Advisacare Hospice

“Based on record review and interview, the hospice agency failed to ensure that the plan of care was followed for 1 (P-5) of 19 records reviewed, resulting in the potential for negative patient outcomes. Findings include: Patient #5 (P-5) was admitted to the Hospice agency on 04/22/2026 with a terminal diagnosis of Congestive Heart Failure. During record review on 08/17/2026 at 10:45 AM, it was noted that the Plan of Care (POC) dated 04/22/26 had a Bumex (A diuretic) order for 4, 0.5 MG tablets to be taken every 12 hours. That order for 120 tablets was filled on 05/01/26 and would have run out on 05/13/26. A review of P-5’s Medication Reconciliation Record (MAR) on 08/19/26 at 3:55 PM showed an order for Bumex was placed on 04/30/26 for 30, 2 MG tablets to be taken daily. That order would have run out on 05/29/26. There was no other order for Bumex documented in the record or in the MAR until 07/07/26. P-5 was without Bumex from 05/29/26 until 07/07/26, approximately 5 weeks. During that time without the Bumex, P-5’s legs and feet became swollen making it difficult for P-5 to walk without a cane and a walker. On 08/19/26 at 3:55 PM, the agency’s complaint log was reviewed and a complaint dated 07/11/26 was documented. The complaint said P-5’s daughter called to report no registered nurse (RN) visit this week, and medications and supplies not being ordered. During an interview with the administrator (Staff-A) on 08/19/26 at 3:55 PM, Staff-A said, “I remember speaking to the patient, and the nurse was not ordering medications like they were supposed to be. That nurse was let go from the agency,””

“Based on record review and interview, the agency failed to ensure services were provided as ordered in the plan of care for 5 (P-5, P-6, P-9, P-10, P-19) of 19 records reviewed, resulting in the patient not receiving services as ordered in the plan of care. Findings include: Patient #5’s (P-5) Start of Care (SOC) was dated 04/22/2026. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 08/17/2026 at 10:45 AM, it was noted that the POC ordered Skilled Nursing (SN) and Home Health Aide (HHA) at a frequency of weekly visits. The SN failed to complete a visit for weeks 5 (05/18/2026-05/24/2026), 11 (06/29/2026-07/05/2026) and 15 (07/27/2026-08/02/2026). Furthermore, the HHA failed to complete a visit for weeks 11 (06/29/2026-07/05/2026) and 12 (07/06/2026-07/12/2026). The agency failed to complete visits as ordered. Patient #6’s (P-6) Start of Care (SOC) was dated 06/29/2026. The Plan of Care (POC) identified a terminal diagnosis of Senile Degeneration of the Brain. During record review on 08/19/2026 at 10:30 AM, it was noted that the POC ordered SN and HHA at a frequency of 2 weekly visits. The SN failed to complete 2 visits for week 5 (07/27/2026). Furthermore, the HHA failed to complete 2 visits for weeks 2 (07/06/2026-07/12/2026) and 7 (08/10/2026-08/16/2026). The agency failed to complete visits as ordered.Patient #9’s (P-9) Start of Care (SOC) was dated 06/27/2026. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 08/19/2026 at 12:50 PM, it was noted that the POC ordered HHA at a frequency of 2 weekly visits. The HHA failed to complete visits for weeks 4 (07/13/2026) and 5 (07/20/2026-07/26/2026). The agency failed to complete visits as ordered.Patient #10’s (P-10) Start of Care (SOC) was dated 06/11/2026. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 08/19/2026 at 2:00 PM, it was noted that the POC ordered SN and Home HHA at a frequency of 2 weekly visits. The SN failed to complete a visit for week 8 (07/27/2026-08/02/2026). Furthermore, the HHA failed to complete a visit for weeks 3 (06/22/2026-06/28/2026), 5 (07/06/2026-07/12/2026) and 10 (08/10/2026-08/16/2026). The agency failed to complete visits as ordered.Patient #19’s (P-19) Start of Care (SOC) was dated 06/18/2026. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 08/20/2026 at 9:50 AM, it was noted that the POC ordered HHA at a frequency of 2 weekly visits. The HHA failed to complete both visits for weeks 6 (07/20/2026-07/26/2026) and a visit for week 8 (08/03/2026-08/09/2026). The agency failed to complete visits as ordered.A review of the agency policy occurred on 08/24/2026 titled “Hospice Plan of Care “ (Undated). The policy states, “The plan of treatment shall include but not be limited to: …Specific discipline and frequency of services.”The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 08/20/2026 at 11:15 AM.”

“Based on record review and interview, the agency failed to ensure that each patient’s record included timely clinical assessment notes in 12 (P-1, P-2, P-3, P-4, P-6, P-7, P-8, P-9, P-10, P-16, P-17, P-19) of 19 records reviewed, resulting in a lack of documented care. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 01/09/2026. The Plan of Care (POC) identified a terminal diagnosis of Senile Degeneration of the Brain. During record review on 08/18/2026 at 3:30 PM, it was noted that the Home Health Aide (HHA) completed visits and finalized the documentation late:-Completed on 06/16/2026, finalized on 06/23/2026-Completed on 06/17/2026, finalized on 06/26/2026-Completed on 06/19/2026, finalized on 06/29/2026-Completed on 06/22/2026, finalized on 06/29/2026-Completed on 06/30/2026, finalized on 07/12/2026-Completed on 07/01/2026, finalized on 07/12/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #2’s (P-2) Start of Care (SOC) was dated 12/18/2025. The Plan of Care (POC) identified a terminal diagnosis of Prostate Cancer. During record review on 08/17/2026 at 3:30 PM, it was noted that the documentation for the Interdisciplinary Group (IDG) had not been finalized for 07/30/2026 and 08/13/2026. The agency failed to maintain a complete and accurate medical record. Patient #3’s (P-3) Start of Care (SOC) was dated 07/17/2026. The Plan of Care (POC) identified a terminal diagnosis of Non-Rheumatic Aortic Stenosis. During record review on 08/19/20266 at 9:30 AM, it was noted that the Registered Nurse (RN) completed visits and finalized the documentation late:-Completed on 08/08/2026, finalized on 08/18/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #4’s (P-4) Start of Care (SOC) was dated 12/16/2025. The Plan of Care (POC) identified a terminal diagnosis of Unspecified Protein Calorie Malnutrition. During record review on 08/19/2026 at 9:45 AM, it was noted that the documentation for the IDG had not been finalized for 08/13/2026. The agency failed to maintain a complete and accurate medical record.Patient #6’s (P-6) Start of Care (SOC) was dated 06/29/2026. The Plan of Care (POC) identified a terminal diagnosis of Senile Degeneration of the Brain. During record review on 08/19/2026 at 10:30 AM, it was noted that the RN completed visits and finalized the documentation late:-Completed on 07/21/2026, finalized on 07/28/2026-Completed on 07/31/2026, finalized on 08/04/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #7’s (P-7) Start of Care (SOC) was dated 06/15/2026. The Plan of Care (POC) identified terminal diagnoses of Skin Cancer and Brain Cancer. During record review on 08/19/2026 at 11:30 AM, it was noted that the RN completed visits and finalized the documentation late:-Completed on 07/09/2026, finalized on 07/20/2026-Completed on 07/14/2026, finalized on 07/20/2026-Completed on 07/28/2026, finalized on 08/13/2026-Completed on 07/31/2026, finalized on 08/13/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #8’s (P-8) Start of Care (SOC) was dated 06/19/2026. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 08/19/2026 at 12:20 PM, it was noted that the documentation for the IDG had not been finalized for 07/30/2026 and 08/13/2026. The agency failed to maintain a complete and accurate medical record.Patient #9’s (P-9) Start of Care (SOC) was dated 06/27/2026. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 08/19/2026 at 12:50 PM, it was noted that the RN completed visits and finalized the documentation late:-Completed on 07/15/2026, finalized on 07/27/2026-Completed on 07/18/2026, finalized on 07/27/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #10’s (P-10) Start of Care (SOC) was dated 06/11/2026. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 08/19/2026 at 2:00 PM, it was noted that the RN completed visits and finalized the documentation late:-Completed on 06/12/2026, finalized on 07/13/2026-Completed on 06/17/2026, finalized on 06/30/2026-Completed on 07/02/2026, finalized on 07/07/2026-Completed on 07/21/2026, finalized on 07/28/2026-Completed on 07/31/2026, finalized on 08/04/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #16’s (P-16) Start of Care (SOC) was dated 06/18/2026. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 08/19/20/26 at 3:30 PM, it was noted that the disciplines completed visits and finalized the documentation late:-HHA completed on 07/03/2026, finalized on 07/13/2026-Licensed Practical Nurse (LPN) completed on 07/03/2026, finalized on 07/12/2026-Medical Social Worker (MSW) completed on 07/14/2026, finalized on 07/22/2026-RN completed on 07/13/2026, finalized on 07/20/2026The agency failed to complete documentation timely to maintain a complete and accurate medical record.Patient #17’s (P-17) Start of Care (SOC) was dated 06/04/2026. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 08/19/2026 at 4:00 PM, it was noted that the disciplines completed visits and finalized the documentation late:-MSW completed on 07/02/2026, finalized on 07/09/2026-RN completed on 08/03/2026, finalized on 08/06/2026-RN completed on 08/03/2026, finalized on 08/10/2026Furthermore, the RN completed two visits on 8/3/26 with the same start and end time for the visit. The agency failed to complete documentation timely to maintain a complete and accurate medical record. Patient #19’s (P-19) Start of Care (SOC) was dated 06/18/2026. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 08/20/2026 at 9:50 AM, During record review on 08/19/2026 at 12:20 PM, it was noted that the documentation for the IDG had not been finalized for 07/30/2026 and 08/13/2026. The agency failed to maintain a complete and accurate medical record.A review of the agency policy occurred on 08/20/2026 titled “Clinical Record Contents and Maintenance” (Undated). The policy states, “The record will contain pertinent past and current medical, nursing, social and other information as appropriate to the care and treatment of the patient… All medical entries should be made as soon as possible after the care is provided, or an event or observation is made.”A review of the agency policy occurred on 08/20/2026 titled “IDG Case Conference / Update of Comprehensive Assessment” (Undated). The policy states, “ Documentation of the conference shall be the responsibility of the primary nurse or supervisor, or other professional as instructed by the supervisor. The documentation shall include a summary of progress, assessment of the needs for continuing care, medication effectiveness for pain management and relief, and patient status.”The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 08/20/2026 at 11:15 AM.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all disciplines no later than 5 calendar days after the election of hospice care (see L523); failed to ensure the initial comprehensive assessment included wound measurements (see L524); failed to ensure the physician was notified of potential medication interactions and failed to perform an appropriate review concerning listed medication allergies (see L530); failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient’s family to determine factors that may impact the family’s ability to cope with the patient’s impending death (see L531); and failed to ensure the comprehensive assessment was updated by the social worker every 15 days (see L533), resulting in the potential for unmet care needs and poor patient outcomes. .”

