director stated that a follow-up nursing visit should have been ordered and completed on 02/15/2026 and confirmed agency expectations that nurses communicate changes in patient condition and symptom management needs to the appropriate Physician or Nurse Practitioner, and obtain orders for additional visits, interventions, and medications to update the plan of care.”

“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 1 of 2 (50%) clinical records reviewed, the agency did not ensure that the Hospice Aide reported to the agency Registered Nurse that the aide did not complete all assigned tasks on the Hospice Aide plan of care as written. CLINICAL RECORD 1: A review of the patient’s plan of care (POC) for the benefit period from 06/20/2026 to 08/18/2026 confirmed orders for the Hospice Aide (HA) to visit the patient twice a week. The HA POC dated 03/17/2026 and active at the time of review included the following hygiene tasks to be completed at every Hospice Aide visit: bed bath, shampoo, hair care, perineal care, oral care, nail care, pluck facial/ear/nose hair, and dress the patient. During the Hospice Aide visit on 07/08/2026, the Hospice Aide documented that the shampoo had already been completed and that oral care was refused, but only noted that the facility nurse aide was notified. Then, on 07/16/2026, the Hospice Aide noted again that the patient refused oral care and that nail care and plucking of the patient’s facial/ear/nose hair had already been completed, but only the “floor nurse” at the facility was notified that the plan of care was not followed as directed. During a review of the clinical record information and an interview with the Director of Clinical Services (DCS) (Personnel Record 4) on 08/24/2026, it was confirmed that the Hospice Aide must report to the RN when the plan of care is not followed as written.”

“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. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 3 (67%) personnel records reviewed, the agency did not ensure that the nurse’s competency was documented upon hire. HOSPICE POLICY - NURSING SERVICES: Personnel File Documentation and Management (UNV-P02) effective 08/1/2021, last revised 07/01/2021, and last reviewed 07/22/2026 “...A file is maintained for all team members that includes validation of competency for the role at the time of hire...” PERSONNEL RECORD 1: A review of the personnel record for the After-Hours/Weekend Registered Nurse hired on 01/20/2026 revealed no documented Hospice Registered Nurse Competency Assessment at the time of hire. PERSONNEL RECORD 2: A review of the personnel record for the On-Call Registered Nurse hired on 02/02/2026 and who exited on 04/10/2026 revealed no documented Hospice Registered Nurse Competency Assessment at the time of hire. A joint personnel record review and Interview with the Regional Director of Quality Outcomes and the Business Office Manager on 08/25/2026 confirmed that the personnel records for the two Registered Nurses did not contain Hospice Registered Nurse competency assessments.”

“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: responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure the patient’s clinical record included documented responses to medications and symptom management. HOSPICE POLICY: The agency policy “Hospice On-Call Services (HOS-C_22A),” effective 07/21/2022, last revised 07/21/2026, last reviewed 07/23/2026, “To ensure timely and appropriate intervention is provided by trained professional team members as needed...The expectation from our patients is a compassionate, professional response...The nurse must use professional judgement...to determine the type of response needed and communicate to the patient/family/facility caregiver regarding the planned intervention...Communication: The On-Call RN is the primary person responsible for communication regarding after-hours/weekends responses and interventions required for positive patient outcomes. This includes communicating with: Patients and/or Family Members, Caregivers...On-Call Physician...Pharmacy...In the following situations, a visit is necessary to establish a baseline for care plan management...The patient has a change in condition including escalation of pain or other symptoms...If the patient or caregiver calls more than 1x in an after-hours/weekend shift, a visit is made...Nurses must obtain orders from the physician for all medical interventions...All interactions with the patient/caregiver are documented...Coordination notes are completed for phone calls...” HOSPICE POLICY: The hospice policy “Pain Management (HOS-C_08A),” effective 01/01/2024, last revised 02/25/2026, last reviewed 03/19/2026, included in part that “...At every nursing visit, fully assess and document the patient’s pain, pain interventions, and outcomes...Self-Identified Threshold (SIT) for Pain: The SIT is the level of pain severity at which the person experiencing the pain requires additional intervention to bring the pain under control...At the admission nursing visit, the nurse completes the comprehensive pain assessment and then establishes with the patient the level of pain severity which will require a change in current pain management strategy....If the patient has pain above his/her SIT...the nurse will contact the physician, obtain orders, and implement the intervention. The nurse will ensure that the patient is at or below his/her SIT before leaving the patient...The nurse will notify the physician if the intervention is ineffective and obtain revised orders... CLINICAL RECORD 3: During the admission visit on 02/13/2026, the nurse documented severe pain evidenced by labored breathing, repeated calling out, loud moaning, crying, facial grimacing, tense body language, agitation, anxiety, possible hallucinations, and recent episodes of screaming and restlessness. The record noted the patient had received pain medication upon the nurse’s arrival and documented that psych services had been initiated, with Klonopin likely to be started for anxiety and agitation. While medications were reviewed for effectiveness and side effects, the clinical record did not document the patient’s response to administered pain medication, the effectiveness of existing symptom management measures, or whether the patient’s pain, anxiety, agitation, and distress improved after nursing interventions. During the follow-up visit on 02/14/2026, the patient continued to exhibit severe symptom distress, including yelling, loud moaning, crying, facial grimacing, rigidity, striking out, and a PAINAD score of 7/10. The nurse documented that Tramadol was in use, reviewed medications, and noted no medication changes; however, the record lacked documentation describing the patient’s response to analgesic therapy, the effectiveness of hospice interventions, or reassessment demonstrating whether symptoms improved, stabilized, or remained uncontrolled after care was provided. Although severe pain, anxiety, and agitation continued to be documented, the clinical record did not contain evidence of ongoing evaluation of treatment outcomes or the patient’s response to symptom management measures. The patient died on 02/16/2026. On 08/25/2026 at 12:26 p.m., I conducted a joint review of the clinical information and an interview with the Director of Clinical Services (DCS) (Personnel Record 4). The DCS acknowledged that the medical record lacked documentation of interventions and documented response to care. Of the two nurse visits documented, the admission nurse was new to their agency and new to hospice care, and the weekend on-call nurse was no longer employed.”

