Upper Peninsula Home Health & Hospice

“Based on document review and interview, the agency failed to develop and maintain an emergency preparedness program that included the required elements, that had be reviewed, and updated at least every 2 years, resulting in the potential for the agency’s inability to provide safe care to all patients currently serviced by this agency in the event of an actual emergency. Findings Include: On 7/22/26 at 12:12 PM, the agency’s Emergency Management Plan (Emergency Preparedness) was reviewed with the Director of IT (Information Technology) Services (Staff-K). During the review, it was noted that the Emergency Plan reflected dates of 2009 and 2022. There was no documented evidence that the plan had been reviewed and updated at least every 2 years, as per this requirement. Staff-K reviewed and acknowledged the above findings at the time of discovery.”

“Based on record review and interview, the agency failed to ensure the emergency plan included strategies based on a documented facility and community-based risk assessment from an all-hazards approach and failed to ensure the risk assessment had been reviewed and updated at least every 2 years in effort to effectively address emergency events, resulting in the potential to affect the Agency’s ability to provide patient care in the event of an actual emergency. Findings include: On 7/2/26 at 8:30 AM, the agency’s Emergency Management Plan and documents were reviewed with the Director of IT (Information Technology) Services (Staff-K). During the review, it was noted that the risk assessment (Hazardous Vulnerability Assessment) reflected the dates of 2022-22. There was no evidence that the assessment had been reviewed and updated at least every 2 years as per this requirement. Additionally, the agency’s Emergency Management Plan was void of mitigating strategies that would address the potential hazards identified in the risk assessment. Staff-K reviewed and acknowledged the above findings at the time of discovery during the above review.”

“Based on record review and interview, the agency failed to develop and maintain a Communication Plan that included methods of communication with state and local officials, as well as patients, families and staff in the event of a communication failure, resulting in the inability to effectively communicate with staff and officials and all patients serviced by this agency in the event of a facility emergency or disaster. Findings include: On 7/22/26 at 8:30 AM, during a review of the agency’s Emergency Preparedness documentation, it was noted that there was no communication plan available for review that directed how agency personnel were to communicate with Federal, State, and local emergency officials, staff and patients in the event of an actual disaster. The Director of IT (Information Technology) Services (Staff-K) reviewed and acknowledged these findings at the time of discovery during the above review and reported, “We have an agreement with a local ham radio group to assist with wellness checks.” When asked to review the aforementioned agreement, Staff-K was unable to locate the documents. The agency failed to develop and maintain a Communication Plan that included methods of communication.”

“Based on record review and interview, the agency failed to provide documented evidence to support that all staff, including contracted staff and volunteers, had received initial and ongoing training in emergency preparedness policies and procedures, and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 7/22/26 at 8:30 AM, the Director of IT (Information Technology) Services (Staff-K) was asked to provide documented evidence to support that all staff, including contracted staff and volunteers, had received initial and ongoing training in Emergency Preparedness policies and procedures. Staff-K was asked to upload the requested information to the state drop box. Upon review, no information had been provided as requested. There was no evidence to support that all staff, including contracted staff and volunteers had received initial and ongoing training in Emergency Preparedness. These findings were discussed with the Administrator (Staff-A) and Director of Hospice (Staff-B) during the exit conference on 7/22/26 at 4:00 PM.”

“Based on record review and interview, the hospice failed to ensure the registered nurse completed the Initial Assessment within 48 hours to address the immediate care needs for 2 (P-1, P-6) of 2 patients who required hospice services, resulting in a delay in needed services and the potential for unmet care needs. Findings include: Patient #1 (P-1) was admitted to hospice on 6/4/26 with a terminal diagnosis of Congestive Heart Failure. The clinical record review was conducted on 7/20/26 at 4:10 PM. The referral for hospice services was dated 5/27/26 and stated, “Admit to hospice services after consents are signed; Start date 5/27/26.” The SOC was conducted 7 days after the date of the referral. Upon further review, there was no documented rationale for the delay in needed services and no indication that the Physician had been notified of the delay. The Administrator (Staff-A) and the Director of Hospice (Staff-B) reviewed and acknowledged these findings during an interview on 7/22/26 at 11:28 AM. Patient #6 (P-6) was admitted to hospice on 3/7/25 with a terminal diagnosis of Chronic Systolic Congestive Heart Failure. During the record review on 7/22/26 at 3:00 PM, it was noted that the referral for hospice services was dated 2/20/25. The SOC was conducted 15 days after the date of the referral. Upon further review, there was no documented rationale for the delay and no indication that the Physician had been notified accordingly. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 3:40 PM”