“Based on record review and interview, it was determined the hospice agency failed to implement and maintain a coordinated agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases that was a required portion of the agency’s Quality Assurance and Performance Improvement program (See L 580); failed to incorporate a method of identifying infectious and communicable diseases problems and implement appropriate actions that would improve disease prevention (See L 581); and failed to provide documentation of any infection control education instructed to employees, contracted providers, patients, and family members and other caregivers (See L 582). .”

“Based on record review and interview the agency failed to ensure nursing needs of the patient were identified and met and failed to ensure the Registered Nurse provided oversight and supervision of its Licensed Practical Nurses (See L591); failed to ensure medical social work services provided ongoing assessment of patients (See L594); failed to make bereavement services available to all of the bereaved family members who would be affected by the patient’s death and failed to complete a bereavement plan of care that reflected the needs of each bereaved family member, the kind of bereavement services to be offered, and the frequency of service delivery (See L596). .”

“Based on record review and interview, the registered nurse failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient and failed to ensure safety precautions were included on the hospice aide plan of care (See L625); failed to ensure the hospice aide provided care and services as ordered in the plan of care (See L0626); failed to ensure its hospice aides reported changes in patient’s care and documented tasks upon completion (See L628); and failed to ensure the Registered Nurse made on-site visits to the patient’s home no less than every 14 days to assess the adequacy of aide services (See L629). .”