“It is required that the Interdisciplinary Group member ensures that the IDG communicates with the SNF/NF or ICF/IID medical director, the patient’s attending physician, and other physicians participating in the patient’s/resident’s care to coordinate the hospice care with the medical care provided by other physicians. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure coordination of patient care among the patient’s Attending Facility Physician, the Psychiatric Physician, and/or the Hospice Medical Director. HOSPICE POLICY: The hospice policy “Care in the Nursing Home (HOS-C26),” effective 05/17/2018, last reviewed 11/28/2025 “read in part that “...(the hospice) ensures professional management of the care and services provided to hospice patients residing in a Skilled Nursing Facility....(the hospice) ensures the IDT communicates with...the patient’s attending physician, or other physicians participating in the provision of care to the patient as needed, to coordinate the hospice care of the patient with the medical care provided by other physicians.” CLINICAL RECORD 3: A review of the clinical record revealed that at the admission visit on 02/13/2026, the nurse documented moderate to severe pain, agitation, anxiety, possible hallucinations, daily symptom occurrence, and a severe impact of anxiety and agitation on the patient. The record further documented that psych services had been initiated and that Klonopin would likely be started for anxiety and agitation. The record did not include documentation of care coordination with a Facility Physician or Nurse Practitioner to obtain new orders for the patient’s symptoms; only the hospice Medical Director was notified for admission approval. During the follow-up visit on 02/14/2026, the patient continued to exhibit severe pain evidenced by yelling, loud moaning, crying, facial grimacing, rigidity, clenched fists, and striking out, with a PAINAD score of 7/10 and documentation that no breakthrough pain medication had been ordered. Although symptoms continued, no medication changes were made. There was no documented evidence of nursing communication with the patient’s Facility Physician, the mentioned mental health provider, or the Hospice Medical Director regarding symptom management needs. During a joint review of the clinical record and an interview with the Director of Clinical Services (DCS) (Personnel Record 4) on 08/25/2026 at 12:26 p.m., she stated that the facility requires the Facility Physician and Nurse Practitioner (NP) to be contacted for all new orders, interventions, and medications. The DCS acknowledged that a nurse new to hospice practice and to the agency completed this patient’s admission and that the on-call nurse involved was no longer employed by the agency. She confirmed that the clinical record included no evidence that the Hospice Medical Director, Facility Physician, or Nurse Practitioner was contacted during either visit to obtain orders addressing the patient’s persistent symptoms.”

“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, document review, and interview. Agency policy #HOS-C_15C “Medication Reconciliation and Management” (dated 01/24/2025) stated in part, “It is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation according to the following steps: Document a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that all current medications were included in the patient’s drug profile. Clinical Record 2: The patient elected the hospice benefit on 12/30/2024. The initial nursing assessment dated 12/30/2024 documented, “Patient is receiving 3 liters oxygen.” The drug profile dated 12/30/2024 did not include documentation of oxygen. During a joint record review on 01/27/2025, the Area Executive of Clinical Operations confirmed that oxygen was not included in the patient’s drug profile.”