“Based on record review and interview, the agency failed to ensure a review of all medications for significant drug interactions for 2 (P-14, P-16) of 19 records reviewed, resulting in the potential for harmful drug interactions. Findings include: Patient #14’s (P-14) Start of Care (SOC) was dated 4/9/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/21/26 at 12:15 PM, it was noted that the “Medication Interaction” report within the EMR (Electronic Medical Record) noted 1 Drug-Drug interactions with “Severe Interaction” between Lorazepam and Morphine. There was no documented evidence that a drug review was completed per the policy. Patient #16’s (P-16) Start of Care (SOC) was dated 6/28/25. The Plan of Care (POC) identified a terminal diagnosis of Pancreatic Cancer. During record review on 7/21/26 at 3:15 PM, it was noted that the “Medication Interaction” report within the EMR noted 2 Drug-Drug interactions with “Severe Interaction” between Lorazepam and Fentanyl, and Fentanyl and Oxycodone. There was no documented evidence that a drug review was completed per the policy. A review of the agency policy occurred on 7/22/26 titled “Medication Profile” (Revised July 2025). The policy states, “2. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify: I. Actual and potential drug interactions.The Administrator (Staff-A) and Director of Hospice Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/22/26 at 1:40 PM.”

“Based on record review, interview and observation, the agency failed to complete a comprehensive assessment that included an initial bereavement assessment that captured all the identified potential bereaved family member’s social, spiritual, and cultural needs, that may impact their ability to cope with the patient’s death for 10 (P-1, P-2, P-3, P-4, P-6, P-12, P-13, P-14, P-16, P-17) of 10 records, resulting in the potential for ineffective grieving and lack of bereavement support upon the patient’s death. Findings include: Patient #13’s (P-13) Start of Care (SOC) was dated 6/3/26. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 7/20/26 at 3:50 PM, it was noted that the bereavement risk assessment has not been completed. The Medical Social Worker (MSW) completed a comprehensive assessment on 6/5/26 and stated, “Bereavement Risk Assessment: Risk Assessment completed: No. None of patient’s family were available during this meeting with the patient. MSW has spoken with all of them at various times, no concerns from any of them during these conversations. MSW will continue to look for opportunities to complete bereavement assessment.” The MSW has completed 2 additional visits, 6/29/26 and 7/17/26. The agency failed to complete a bereavement risk assessment. Patient #14’s (P-14) Start of Care (SOC) was dated 4/9/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/21/26 at 12:15 PM, it was noted that the bereavement risk assessment was completed by the MSW on 4/11/25 for the patient’s daughter. During a joint survey visit with the Registered Nurse (RN) on 7/21/26, it was observed that P-14 has a son-in-law. The bereavement risk assessment failed to include the patient’s son-in-law. Patient #16’s (P-16) Start of Care (SOC) was dated 6/28/25. The Plan of Care (POC) identified a terminal diagnosis of Pancreatic Cancer. During record review on 7/21/26 at 3:15 PM, it was noted that the bereavement risk assessment has not been completed. The MSW completed a comprehensive assessment on 6/226 and stated, “Bereavement Risk Assessment: Risk Assessment completed: No. Family not available today.” The agency failed to complete a bereavement risk assessment. Patient #17’s (P-17) Start of Care (SOC) was dated 4/11/25. The Plan of Care (POC) identified a terminal diagnosis of Sarcopenia. During record review on 7/21/26 at 4:00 PM, it was noted that the bereavement risk assessment was completed by the RN on 8/9/25 for the patient’s daughter. The RN documented a Narrative Note on 4/13/25 stating, “…The patient’s son, currently on vacation in Italy, resides in Washington, D.C…” The bereavement risk assessment failed to include the patient’s son. A review of the agency policy occurred on 7/22/26 titled “Bereavement Assessment” (Revised July 2026). The policy states, “1. On admission, a social worker or hospice registered nurse will complete a bereavement risk assessment. At a minimum, it will include: a) Patient and family/caregiver loss issues… 2. The Holistic Team, including Social Work and the Bereavement Coordinator, will