“Based on record review and interview, it was determined that the hospice agency failed to maintain documentation of emergency preparedness training, which resulted in the potential for inappropriate, unprepared responses to emergencies and an interruption in the provision of needed patient care and services. Findings include: During a review of the hospice emergency preparedness program, it was discovered that no sign-in sheets were available to document the 88 employees’ participation in the emergency preparedness drills. The agency failed to document employee participation-including that of all new, existing, and contract employees-in the drills. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all disciplines no later than 5 calendar days after the election of hospice care in 2 (P-1 and P-5) of 19 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was determined social work did not complete an assessment until 9/22/24 – 8 days after care was started. There were no orders or documentation regarding the delay in care.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was determined no assessment had been completed by social work - 16 days after care was started. Additionally, there were no orders or documentation by the social worker regarding missed visits or the reason for no assessment.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “A comprehensive assessment will be conducted within 5 days of the patient’s election of hospice services and shall include all disciplines needed.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the agency failed to ensure the initial comprehensive assessment included wound measurements in 4 (P-1, P-2, P4, and P-5) of 19 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the initial comprehensive assessment indicated P-1 had, “a dime sized ‘black’ area noted to coccyx, no odor or discharge noted,” however, there were no objective measurements of the wound.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the initial comprehensive assessment indicated P-2 had, “Wound / Drain (dime size st 2 on r hip), SkinLesions/Wounds Current: [“Pressure Ulcer(s)/Injuries”], Skin and Ulcer/Injury” [sic], however, there were no objective measurements of the wound or any further assessment.During a joint home visit with P-2 and a skilled nurse (RN #3) on 10/16/25 at 11:00 AM, RN #3 was asked about the expectation for wound assessment during the initial comprehensive assessment. RN #3 admitted she hasn’t measured the wounds because she wasn’t sure what she was supposed to do, however, she agreed the wounds should be assessed and documented to establish a baseline and establish a plan of care.Upon return to the agency on 10/16/25 at 12:33 PM, the administrator (Adm #1) was asked to provide an agency policy regarding the agency expectation for wound care and assessment. Adm #1 stated there is no agency policy regarding wound care, but stated wounds should be measured and assessed at the initial comprehensive assessment or upon discovery of new wounds.Patient #4 (P-4) was admitted to this hospice agency on 8/25/25 with the terminal diagnosis of cerebrovascular disease and hypertension. During record review on 10/17/25, it was noted the comprehensive assessment indicated P-4 “…has some healing skin tears to her left forearm along with bruises.” Additionally, a face-to-face note by the physician dated 8/25/25 indicated P-4 had a recent fall with a “laceration to the L UE (arm)” and a skilled nursing note dated 8/26/25 indicated P-4 had “stitches noted to left forearm.” Upon further review of the record, it was determined the initial comprehensive assessment failed to include objective measurements or further assessment of P-4’s wounds.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted a skilled nursing note dated 10/3/25 stated, “…Has dressing on right chest wall. Will remove today to shower.” Upon review of the initial comprehensive assessment, it was noted there were no measurements or assessments made of this wound.The agency failed to identify and assess wounds at the initial comprehensive assessment to establish a baseline and to establish a plan of care.Adm #1 again reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM. The director of clinical services (DCS #1) was also present at this time and acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure the physician was notified of potential medication interactions and took them into consideration when creating the patients’ plan of care in 5 (P-3, P-9, P-15, P-16, P-18) of 5 patients with identified major drug interactions, from a total of 19 sampled records reviewed; and failed to perform an appropriate review concerning listed medication allergies in 1 (P-15) of 19 records reviewed for medication allergies, from a total of 19 sampled records, resulting in the potential for harm from adverse medication interactions to all 139 patients currently receiving hospice services. Findings include: Patient #15 (P-15) was admitted to hospice on 7/11/25 with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25 at 3:50 PM, a review of the agency’s “Drug Interactions” report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:17 AM that the hospice agency does not have a procedural pathway yet to notify the physician.Further, when comparing the listed patient allergies found in the attached hospital records dated 4/5/25, the following allergies were listed: Codeine (for pain) “Acts crazy”, Diazepam (for anxiety) “hallucinates”, and Hydrocodone-Acetaminophen (for pain) “hallucinates”. However, the hospice’s listed medication allergies for P-15 failed to include Diazepam. This is significant as P-15’s history is positive for anxiety and this was noted by the skilled nurse who documented on the initial comprehensive assessment (dated 7/11/25) under “Social Assessment” the following: “Sleep Disturbances: Yes, Anxiety/Panic: Yes.”Patient #16 (P-16) was admitted to hospice on 9/16/25 with terminal diagnoses of cerebral infarction (brain stroke). On 10/16/25 at 8:45 AM, a review of the agency’s “Drug Interactions” report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:17 AM that the hospice agency does not have a procedural pathway yet to notify the physician.Patient #18 (P-18) was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25 at 10:10 AM, a review of the agency’s “Drug Interactions” report was reviewed. This report noted a major drug to drug interaction, but additional review found no evidence that the physician had been notified. This was verified by the administrator on 10/16/25 at 09:18 AM that the hospice agency does not have a procedural pathway yet to notify the physician.The Administrator and Director of Clinical Services reviewed and acknowledged the above findings during an interview on 10/21/25 at 11:40 AM. Both further acknowledged this did not meet agency expectations or its policy noted above for P-9. Policy: III.20 Medication Management & Administration, undated, stated, “All medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy and for patient non-compliance with drug therapy. The admitting nurse will contact the patient’s physician immediately if there are any questions or concerns regarding the medications a patient is taking.” Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. On 10/16/25 at 1:35 p.m., a review of the agency’s “Drug Interactions” report was reviewed. The report revealed that major drug to drug interactions had been identified. Upon further review, there was no documented evidence that the Physician had been notified.The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m. Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was noted the drug interaction report in the agency’s electronic medical record system identified 1 major drug to drug interaction. Upon further review of the record, it was determined there was no evidence the physician was notified of the interaction.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the hospice failed to ensure the comprehensive assessment included an initial bereavement assessment of the patient’s family to determine factors that may impact the family’s ability to cope with the patient’s impending death for 3 (P-3, P-15 and P-18) of 19 total sampled records reviewed, resulting in the potential to negatively affect the loss/grief issues for all 139 patients current receiving hospice services. Findings include: P-15: The start of care date to hospice was on 7/11/25, with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25, a review of P-15’s bereavement assessment (BA) noted on three occasions a BA was performed: 7/11/25 by the RN; 7/14/25 by the Chaplin, and 7/16/25 by the Social Worker. All (3 of 3) documented a BA which listed only the patient’s nephew. However, on 10/15/25 during a joint home visit with aide services, P-15 during an interview was asked, “Who do you feel would significantly grieve and mourn upon your passing?” P-15 who is alert and oriented with no documented confusion replied, “George (nephew), Barb (niece), Sharon (P-15’s sister), and Claudia (best friend of 40 years).” P-15 was then queried again if anyone from the hospice team inquired about any of the listed loved ones you just mentioned? P-15 responded, “No, not that I can remember at least.”P-18 was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25, a review of P-18’s BA noted on three occasions a BA was performed: 8/30/25 by the RN; 9/2/25 by the Chaplin, and 9/4/25 by the Social Worker. All (3 of 3) documented a BA which listed only the patient’s one daughter. However, further record review found documentation within the Social Worker’s initial assessment on 9/4/25 which documented the following, “She (P-18) later moved to Bay City where she raised her two daughters (twins) who live in town and are very supportive.” The findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services during an interview on 10/21/25 at 11:44 AM. A quick audit review during the time of the interview above, noted that a vast majority of hospice patients had only one individual listed on the BA. Both noted this is an area that will be addressed to align with the agency’s policy referenced below.Agency Policy: “III.39 Bereavement Program” (undated) stated, “The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The program shall involve out-of-town family members as well, referring them to support resources in their geographical area if requested.” Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was determined P-3’s daughter (who is her primary caregiver) was listed as the only individual on the initial bereavement assessment. However, upon review of the social work evaluation dated 9/24/25, it was documented that, “Caregiver is mainly her daughter, but she does have her other children, and also grandchildren who help each other out.” [sic] The social work note also stated that in addition to her daughter, a son and grandson were also present during the assessment. The agency failed to identify and assess all individuals that may be affected by P-3’s death.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated by the social worker every 15 days for 1 (P-2) of 19 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, 4 of 11 interdisciplinary group (IDG) notes (dated 5/22/25, 6/19/25, 9/11/25, and 10/9/25) failed to include an update of the patient by a social worker. There was no evidence a social worker participated in the IDG meetings listed above to update the comprehensive assessment.A review of agency policy titled “III.16 IDG CASE CONFERENCE/UPDATE OF COMPREHENSIVE ASSESSMENT” (not dated) revealed, “All professional disciplines participating in the patient’s care, including contractual staff, should have input at this conference. For personnel participating in the patient’s care but unable to attend the conference, a telephone conference should be established. Documentation of the conference shall be the responsibility of the primary nurse or supervisor, or other professional as instructed by the supervisor. The documentation shall include a summary of progress, assessment of the needs for continuing care, medication effectiveness for pain management and relief, and patient status.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review, and interview, it was determined the hospice failed to develop an individualized plan of care (POC) that included safety precautions in 3 (P-1, P-12, and P-14) of 19 records reviewed, out of a total sample of 19 records reviewed; and failed to incorporate wound care interventions and treatment in 5 (P-1, P-2, P-4, P-5, and P-17) of 7 records reviewed with wound care, out of a total of 19 records reviewed, resulting in the potential for patient harm and unmet clinical needs. Findings include: Patient #17 (P-17) was admitted to hospice on 9/20/25, with a terminal diagnosis vascular dementia with agitation, diabetes-type 2, hypertension and repeated falls. On 10/16/25, a review of the referral for hospice from the rehabilitation and skilled nursing center where P-17 resides noted the following documentation (dated 9/12/25): “Sacral/bilateral buttocks continue with Stage 3 Pressure Ulcer, current measurements are 2.2 cm length x 5.5 cm width x 0.4 depth. 25% yellow slough, 50% pink granulation, small amount of serosanguinous drainage... resident needs reminders/cues and assistance with repositioning and offloading frequently. Continue with low air loss mattress, bilateral heel lift boots AAT (at all times).”Further review of the initial comprehensive assessment (ICA) performed by skilled nursing (SN) on 9/20/25 documented the following in the ICA: “Pt. (patient) current weight is 160 pounds down from 210 pounds in Jan. 2025. In June (2025) pt. was able to have mobility via wheelchair. Now in September pt. is bedbound, with an unstageable decubitus pressure injury.” The hospice’s EMR (electronic medical record) noted an individual order on 9/20/25 under “Wound Type” a pressure ulcer to the sacrum and to “remove prior dressing, cleanse wound with wound wash, pat dry with gauze. Apply Medi-Honey (wound care ointment), cover with clean dressing, change daily and prn (as needed) if soiling occurs.”However, review of the submitted POC (effective 9/24/25) failed to have any documentation directing SN to perform wound assessments, interventions or treatments concerning P-17’s pressure ulcer. Subsequently, additional review of the SN visit notes performed after 9/20/25 found 7 (9/23/25, 9/25/25, 9/27/25, 9/30/25, 10/1/25, 10/2/25, and 10/3/25) of 7 SN notes failed to acknowledge P-17’s wound in any manner. Additionally, the hospice POC failed to direct staff on coordinating wound care needs and preventative comfort measures (air mattress, bridging both heels) with the facility where P-17 resided. P-17 passed away on 10/3/25 and the hospice agency failed to provide documentation if P-17’s wound care needs were ever met. The findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services during an interview on 10/21/25 at 11:37 AM. Both noted this did not meet agency expectations or its policy referenced below.Agency Policy: “III.10 Provision of Care to Residents of a Facility” (undated) stated, “The Hospice will have written agreements that meet State and Federal regulations with a skilled nursing facility (SNF), nursing facility (NF), or inpatient care facility (ICF) to provide hospice care to residents. It is the hospice’s responsibility to provide services at the same level and to the same extent as those services would be provided if the resident were in his or her own home.” Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. The Plan of Care (POC) dated 11/1/24 identified diagnoses of breast cancer and hypertension. Upon review of the POC, it was noted that no oxygen precautions were documented for a patient receiving supplemental oxygen.Patient #14 (P-14): The Start of Care (SOC) was dated 9/22/25. The Plan of Care (POC) dated 9/22/25 identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus. Upon review of the POC, it was noted that no oxygen precautions were documented for a patient that smokes/vapes and is receiving supplemental oxygen. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings. Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the initial comprehensive assessment indicated P-1 had, “a dime sized ‘black’ area noted to coccyx, no odor or discharge noted.” The next skilled nursing note dated 9/18/24 also indicated P-1 had a “Wound to right ankle posterior.” [sic] Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Additionally, it was noted the initial comprehensive assessment dated 9/14/24 indicated P-1 was “strict npo” -meaning he was not allowed to eat or drink anything by mouth. Upon further review of the plan of care, it was determined the there were no safety precautions listed regrading P-1’s NPO status.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the initial comprehensive assessment indicated P-2 had, “Wound / Drain (dime size st 2 on r hip), SkinLesions/Wounds Current: [“Pressure Ulcer(s)/Injuries”], Skin and Ulcer/Injury.” [sic] Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Patient #4 (P-4) was admitted to this hospice agency on 8/25/25 with the terminal diagnosis of cerebrovascular disease and hypertension. During record review on 10/17/25, it was noted the initial comprehensive assessment indicated P-4 had “she has some healing skin tears to her left forearm along with bruises.” Additionally, a face-to-face note by the physician dated 8/25/26 indicated P-4 had a recent fall with a “laceration to the L UE” and a skilled nursing note dated 8/26/25 indicated P-4 had “stitches noted to left forearm.” A licensed practical note dated 9/3/25 noted, “Wound rewrapped with dry dressing to protect area.” Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted the initial comprehensive assessment indicated P-5 had a “diabetic foot wound” that measured 1x1x0.4 (no unit of measurement given). Additionally, a skilled nursing note dated 10/3/25 indicated P-5 “…has dressing on right chest wall. Will remove today to shower.” Upon review of the plan of care, it was determined there were no wound care orders or interventions listed.A review of agency policy titled “III.7 HOSPICE PLAN OF CARE” (not dated) revealed, “The plan of care shall include all hospice care and services necessary to meet the patient and family needs identified in the comprehensive assessment, as such needs relate to the terminal illness and related conditions. If needs are identified that are not related to the terminal illness and conditions, the IDG shall document that they are aware of the needs and note who is addressing them.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM”