“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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included the drugs and treatment necessary to meet the patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 12/30/2024. The plan of care dated 12/30/2024 through 03/28/2025 ordered: “Supplies: Oxygen Concentrator... Safety Precautions: Oxygen Precautions.” The plan of care did not include documentation of the oxygen flow rate, route of administration, or frequency of administration. Clinical Record 6: The patient elected the hospice benefit on 11/25/2024. The plan of care dated 11/25/2024 through 02/22/2025 ordered: “Supplies: Foley Catheter...SN to educate the family on maintenance and care of Foley catheter.” The plan of care did not include specific orders for the size or the care and maintenance of the Foley catheter. Clinical Record 18: The patient elected the hospice benefit on 09/16/2024. The plan of care dated 09/16/2024 through 12/14/2024 ordered: “Supplies: Foley Catheter...SN to educate the family on maintenance and care of Foley catheter.” The plan of care did not include specific orders for the size or care and maintenance of the Foley catheter. During a joint record review on 01/28/2025, the Area Executive of Clinical Operations confirmed that the plans of care did not include specific physician’s orders for the dosage, route, and frequency of oxygen and the size and maintenance of the Foley catheter.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy C_12A “Supervision of Hospice Aides and LP/VN Colleagues,” dated 08/18/2022, read in part, “The Registered Nurse is responsible for performing a supervisory visit of the LPN/LVN at least every 30 days.” In 9 of 19 (47%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that supervisory visits were completed by the Registered Nurse (RN) no less frequently than every 30 days per agency policy. Clinical Record 4: The patient elected the hospice benefit on 11/10/2024. The plan of care dated 11/10/2024 through 02/08/2025 ordered “SN 2x/week.” The LPN documented visits on 11/17/2024 and 12/02/2024. A clinical record review revealed a RN supervisory visit dated 11/20/2024. No other LPN supervisory visits were documented. Clinical Record 5: The patient elected the hospice benefit on 12/05/2024. The plan of care dated 12/05/2024 through 02/02/2025 ordered “SN 2x/week.” The LPN documented a visit on 12/06/2024. A clinical record review revealed a RN supervisory visit dated 01/07/2025, with 31 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 04/18/2024. The plans of care dated 04/18/2024 through 05/16/2024, 05/17/2024 through 07/15/2024, 07/16/2024 through 09/14/2024, 09/15/2024 through 11/13/2024, 11/14/2024 through 01/12/2025, and 01/13/2025 through 03/13/2025 ordered “SN 2x/week.” The LPN documented visits on 04/25/2024, 09/11/2024, 10/17/2024, 11/07/2024, 12/19/2024, and 01/14/2025. A clinical record review revealed no documented RN supervisory visits. Clinical Record 9: The patient elected the hospice benefit on 07/09/2024. The plans of care dated 07/09/2024 through 10/06/2024, 10/07/2024 through 01/04/2025, 01/05/2024 through 03/05/2025 ordered “SN 2x/week.” The LPN documented visits on 07/17/2024, 10/16/2024, 10/30/2024, 11/27/2024, 12/10/2024, and 01/08/2025. A clinical record review revealed no documented RN supervisory visits. Clinical Record 11: The patient elected the hospice benefit on 10/14/2024. The plan of care dated 10/14/2024 through 01/11/2025 ordered “SN 1x/week.” The LPN documented a visit on 11/05/2024. A clinical record review revealed no documented RN supervisory visit. Clinical Record 12: The patient elected the hospice benefit on 06/07/2024. The plans of care dated 09/04/2024 through 12/01/2024 and 12/02/2024 through 02/01/2025 ordered “SN 2x/week.” The LPN documented visits on 11/08/2024, 11/11/2024, 12/09/2024, 01/07/2025 and 01/20/2025. A clinical record review revealed RN supervisory visits dated 12/06/2024 and 01/22/2025, with 47 days outstanding. Clinical Record 13: The patient elected the hospice benefit on 12/11/2024. The plan of care dated 12/11/2024 through 03/10/2025 ordered “SN 1x/week.” The LPN documented visits on 12/26/2024 and 01/02/2025. A clinical record review revealed no documented RN supervisory visit. Clinical Record 16: The patient elected the hospice benefit on 10/30/2024. The plan of care dated 10/30/2024 through 12/31/2024 ordered “SN 2x/week.” The LPN documented visits on 11/18/2024 and 11/25/2024. A clinical record review revealed no documented RN supervisory visit. Clinical Record 18: The patient elected the hospice benefit on 09/16/2024. The plan of care dated 09/16/2024 through 12/14/2025 ordered “SN 3x/week.” The LPN documented visits on 10/03/2024, 10/30/2024, 11/01/2024 and 11/20/2024. A clinical record review revealed a RN supervisory visit dated 11/22/2024, with 50 days outstanding. During a joint record review on 01/29/2025, the Area Executive of Clinical Operations confirmed the findings, stating, “We just discovered during some audits a few days ago that LPN supervisory visits were not being completed every 30 days.””

“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 1 of 15 (7%) clinical records reviewed of patients with Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 13: The patient elected the hospice benefit on 12/11/2024. The plan of care dated 12/11/2024 through 03/10/2025 ordered “Aide 3x/week.” A clinical record review revealed HA supervisory visits dated 12/19/2024 and 01/09/2025, with 21 days outstanding. During a joint record review on 01/29/2025, the Area Executive of Clinical Operations confirmed that aide supervisory visits were completed less frequently than every 14 days.”