review the bereavement risk assessment to determine the potential needs of the survivors.” The Administrator (Staff-A) and Director of Hospice Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/22/26 at 1:40 PM. Patient #12 (P-12): During the record review on 7/22/26 at 12:50 PM, it was noted the patient resided with their spouse who was the primary caregiver and documented P-12’s daughter as an emergency contact. The comprehensive assessment completed by skilled nursing (SN) at start of care (SOC) on 6/12/2026, documented a bereavement assessment of the patient’s spouse. The review of the plan of care dated 6/12/2026, noted in the SN narrative notes that the “wife and daughter present during visit…” However, no record was found that a bereavement assessment was completed for the daughter during the visit. Additionally, the review of the social worker’s (SW) initial assessment dated 6/16/2026, revealed that the social worker met with both the spouse and the daughter. During the visit the SW completed a second bereavement assessment for the spouse. Findings reveal that the daughter is an identified potential bereaved family member, and no records were found that the agency assessed her bereavement needs at the SOC or during the initial SW visit. The administrator (Staff-A) and the director of hospice services (Staff-B) reviewed and acknowledged the findings during an interview on 7/22/2026 at 3:13 PM. Staff-B reviewed P-12’s record during the interview and confirmed no bereavement assessment was completed for the patient’s daughter. Patient #1 (P-1) was admitted to hospice on 6/4/26 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 7/20/26 at 4:10 PM, it was noted that the patient’s contact list dated 6/4/26 listed a son, grandson and a friend. During this review, it was also noted that the patient had another son. The Initial Plan of Care dated 6/4/26 documented, “Patient lives at home with her grandson...” A Skilled Nurse Visit note dated 6/4/26 documented, “No reason bereavement risk assessment not completed: Other: SW (Social worker) will need to complete this task as grandson is not available during this SNV (skilled nurse visit).” At the time of this record review and by the survey’s end, the patient’s son, friend and grandson had not been included in the initial bereavement assessment. The Administrator (Staff-A) and the Director of Hospice (Staff-B) reviewed and acknowledged these findings during an interview on 7/22/26 at 11:28 AM. P-2 was admitted to hospice on 7/30/25. The benefit period of review was 5/26/26 through 7/22/26 with a terminal diagnosis of Sarcopenia. During the clinical record review on 7/21/26 at 1:25 PM, it was noted that the patient’s contact list included two daughters and a son. Further review of the record revealed the patient had another son that was not included in the contact list. Upon review of the bereavement risk assessment dated 8/20/25, there was no mention of one of the patient’s daughters and one of the patient’s sons in the assessment. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 11:48 AM. P-3 was admitted to hospice on 6/24/26 with a terminal diagnosis of Congestive Heart Failure. During the record review on 7/21/26 at 10:45 AM, it was noted that the patient’s contact list included a son, paid caregiver, and a grandson. At the time of this record review, no bereavement assessment had been completed for all parties who would be affected by the patient’s death. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 12:05 PM. P-4 was admitted to hospice on 10/6/25. The benefit period of review was 6/3/26 through 7/12/26 with terminal diagnoses that included Malignant Neoplasm of Bone and Lung. During the clinical record review on 7/22/26 at 1:10 PM, it was noted that the patient’s personal contacts listed a husband and 2 sons. The bereavement risk assessment failed to include one of the patient’s sons. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 3:35 p.m. P-6 was admitted to hospice on 3/7/25 with terminal diagnosis of Sarcopenia. The patient’s personal contacts included a daughter, son and a daughter-in-law. During the clinical record review on 7/22/26 at 3:00 PM, it was noted that no bereavement assessment had been completed for the patient’s son and daughter-in-law. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 3:40 p.m. The agency failed to ensure the bereavement risk assessments included all parties who would be affected by the patient’s death.”