“Based on record review and interview, the hospice agency failed to develop a patient specific plan of care that included specific interventions for pain and symptom management for 3 (P-9, P-10, P-19) of 3 records reviewed for appropriate pain and symptom management, from a total of 19 sampled records reviewed, resulting in the potential for unrelieved pain and poor symptom management. Findings include: Policy: III.7 Hospice Plan of Care, undated, stated, “The plan of treatment shall include but not limited to: Interventions to manage pain & symptoms.” Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The Plan of Care (POC) ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. During the record review on 10/16/25 at 1:35 p.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, that included alternative interventions to manage pain and symptomology during the end of life. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m.P-10 was admitted to hospice on 9/26/25 with a terminal diagnosis of Senile Degeneration of the Brain. The POC ordered SN, HHa and MSW services to be provided. On 10/17/25 at 10:00 a.m., during the clinical record review, it was noted that the POC was void of interventions to monitor, assess and treat pain, with alternative interventions to manage pain and symptomology during the end of life. Adm #1 reviewed and acknowledged these findings during an interview on 10/21/25 at 9:08 a.m.P-19 was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower right Lobe (Lung Cancer). The POC ordered SN, HHa and MSW services to be provided. During the record review on 10/21/25 at 10:40 a.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, and alternative interventions to manage pain and symptomology during the end of life. Adm #1 reviewed and acknowledged these findings during an interview on 10/21/25 at 1:32 p.m.”

“Based on record review and interview, it was determined that the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 8 of 19 records reviewed (P-11, P-12, P-13, P-14, P-15, P-16, P-17, P-18) out of a total sample of 19 records reviewed, which resulted in the potential for unmet patient needs. Findings include: Patient #15 (P-15) was admitted to hospice on 7/11/25 with terminal diagnoses that included chronic obstructive pulmonary disease and diabetes-type 2. On 10/15/25 at 3:50 PM, a review of the Plan of Care (POC) effective 7/11/25, it was noted 4 of 4 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, “Patient will maintain optimal cardiac function within constraints of disease process.” Patient #16 (P-16) was admitted to hospice on 9/16/25 with terminal diagnoses of cerebral infarction (brain stroke). On 10/16/25 at 8:45 AM, a review of the POC effective 7/11/25, it was noted 8 of 8 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, “Patient will maintain optimal cardiac function within constraints of disease process.” Patient #17 (P-17) was admitted to hospice on 9/20/25 with a terminal diagnosis vascular dementia with agitation. On 10/16/25 at 3:45 PM, a review of the POC effective 9/20/25, it was noted 2 of 2 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Call advisacare 24/7 if needs or concerns aris.” (sic) Another example documented, “Patient/Caregiver will understand pain scale, how to manage pain and report changes to Hospice. Patient’s pain level will be at their acceptable level as evidence by nonverbal cues.” Patient #18 (P-18) was admitted to hospice on 8/30/25 with terminal diagnoses of hypertensive heart disease with heart failure. On 10/17/25 at 10:10 AM, a review of the POC effective 7/11/25, it was noted 9 of 9 listed goals were not written in measurable terms to ascertain progress made (or lack of) towards the intended goal. Examples include: “Patient/Caregiver will verbalize understanding of oxygen use related to uses and safety.” Another example documented, “Patient will maintain optimal cardiac function within constraints of disease process.” The Administrator and Director of Clinical Services reviewed and acknowledged the above findings during an interview on 10/21/25 at 11:37 AM. Patient #11 (P-11): The Start of Care (SOC) was dated 2/28/25. The Plan of Care (POC) dated 2/28/25 identified a diagnosis of Post Polio Syndrome. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient/caregiver will understand pain scale, how to manage pain and report changes to hospice.” Another goal stated, “Patient will maintain optimal cardiac function.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. The Plan of Care (POC) dated 11/1/24 identified diagnoses of breast cancer and hypertension. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient/Caregiver able [sic] to verbalize measures to promote comfort related to respiratory system in the terminal patient as evidenced by having decrease in SOB.” Another stated, “Patient verbalize [sic] understanding of pain medication administration and side effects, patient’s pain will be at a tolerable level, patient will exhibit abilities to implement alternate pain/symptom management with nonpharmacological interventions.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #13 (P-13): The Start of Care (SOC) was dated 8/22/25. The Plan of Care (POC) dated 8/22/25 identified a diagnosis of Parkinsonism. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient will receive personal care and hygiene including activities of daily living to his optimallevel.” Another goal stated, “Patient will demonstrate O2 sat to his optimal level as established by physician.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.Patient #14 (P-14): The Start of Care (SOC) was dated 9/22/25. The Plan of Care (POC) dated 9/22/25 identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus. Upon review of the POC, it was noted that the goals were not objectively measurable. For example, one goal stated, “Close to Home facility staff willverbalize/demonstrate adequate knowledge of endocrine status as evidenced by verbal teach back.” Another goal stated, “Close to home facility staff will understand thepain scale, how to manage pain and report changes to Hospice. Patient’s pain level will be at their acceptable level as evidence [sic] by patient report.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings.”

“Based on record review and interview, it was determined that the hospice agency failed to collect any data which could be measured, analyzed, and tracked to evaluate the hospice’s processes of care for all of 2024, and failed to acknowledge and track any adverse patient events as required since 2024, resulting in the potential for unrecognized negative patient outcomes for all 139 patients currently receiving hospice services. Findings include: On 10/16/25, a request was made to review the hospice agency’s QAPI program. Review of the QAPI (Quality Assurance Performance Improvement) binder and Governing Body meeting minutes were reviewed since 2023 and found no evidence of data collection for 2024. In addition, no evidence was found that the hospice agency acknowledged and tracked adverse patient events from 2024 through 10/16/25 as required.These findings were reviewed with and confirmed by the agency’s Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 11:55 AM. Both further acknowledged this did not meet agency’s QAPI expectations or its policy referenced below.Agency Policy: “VI.3 Evaluation of Services and Scope of Care” (undated) stated, “The Hospice will identify important processes and functions that affect health care outcomes… The focus will be on high-risk, high volume and/or problem-prone activities, choosing at least one process to be analyzed per year to review, based on results of data collection…””

“Based on record review and interview, it was determined that the hospice agency failed to collect data which could be utilized to monitor the safety, effectiveness and quality of patient care services for all of 2024, resulting in the potential for unrecognized negative patient outcomes for all 139 patients currently receiving hospice services. Findings include: On 10/16/25, a request was made to review the hospice agency’s QAPI (Quality Assurance Performance Improvement) program. Review of the QAPI binder found no evidence of data collection for 2024 as required. This finding was reviewed with and confirmed by the agency’s Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 11:58 AM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.3 Evaluation of Services and Scope of Care” (undated) stated, “The Hospice will identify important processes and functions that affect health care outcomes… The focus will be on high-risk, high volume and/or problem-prone activities, choosing at least one process to be analyzed per year to review, based on results of data collection…””

“Based on record review and interview, the hospice agency failed to ensure its Governing Body (GB) approved the frequency and detail of the data collection for the QAPI (Quality Assurance Performance Improvement) program, which had the potential to negatively affect all 385 patients admitted during the past 12 months. Findings included: On 10/16/25, a request was made to review the hospice agency’s QAPI (Quality Assurance Performance Improvement) program. Review of the QAPI binder for the last 3 years found no evidence that the frequency and detail of the hospice’s data collection was presented to or approved by agency’s GB for the years 2023 and 2024. This finding was reviewed with and confirmed by the agency’s Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 12:01 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.2 QAPI Monitoring and Responsibility” (undated) stated, “Responsibility for the QAPI program ultimately rests with the Governing Body. At least annually, receives reports on all QAPI activities, including the assessment of the effectiveness of QAPI activities in identifying the quality of care, opportunities to improve patient care …” No specific language was found in 3 of 3 submitted QAPI policy and procedures concerning the GB’s approval of the frequency and detail of data collection for the QAPI program.”

“Based on record review and interview, the Hospice’s Governing Body (GB) failed to perform an evaluation of the implementation and maintenance of its QAPI (Quality Assurance and Performance Improvement) program annually for the period of January 2023 through October 16th, 2025. Findings include: On 10/16/25, a request was made to review the hospice agency’s QAPI program and GB meeting minutes since 2023. Subsequent review of QAPI program documentation and GB meeting minutes found no evidence that the agency’s GB had evaluated the implementation and maintenance of its QAPI activities since January 2023. The findings above were reviewed with and confirmed by the agency’s Administrator (Adm#1) and Director of Clinical Services (DCS #1) during an interview on 10/21/25 at 12:06 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “VI.2 QAPI Monitoring and Responsibility” (undated) stated, “Responsibility for the QAPI program ultimately rests with the Governing Body. At least annually, receives reports on all QAPI activities, including the assessment of the effectiveness of QAPI activities in identifying the quality of care, opportunities to improve patient care …””

“Based on document review and interview, the hospice failed to have an infection control program that is an integral part of their Quality Assessment and Improvement Program which includes surveillance, identification, prevention, control, and investigation of infectious diseases, resulting in the potential for poor palliative outcomes and services for the 139 current hospice patients. Findings include: On 10/16/25, review of the hospice’s QAPI (Quality Assurance and Performance Improvement) program concerning infection control revealed it was void of any information except for the following: An undated document of an influenza “Outbreak at Park Place” and an undated “Covid outbreak at Lasher” which had no data or other information. An infection control log regarding 5 staff members symptom of infection (date of year is unknown) were found with no follow-up or other information found. Otherwise, no documented evidence was found that indicated the agency had conducted any infection control activities/monitoring over the last 3 years. The above findings were reviewed with and confirmed by the agency’s Administrator and Director of Clinical Services during an interview on 10/21/25 at 12:10 PM. Both further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “X.3 Infection Control Program (undated) stated, “The goal of the surveillance, prevention and control of the infection control program is to improve patient health outcomes through identification and risk reduction… and to reduce the risk of transmission of infectious agents among patient’s staff and other care givers… Educating staff in the prevention and control of infections initially and at least annually… Observing and evaluating all staff at least annually in an effort to identify sources or causative factors of infection and track patterns and trends of infection.””

“Based on record review and interview, the hospice agency failed to develop a method that identified infectious diseases with responding actions that would have an anticipated outcome in improvement of disease prevention and infection control, resulting in the potential to negatively affect care for all 139 patients currently receiving hospice services. Findings included: On 10/16/25, review of the hospice’s QAPI (Quality Assurance and Performance Improvement) program concerning infection control since 2023, noted a failure of any methodology that identified infectious and communicable diseases. In addition, no actions or interventions were found that were geared towards intended improvement/containment in disease prevention and infection control during the last 3 years. Further, no documentation was evidenced concerning when and to what level an infectious issue would warrant the activation of further infection control measures as stipulated by the agency’s policy referenced below. The above findings were reviewed with and confirmed by the agency’s Administrator and Director of Clinical Services during an interview on 10/21/25 at 12:13 PM. Both acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “X.3 Infection Control Program (undated) stated, “The best course of action to prevent the spread of infection and interventions will be applied to protect staff and patients. The risk for and trends of infections are used to study ways to improve both prevention and control activities and to reduce the risk of occurrence of infections to the lowest possible levels.””

“Based on record review and interview, it was determined the hospice agency failed to ensure all hospice employees received education on infection control outside of orientation of new hires since 2023, resulting in the potential for the development and spread of infectious diseases to all 139 patients currently serviced by this agency. Findings include: On 10/16/25, review of the hospice’s QAPI (Quality Assurance and Performance Improvement) program concerning infection control education to staff and patients since 2023 was performed. No evidence (outside the agency’s orientation of new hires) was found regarding the provision of education that was specific towards infection prevention and control for the last 3 years. These findings were acknowledged by the agency’s Administrator (Adm #1) during an interview conducted on 10/17/25 at 11:40 AM. Adm #1 stated that education was performed to staff but failed to retain any of the documentation of the content or in-services conducted in 2025. Further, agency efforts to retrieve documentation for 2023 and 2024 found no evidence of infection control education being performed to staff or patients. Adm #1 further acknowledged on 10/21/25 at 12:15 this did not meet agency expectations or its policy referenced below. Agency Policy: “X.3 Infection Control Program (undated) stated, “Educating staff in the prevention and control of infections initially and at least annually thereafter, or as needed per change in policies. Patients, family members and/ or caregivers will receive education regarding basic infection control measures on admission and as needed during the delivery of services.””