“Based on record review and interview, the agency failed to ensure the plan of care (POC) included patient specific measurable goals in 9 (P-7, P-8, P-12, P-13, P-14, P-15, P-16, P-17, P-18) out of 19 records reviewed, which resulted in the potential for unmet patient needs. Findings include: Patient #13’s (P-13) Start of Care (SOC) was dated 6/3/26. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 7/20/26 at 3:50 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/family will express satisfactory control of symptoms, Family/caregiver will verbalize when to notify hospice of concerns, changes in patient condition, and at time of death.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.Patient #14’s (P-14) Start of Care (SOC) was dated 4/9/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/21/26 at 12:15 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/caregiver administers medications appropriately with understanding of side effects and states implications and expected results, Patient’s symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.Patient #15’s (P-15) Start of Care (SOC) was dated 6/15/26. The Plan of Care (POC) identified a terminal diagnosis of Alzheimer’s. During record review on 7/21/26 at 2:00 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient will be free of preventable complications, Family/caregiver will express satisfaction with hospice support received.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.Patient #16’s (P-16) Start of Care (SOC) was dated 6/28/25. The Plan of Care (POC) identified a terminal diagnosis of Pancreatic Cancer. During record review on 7/21/26 at 3:15 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/caregiver will verbalize understanding/demonstrate compliance and independence of medication regimen and s/s (signs and symptoms) of adverse reactions to report, Patient/family will express satisfactory control of symptoms.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.Patient #17’s (P-17) Start of Care (SOC) was dated 4/11/25. The Plan of Care (POC) identified a terminal diagnosis of Sarcopenia. During record review on 7/21/26 at 4:00 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient will maintain joint integrity and prevent complications of immobility, Patient will remain free from further injury of falls throughout hospice care.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.Patient #18’s (P-18) Start of Care (SOC) was dated 7/7/26. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 7/21/26 at 4:40 PM, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient and/or representative will demonstrate involvement, verbalize understanding and agree with the plan of care, Patient/family will express satisfactory control of symptoms.” The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal.A review of the agency policy occurred on 7/22/26 titled “The Plan of Care” (Revised July 2025). The policy states, “12. The written plan of care will contain, but will not be limited to, the following: W. Measurable outcomes anticipated from implementing and coordinating the plan of care.”The Administrator (Staff-A) and Director of Hospice Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/22/26 at 1:40 PM. Patient #7 (P-7): The POC for episode 5/14/2026 through 8/1/2026 was reviewed on 7/21/2026 at 12:58 PM. It was found that 8 out of 10 goals were not patient-specific or objectively measurable, preventing evaluation of progress toward achieving each goal. For example, “Family/CG (caregiver) will have mechanisms to cope appropriately.” Another stated, “Patient symptoms will be controlled, and family will be educated and supported during his time in Hospice.” Patient #8 (P-8): The POC for episode 6/4/2026 through 9/1/2026 was reviewed on 7/21/2026 at 2:52 PM. It was found that 10 out of 11 goals were not patient-specific or objectively measurable, preventing evaluation of progress toward achieving each goal. For example, “Patient will maintain optimal coping through hospice care.” Another stated, “Family will state signs and symptoms of disease progression and need for increased patient care including increased assistance and supervision.” Patient #12 (P-12): The POC for episode 5/29/2026 through 8/26/2026 was reviewed on 7/22/26 at 12:50 PM. It was found that 7 out of 8 goals were not patient-specific or objectively measurable, preventing evaluation of progress toward achieving each goal. For example, “Patient/family will express satisfactory control of symptoms.” Another stated, “Family/caregiver effective in care management and knows to call hospice for questions and concerns.” The administrator (Staff-A) and the director of hospice services (Staff-B) reviewed and acknowledged the findings above during an interview on 7/22/2026 at 3:13 PM, which did not reflect the agency’s expectations or policy referenced below.Review of agency policy on 7/22/26 at 2:30 PM, titled, “The Plan of Care”, (revised 2025), revealed that plan of care will contain, “… measurable outcomes anticipated from implementing and coordinating the plan of care…””