“Based on record review and interview, the agency failed to ensure the Registered Nurse provided oversight and supervision of its Licensed Practical Nurses in 4 (P-2, P-3, P-4, and P-9) of 10 records of patients who received care from Licensed Practical Nurses, from a total of 19 sampled records reviewed; and failed to ensure nursing needs of the patient were identified and met in 1 (P-2) of 19 records reviewed, resulting in the potential for substandard care and unmet patient care needs. Findings include: Policy: II.5 Supervision and Evaluation of Staff, undated, stated, “Each case receiving care provided by an LPN or therapy/social work assistant will be assessed by the appropriate registered nurse, therapist or social worker no less often than monthly.”Patient #9 (P-9) was admitted to hospice on 6/12/25 with diagnoses that include Chronic Obstructive Pulmonary Disease and Vascular Dementia. The Plan of Care ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. During a review of the clinical record on 10/16/25 at 1:35 p.m., it was noted that the Licensed Practical Nurse (LPN) provided care of P-9 on the following dates: 8/15/25, 8/22/25, 8/29/25, 9/5/25, 9/12/25, 9/19/25, 9/26/25 and10/3/25. Upon further review, there was no documented evidence that the Registered Nurse provided oversight and supervision of the LPN, no less often than monthly, as per this requirement and in accordance with the agency’s policy. The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 8:55 a.m. Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted skilled nursing notes dated 3/28/25, 4/9/25, and 6/30/25 all documented new or changing wounds noted on P-2’s skin. However, it was also noted there were no objective measurements or assessments made of these wounds. The note dated 4/9/25 indicated wound care was provided by the skilled nurse. Upon review of the orders and plan of care, it was determined there were no orders written for wound care for who would take care of the wounds going forward and how.Additionally, during a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, it was noted P-2 had square adhesive bandages on her right hip, right knee, and left heel. A staff member from the skilled nursing facility (SNF) was present to assist in positioning P-2 stated the bandages were “for protection”, however, upon removing them, it was noted there were open areas on each location. During the visit, RN #3 was asked what the procedure was for new wounds. RN #3 stated she “sucks at wounds” and wasn’t sure what to do. RN #3 also acknowledged she hadn’t made any wound measurements “from the beginning” and that a wound care nurse “takes care of it.” RN #3 stated she can contact the SNF wound care nurse to look at them, but the night shift nurses often do the dressing changes. RN #3 was also asked how she would know how to care for the wounds if she had to provide the wound care (as done during the joint home visit). RN #3 stated there should be wound care orders to follow, however, she was unable to provide evidence of wound care orders in P-2’s record for any current or previous wounds.The agency failed to provide care to ensure ongoing nursing needs were met as identified in the patient assessments.The records for P-2, Patient #3 (P-3), and Patient #4 (P-4) were reviewed from 10/15/25 through 10/21/25. During review of the records to assess licenses practical nurse (LPN) supervision, it was noted skilled nursing notes included a section under “Supervisory Visit” titled “LPN/LVN Information” that was filled out at least every 30 days. However, the only information under this section was the name of the LPN being supervised and the word “indirect” under “Type of Supervision” for all notes. There was no other documentation regarding how the LPN was supervised, therefore, there was no evidence of LPN supervision.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, it was determined the hospice agency failed to provide ongoing psychosocial assessments to identify issues that may impede or facilitate care in 1 (P-2) of 19 records reviewed; and failed to provide the core service of medical social worker (MSW) as ordered in the Plan of Care (POC) to meet the needs of the patient and family in 2 (P-5 and P-17) of 19 total sampled records reviewed, resulting in the potential for unaddressed social care needs and lack of community resources. Findings include: P-17: The hospice start of care date (SOC) was 9/20/25, with diagnoses that included vascular dementia with agitation, diabetes-type 2, hypertension and repeated falls. On 10/17/25, review of P-17’s plan of care (POC), effective 9/20/25, noted an order to provide Master of Social Work (MSW) services at a frequency of once monthly with 2 as needed visits every 30 days. Further record review revealed that no MSW services had been provided as of 10/17/25 (28 days after SOC). No evidence was found in the medical record of the patient/family refusing services or an order to discontinue MSW services. No evidence was found in the medical record that the physician was notified of this.During an interview on 10/21/25 at 12:35 PM, the findings above were reviewed and acknowledged by the Administrator and Director of Clinical Services. Both further acknowledged this did not meet agency expectations or its policy referenced below.Agency Policy: “III.8 Patient Assessment & Reassessment” (undated) stated, “A comprehensive assessment will be conducted within 5 days of the patient’s election of hospice services and shall include all disciplines needed. The social worker shall perform a thorough psychosocial assessment of the patient at the time of admission and shall reassess the patient throughout the course of care.” Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the electronic medical record system had an alert that indicated no information should be shared with who was initially listed as P-2’s significant other. Additionally, the alert indicated that P-2’s daughter was now her guardian.During a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, RN #3 was asked about the situation. RN #3 stated P-2 lived with her significant other when she was admitted to hospice. RN #3 stated P-2 and her significant other had been evicted from their apartment and had issues finding somewhere for her live. RN #3 stated P-2 was hospitalized at one point and eventually moved the skilled nursing facility (SNF) where she currently resided. RN #3 stated that sometime after P-2 moved to the facility, there were concerns P-2’s significant other was abusing her and was stealing money. RN #3 also indicated adult protective services was called. Eventually, it was decided P-2’s significant other could no longer come to the facility and P-2’s daughter would be her guardian.Upon return to the agency to further review the record, it was noted the social worker performed the initial assessment on 4/1/25 with P-2’s significant other and a family friend because the patient was sleeping. It was also noted P-2 requested assistance with getting a wheelchair ramp. There was no documentation this was ever followed up on. The next social work notes on 5/21/25 and 5/28/25 indicated phone calls were made, but no physical visit. On 5/28/25, P-2’s significant other called back and reported they had been evicted, P-2 was in the hospital, and the social worker at the hospital was working on a facility for P-2 to move to. The next social work note was not dated until 6/27/25 and did not mention the move the SNF. The following social work notes dated 7/3/25, 7/26/25, 7/30/25, 8/7/25, 8/14/25, 8/23/25, 8/29/25, 9/6/25, 9/9/25, 9/19/25, 9/27/25, 10/4/25, and 10/7/25 were also reviewed. Upon review of the visit notes, it was determined there was no mention of P-2’s move to the SNF, of P-2’s significant other no longer being allowed to visit her, or of P-2’s daughter now being her guardian. Additionally, there was no signed documentation of guardianship to confirm this.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “Ongoing counseling will be provided to address areas in which the patient or family unit of care require assistance.”A review of agency policy titled “III.1 TERMINALLY ILL PATIENTS/LEVELS OF CARE & SERVICES AVAILABLE” (not dated) revealed under the “Medical Social Workers” section that the social worker, “Assesses and reassesses social and emotional factors in order to help the patient and family to cope with problems in daily living and to help them follow medical recommendations to maximize the patient’s health condition.”The agency failed to provide ongoing psychosocial assessments to identify issues that may impede or facilitate patient care, including a significant move and major changes in family dynamics.Patient #5 (P-5) was admitted to this hospice agency on 10/1/25 with the diagnosis of renal failure. During record review on 10/17/25, it was noted the plan of care ordered social work for 1 time per month with 3 PRN (as needed visits). Additionally, skilled nursing notes dated 10/6/25, 10/8/25, and 10/15/25 indicated coordination of care was done between the skilled nurse and social worker. Upon further review of the record, it was determined social work never saw this patient. There was no documentation from the social worker regarding missed visits or the patient declining care. There was also no documentation of the physician being notified.The agency failed to provide social work services as ordered.A review of agency policy titled “III.8 PATIENT ASSESSMENT & REASSESSMENT” (not dated) revealed, “The social worker shall perform a thorough psychosocial assessment on the patient at the time of admission and shall reassess the patient throughout the course of care.”The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the hospice failed to make bereavement services available to all of the bereaved family members who would be affected by the patient’s death, and failed to complete a bereavement plan of care that reflected the needs of each bereaved family member, the kind of bereavement services to be offered and the frequency of service delivery in 1 (BRV #3) of 3 bereavement records reviewed, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: Bereavement Record #3 (BRV #3): This patient was admitted to hospice on 2/11/25 with a terminal diagnosis of Parkinson’s Disease. A review of the clinical record on 10/15/25 at 3:35 p.m., revealed the patient expired on 3/11/25. The Initial Bereavement Assessment dated 2/11/25, conducted by the Registered Nurse, revealed that BRV #3 was survived by his wife, “daughters and families.” The Bereavement Care Plan dated 3/31/25 only identified the patient’s wife. The Bereavement Care Plan made no mention of the patient’s daughters and families as identified in the initial assessment. The hospice failed to ensure a Bereavement Plan of Care was developed for BRV #3’s daughters and families, that reflected and addressed their individualized bereavement needs.The Administrator reviewed and acknowledged the above findings during an interview on 0/21/25 at 8:40 a.m.”

“Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient for 4 (P-1, P-2, P-9, and P-19) of 15 records with hospice aide services ordered, and failed to ensure safety precautions were included on the hospice aide plan of care for 3(P-1, P-12, and P-14) of 15 records with hospice aide services provided, from a total of 19 records reviewed resulting in the potential for unmet patient care needs and patient injury. Findings include: Patient #12 (P-12): The Start of Care (SOC) was dated 11/1/24. Upon review of the hospice aide Plan of Care (POC) dated 11/1/24, it was noted that no oxygen precautions were documented for a patient receiving supplemental oxygen.Patient #14 (P-14): The SOC was dated 9/22/25. Upon review of the hospice aide POC dated 9/22/25, it was noted that no oxygen precautions were documented for a patient that smokes/vapes and is receiving supplemental oxygen. During an interview on October 21, 2025, at 1:50 p.m., the Administrator (ADM #1), the Director of Clinical Services (DCS #1), and the Office Manager (OM #1) acknowledged the above findings. Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25. Upon review of the aide care plan, last reviewed on 6/16/25, it was noted that the Registered Nurse (RN) checked off every task listed on the plan such as, TPR and BP (temperature, pulse, respiration and blood pressure), bathroom assistance, patient independent, urinary catheter, draw sheet, complete bed bath every visit, partial bed bath, shower and shave. The aide care plan indicated that these tasks were to be completed every visit. On 10/17/25 at 9:10 a.m., the Administrator (Adm #1) reviewed the above documentation and reported, “The nurse checked off on every one of the tasks. There is an issue.” Additionally, Adm #1 reported that none of the hospice aides are allowed to check patient’s vital signs as ordered by the nurse in the aide care plan. The Registered Nurse failed to provide clear written patient care instructions and guidance for the hospice aide. Adm #1 reviewed and acknowledged the above findings at the time of discovery during the above review. Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower right Lobe. During the record review on 10/21/25 at 10:40 a.m., it was noted that Hospice Aide services was ordered at a frequency of 2x/wk. with 3 prn (as needed) visits. Further review revealed that the patient was admitted with an unstageable pressure sore on his buttock that measured 3 by 5 (unit of measurement used unknown) to be covered with absorbent foam dressing. Upon review of the aide care plan, there was no instruction or guidance for the aide on measures to take if the dressing should become dislodged or soiled. The Administrator reviewed and acknowledged these findings during an interview on 10/21/25 at 10:40 a.m. No response was offered. Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted a skilled nursing note dated 9/18/24 indicated that P-2 had a “small wound to coccyx, wound to wound to right ankle posterior” [sic] and “Some skin issues small wound to coccyx treated with triad. Wound to right ankle, outer cleaned with wound cleaner and covered with boarder foam.” [sic] The start of care assessment dated 9/14/24 (as well as subsequent skilled nursing notes) also indicated P-1 had a PEG (percutaneous endoscopic gastrostomy) tube (a thin tube inserted through the stomach through a small incision in the abdominal wall used to deliver nutrition and medication to patients who cannot eat or drink orally). Additionally, it was also noted the patient was “strict NPO” – meaning “nothing by mouth.” It was documented P-1 was bed bound and unable to get out of bed without assistance of a mechanical lift. P-1 was receiving hospice aide services 2 times per week.During review of the aide care plan, it was determined there were no written instructions for the aide regarding care for the uncovered coccyx wound during/following bathing or what to do if the dressing on the right ankle was soiled or dislodged.Upon further review of the aide care plan, it was also noted it included interventions to “Assist with Feeding” and to “Encourage Fluids Offer Hydration during every visit, and have next to Patient within reach (Ensure, Juice, Bottled Water).” [sic] However, the aide care plan failed to include safety precautions regarding P-1 not being allowed to eat or drink.Additionally, the aide care plan indicated P-1 could ambulate “with 1 person assist with rolling walker” and transfer with “1 person assist with rolling walker.”The information in the aide care plan is conflicting, inaccurate, and potentially unsafe for the aide to follow.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:00 AM, it was observed that P-2 had severe contractures (permanent tightening of muscles that causes joints to be stiff) of her knees, hips, and elbows. It was observed P-2 was only able to lay with her knees, hips, and elbows fully flexed (bent) and was unable to straighten any of her joints. Additionally, any movement caused P-2 extreme pain and crying. During the joint visit, it was also observed 2 people were needed to assist in changing P-2’s brief.During review of the record for P-2 on 10/16/25, it was noted the aide care plan failed to include information regarding P-2’s contracted status and the need for assistance during care.The aide care plan failed to provide specific guidance for safe care of this patient.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the agency failed to ensure the hospice aide provided care and services as ordered in the plan of care, and in accordance with the specified visit frequency in 3 (P-2, P-3, and P-9) of 15 records of patients ordered to receive hospice aide services, from a total of 19 records reviewed, resulting in patients not receiving services in accordance with their identified needs. Findings include: Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25.During the review, it was noted that the Hospice Aide (HHa #1) had a total of 10 missed visits with associated missed visit notes. Upon further review, HHa #1 made no visits to the patient’s home on the following dates:No aide visits made during the first week of service.Only 1 visit made the week of 6/15/25.Missed visits the week of 6/22/25 and 6/29/25.No aide visits made during the weeks of 6/29/25 or 7/6/25.Only 1 aide visit made the week of 7/20/25.No aide visits made during the weeks of 7/27/25, 8/3/25 or 8/10/25.Two documented missed visits the week of 8/17/25.No aide visits made the week of 8/24/25.No aide visits made the week of 8/31/25 (1 of the 2 scheduled visits was a documented missed visit).Only 1 visit made the week of 9/7/25.Only 1 aide visit made the week of 9/14/25. (1 of the 2 scheduled visits was a documented missed visit).No aide visits made the week of 9/21/25.Only 1 of the 2 scheduled visits was made the week of 9/28/25. (one was a documented missed visit).Only 1 of the 2 scheduled visits was made the week of 10/5/25 (one was a documented missed visit).Only 1 visit made the week of 10/12/25.There was no documented rationale as to why HHa #1 failed to follow the ordered visit frequency. Further, there was no documentation of patient refusal or that the nurse or Physician had been notified accordingly. Additionally, upon review of the aide visit notes dated 6/17/25 to 10/14/25, the hospice aide placed a check mark in the box titled “acknowledged,” next to each assigned task, however, the box titled “completed” was left blank. There was no way to ascertain whether all assigned tasks had been completed. This pattern of documentation was the same in all 9 visit notes documented by the aide. The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 8:55 a.m. Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted hospice aide services were ordered 2 times per week. Upon further review of the record, it was determined P-2 received 1 hospice aide visit the week of 4/6/25 due to P-2’s sister performing bathing for P-2 another day. It was also noted P-2 received no hospice aide visits the week of 4/13/25 due to P-2’s significant other canceling them. There was no documentation of attempts to reschedule the canceled visits to meet the ordered frequency. Additionally, another missed visit due to a cancelation was documented the week of 4/21/25 and it was noted P-2 did not receive any other hospice aide visits that week. After 4/21/25, it was noted the next documentation from a hospice aide was for a visit completed on 6/17/25 – 57 days since the last aide documentation (missed visit) and 71 days after the last aide visit was made. There were no orders to cancel hospice aide services and no documentation as to why there were no aide visits between the last cancellation note on 4/21/25 and the next visit note on 6/17/25.Upon further review of the aide care plan, it was noted there was an intervention to “Document Last BM” (bowel movement) every visit. During review of the hospice aide visits dated 3/31/25, 4/2/25, and 4/7/25, it was determined the date of the last bowel movement was not documented.Patient #3 (P-3) was admitted to this hospice on 9/20/25 with the terminal diagnosis of cerebrovascular disease. During record review on 10/17/25, it was noted hospice aide services were ordered 2 times per week. Upon further review of the record, it was determined P-3 only received 1 hospice visit during the weeks of 9/21/25 and 9/28/25. There was no documentation of missed visits or orders to change the hospice aide frequency.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the hospice failed to ensure its hospice aides reported changes in patient’s care and documented tasks upon completion for 3 (P-1, P-2, and P-9) of 15 patients who received hospice aide services, from a total of 19 records reviewed, resulting in patients not receiving care based on their identified needs and lack of continuity of care. Findings include: Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The clinical record was reviewed on 10/16/25 at 1:35 p.m. and revealed that Hospice Aide (HHa) services were ordered at a frequency of 2x/wk. effective 6/12/25. During the review, it was noted that the patient resided in an Assisted Living Facility. An aide missed visit note dated Tuesday 6/24/25 documented, “Pt (patient) refused care for the day. Stated facility staff said told her (patient) she has showers on Wednesday and Sunday only.” [sic] There was no documented evidence that the aide reported this information to the nurse in order to adjust the visit dates and update the aide care plan. Further, the hospice aide made all but one future visits on Tuesdays and Thursdays. These are the days the shower would not have been available to the patient, per facility staff. Additionally, upon review of the aide visit notes dated 6/17/25 to 10/14/25, the hospice aide placed a check mark in the box titled “acknowledged,” next to each assigned task, however, the box titled “completed” was left blank. There was no way to ascertain whether all assigned tasks had been completed. This pattern of documentation was the same in all 9 visit notes documented by the aide. The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 8:55 a.m. Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was noted the aide visits included a check box for each task with the words “acknowledged” and “completed.” During review of the 17 aide visit notes dated between 9/20/24 and 11/12/24, it was determined “acknowledged” was checked for all listed tasks, however, the box next to “completed” was left blank for several tasks during each visit. There was no indication of why a task was not completed or that the nurse was notified the care had not been completed as ordered.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted the aide visits included a check box for each task with the words “acknowledged” and “completed.” During review of the 3 aide visits dated 3/31/25, 4/2/25, and 4/7/25, it was determined “acknowledged” was checked for all listed tasks, however, the box next to “completed” was left blank for all tasks during these visits. There was no indication of why a task was not completed or that the nurse was notified the care had not been completed as ordered.During an interview with the administrator (Adm #1) on 10/16/25 at 4:03 PM, Adm #1 was asked what it meant if the box next to “completed” was not marked. Adm #1 stated if “completed” wasn’t marked, the task was not completed, and it should be documented as to why and who was contacted about it.The administrator (Adm #1) again reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM. The director of clinical services (DCS #1) was also present during the interview and acknowledged the findings.”

“Based on record review and interview, the Hospice failed to ensure the Registered Nurse made on-site visits to the patient’s home no less than every 14 days to assess the adequacy of aide services for 4 (P-2, P-3, P-4, and P-9) of 15 records in which Hospice Aide services were provided, from a total of 19 records reviewed, resulting in the potential for the rendering of unauthorized substandard care and the potential for unmet patient care needs. Findings include: Policy: II.5 Supervision and Evaluation of Staff, undated, stated, “A registered nurse will make a supervisory visit to all patients receiving hospice aide services at least every 2 weeks. The visits will be made either when the aide is present to observe the aide in the performance of their duties or when the aide is absent to determine the relationship of the aide and the patient.” Patient #9 (P-9) was admitted to hospice on 6/12/25 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease and Vascular Dementia. The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide, Spiritual Care and medical Social Work services to be provided. During the clinical record review on 10/16/25 at 1:35 p.m., it was noted that the Hospice Aide made a total of 9 visits between 6/17/25 to 10/14/25. On 10/17/25 at 11:38 a.m., the Administrator (Adm #1) was asked for assistance in locating the Aide supervisory visits within the Electronic Medical Record (EMR) system. Upon retrieval and review, it was noted that none of the supervisory visits had been completed. The section of the Nurse visit notes titled “Supervision” merely documented, “indirect.” There was no other documentation related to supervision of the Hospice Aide. Adm #1 reported, “The nurses are probably not checking all the appropriate boxes and that’s why it’s not showing up in the supervisory notes.” There was no documented evidence that the Registered Nurse made supervisory visits at least every 2 weeks as per this requirement, and in accordance with the agency’s policy. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery during the above review. The records for Patient #2 (P-2), Patient #3 (P-3), and Patient #4 (P-4) were reviewed from 10/15/25 through 10/21/25. During review of the records to assess hospice aide supervision, it was noted skilled nursing notes included a section under “Supervisory Visit” titled “Hospice Aide Care” that was filled out at least every 14 days. However, the only information under this section was the name of the hospice aide being supervised and the word “indirect” under “Type of Supervision” for all notes except 1 for P-4. There was no other documentation regarding how the aide was supervised.During an interview with the administrator (Adm #1) on 10/17/25 at 11:37 AM, Adm #1 was asked to provide documentation of how the aides were supervised. When shown the above records with the missing information, Adm #1 stated he was made aware of the additional boxed the nurses should be checking about 2 weeks ago and was working on making those mandatory to fill out.Adm #1 acknowledged the findings at the time of interview.”

“Based on record review and interview, the agency failed to provide evidence of volunteer orientation for 1 (Vol #1) of 1 active volunteers, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: During an interview with the volunteer coordinator (VC #1) on 10/15/25 at 1:35 PM, VC #1 was asked to provide evidence of volunteer orientation and training. VC #1 stated the agency currently has 1 active volunteer (Vol #1) who has completed all the required training, however, VC #1 stated he started before she was the volunteer coordinator and was unable to provide evidence of his orientation. VC #1 stated she has 7 volunteers in the process of training, and she has a system to keep track of orientation going forward.A review of agency policy titled “IV.10 ORIENTATION FOR HOSPICE STAFF & VOLUNTEERS” (not dated) revealed, “All Hospice volunteers shall receive orientation and training prior to providing patient, family, and caregiver care…”.VC #1 acknowledged the findings at the time of interview.”

“Based on record review and interview, the agency failed to ensure volunteers provided a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff. Findings include: During an interview with the volunteer coordinator (VC #1) on 10/15/25 at 1:35 PM, VC #1 was asked to provide documentation of volunteer hours. VC #1 provided information from a Quality Assurance Performance Improvement (QAPI) meeting dated 7/29/25. According to the information in the meeting minutes, volunteers only provided 16.75 hours out of a total of 25,672 hours for a total of 0.00065%. VC #1 stated she started her position as the volunteer coordinator recently and has already taken steps to improve this number.VC #1 acknowledged the findings at the time of interview.”

“Based on record review and interview, the agency failed to ensure clinical record entries were clear and complete in 1 (P-2) of 19 records reviewed, resulting in the potential for an inaccurate and incomplete medical record. Findings include: Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/16/25, it was noted social work notes dated 8/23/25, 8/29/25, and 9/6/25 all stated under “General Visit Note Information”:“MSW MET WITH PT IN HER ROOM. PT IS A/OX4. PT REC’D LAYING IN HER HOSPITAL BED. PT PAIN IS 10/10 ON AN A.D SCALE. . PT WAS DRESSED IN APPEARANCE. PT APPETITE HAS DECREASED AND DIFFICULTY SLEEPING DUE TO PAIN LEVEL. MSW PROVIDED SUPPORTIVE PRESENCE, ACTIVE LISTENING, ENCOURAGEMENT, AND CARE AND TOUCH.” [sic]Additionally, it was noted social work notes dated 9/9/25, 9/19/25, 9/27/25, 10/4/25, and 10/7/25 all stated under “General Visit Note Information”:“MSW MET WITH PT IN HER ROOM. PT REC;D LAYING IN HER HOSPITAL BED . PT DRESSED IN APPEARANCE. PT IS VERBAL AND A FALL-RISK. PT IS DEPRESSED. PAIN LEVEL ON AN A.D SCALE IS 10/10. PT APPETITE IS FINE SLEEPING HAS INCREASED. MSW PROVIDED CARE AND TOUCH, ENCOURAGEMENT, AND ACTIVE LISTENING. MSW COLLABORATED WITH RN CONCERNING HER CARE.” [sic]The information was copied and pasted word for word from previous notes, therefore, cannot be an accurate assessment of treatment or response to treatment.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on interview and record review, the Hospice failed to identify the care and services that were needed and identify each provider’s responsibility for performing the needed functions that had been agreed upon and included in the hospice plan of care in 3 (P-1, P-2, and P-19) of 4 records of patients who resided in a Skilled Nursing Facility, from a total of 19 sampled records reviewed, resulting in the potential for needed care and services to be overlooked and unmet patient care needs. Findings include: Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant Neoplasm of Lower Right Lobe (Lung Cancer). The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide and Medical Social Work services to be provided. During the clinical record review on 10/21/25 at 10:40 a.m., it was noted that P-19 resided in a Skilled Nursing Facility (SNF).The POC stated, “Need for Facility Staff Care Coordination.” There was no indication of which services would be provided by the Hospice or the SNF. The Hospice agency failed to establish clear delineation of duties. On 10/17/25 at 1:32 p.m., the Administrator reviewed and acknowledged the above findings and responded, “Theres just a generic plan of care. It doesn’t specify each role.” Patient #1 (P-1) was admitted to this hospice agency on 9/14/24 with the terminal diagnosis of metabolic encephalopathy. During record review on 10/15/25, it was determined that P-1 lived in a skilled nursing facility (SNF). Upon further review of the record, it was determined the plan of care failed to indicate which interventions and services would be provided by the hospice and which would be provided by the SNF.Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. During record review on 10/15/25, it was determined that P-2 lived in a SNF. Upon further review of the record, it was determined the plan of care failed to indicate which interventions and services would be provided by the hospice and which would be provided by the SNF.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the Hospice failed to ensure the plan of care reflected the collaborative participation of the Hospice, Skilled Nursing Facility and the patient/family in 1 (P-19) of 2 records reviewed in which the patients resided in a skilled nursing facility, from a total of 19 sampled records reviewed, resulting in the potential for ineffective coordination of care and unmet care needs. Findings include: Patient #19 (P-19) was admitted to hospice on 10/8/25 with a terminal diagnosis of Malignant neoplasm of the Right Lower Lobe/Lung Cancer. The Plan of Care (POC) ordered Skilled Nursing, Hospice Aide and Medical Social Work services to be provided. The patient resided in a Skilled Nursing Facility (SNF).During a review of the Hospice POC on 10/21/25 at 10:40 a.m., it was noted that participation by the SNF staff, patient and family was not reflected in the problems, interventions and documentation of outcomes. The Administrator reviewed and acknowledged the above findings during an interview on 10/21/25 at 1:32 p.m. No response was offered.”

“Based on observation, record review, and interview, the agency failed to provide the skilled nursing facility (SNF) with the most recent hospice plan of care for 1 (P-2) of 1 patients with home visits that resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes due to a lack of coordination. Findings include: Patient #2 (P-2) was admitted to this hospice agency on 3/28/25 with the terminal diagnosis of multiple sclerosis. Following a joint home visit with the skilled nurse (RN #3) on 10/16/25 at 11:28 AM, RN #3 was asked to locate the plan of care provided to the skilled nursing facility. RN #3 located a binder at the nurse’s station and stated it should be in there under the “Plan of Care” tab. Upon review of the binder, it was noted there were blank forms titled “Community and Hospice Coordination of Care Form” located under the “Plan of Care” tab, however, there was no information filled out for the skilled nursing facility. Additionally, there was no plan of care from the hospice agency. RN #3 stated it should be there and didn’t know why it wasn’t. RN #3 acknowledged the findings at the time of interview.The administrator (Adm #1) and director of clinical services (DCS #1) reviewed and acknowledged the findings during an interview on 10/21/25 at 12:42 PM.”

“Based on record review and interview, the Hospice failed to ensure that staff at 23 of 23 Skilled Nursing Facilities that currently house its hospice residents, received orientation and training regarding the needs of the Hospice patient and the Hospice philosophy, resulting in the potential for the rendering of substandard care and unmet patient care needs at the end of life. Findings include: On 10/21/25 at 2:30 p.m., the Administrator (Adm #1) was asked to provide documented evidence to show that the Skilled Nursing Facility (SNF) staff had received in-service training, orientation and education on the Hospice philosophy, however, was unable to provide the requested information and reported, “There is no formal evidence of training to SNF staff regarding hospice care.”The Hospice failed to ensure SNF staff received the required training on the Hospice philosophy, as per this requirement.Adm #1 acknowledged the above findings at the time of discovery during the above request.”