“Based on record review, interview and observation, the agency failed to ensure care and services were provided in accordance with the patient and families assessed needs for 4 (P-2, P-7, P-10, P-15) of 4 records, resulting in the potential for unmet patient care needs. Findings include: Patient #15’s (P-15) Start of Care (SOC) was dated 6/15/26. The Plan of Care (POC) identified a terminal diagnosis of Alzheimer’s. During record review on 7/21/26 at 2:00 PM, it was noted that the Registered Nurse (RN) on 6/16/26, 6/22/26 and 6/25/26 stated, “…Request volunteer…” On 7/1/26, the RN stated, “Volunteer Needs Assessment: Other: SW (Social Worker) to f/u (follow-up) re: volunteer.” There was no documented evidence within the Electronic Medical Record that the agency provided a volunteer as requested.The Administrator (Staff-A) and Director of Hospice Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/22/26 at 1:40 PM. Patient #7 (P-7): The record review on 7/21/2026 at 12:58 PM, noted the “Physician Visit Note”, dated 7/14/2026, completed by the hospice medical director (Staff-L), documented “Presenting Problem: Generalized pain, heel ulcer right foot” and a skin assessment that noted, “2cm dry ulcer rt (right) heel” with a plan for the “RN to initiate wound care for heel.” Further review of the skilled nursing visit notes dated 7/15/2026, was void of the assessment or care of a right heel wound. No evidence noted in the communication notes or orders that documented the physician’s assessment findings or coordination of care of the right heel wound. During interview with the administrator (Staff-A) and the director of hospice services (Staff-B) on 7/22/2026 at 2:48 PM, the findings were reviewed. Staff-B reviewed the record during the interview and confirmed the findings above. Further explaining that the physician assessment findings will be discussed at the scheduled interdisciplinary group meeting scheduled for 7/23/26.Patient #10 (P-10): During record review on 7/22/2026 at 9:34 AM, it revealed that the P-10’s spouse is the primary caregiver who was assessed as needing respite support. This was noted during the 7/9/2026 “Interdisciplinary Group Meeting” (IDG), under the “Additional Notes” section the social worker (SW), “suggests a volunteer for family respite. Volunteer Coordinator to look into this.” Further review of record indicated that the need for spouse respite remained, as documented in the SW visit notes dated 7/20/2026, in which the spouse stated that she was, “managing as a caregiver… tired and sometimes gets frustrated.” No evidence was found in the record indicating initiation of volunteer services as recommended by SW during the 7/9/2026 IDG meeting. The administrator (Staff-A) and the director of hospice services (Staff-B) reviewed and acknowledged the findings above during an interview on 7/22/2026 at 3:13 PM, which did not meet the agency’s expectations or policy referenced below. Review of agency policy on 7/22/26, titled, “Interdisciplinary Team Plan of Care”, (revised 2025), revealed that, “It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status between Interdisciplinary Team members…” And that, “Written evidence of care coordination will be found in the plan of care and/or inter-disciplinary team meeting forms in the patient’s clinical record…” Patient #2 (P-2) was admitted to hospice on 7/30/25. The benefit period reviewed was 5/26/26 through 7/22/26 with a terminal diagnosis of Sarcopenia. During the clinical record review on 7/21/26 at 1:25 PM, it was noted that the plan of care ordered Skilled Nursing (SN), Hospice Aide (HA), Medical Social work (MSW) and Physical Therapy (PT) services to be provided. An IDG (Interdisciplinary group) note dated 7/9/26 read, “PT services will begin for strengthening, balance and mobility support with the goal of maintaining functioning and quality of life..., Current Orders: Physical Therapy to Assess and Evaluate.” At the time of this review, it was noted that PT made a visit to the patient’s home on 7/9/26, however there was no documented completed evaluation available for review. Additionally, there were no further scheduled PT visits made to meet the patient’s needs. On 7/21/26 at 8:15 AM, a scheduled home visit was conducted with the Hospice Aide (Staff-D). During the visit, the patient reported that he spends a great deal of time alone. The caregiver, who was present during the visit stated she works Tuesdays, Wednesdays and Fridays from 8:00 AM to 1:00 PM and someone else comes to assist after that. The caregiver then stated the patient is alone all afternoon on Mondays and Thursdays from 1:00 PM to 7:00 PM. When asked if he was aware of the agency’s volunteer services, the patient stated he had no knowledge of that service but would be interested in learning more. Upon further review of the clinical record, there was no documented evidence that the patient had been informed of or offered the available volunteer services. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 7/22/26 at 11:48 AM.”

“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 of the bereaved, the kind of bereavement services to be offered and the frequency of service delivery for 2 (P-4, P-6) of 3 bereavement records reviewed, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: Patient #4 (P-4) was admitted to hospice on 10/6/25 with terminal diagnoses that included Malignant Neoplasm of Bone and Lungs. During the clinical record on 7/22/26 at 1:10 PM., it was noted that the patient expired on 7/12/26. The Initial Bereavement Assessment dated 10/9/25, conducted by the Social Worker, revealed that P-4 was survived by her husband and 2 sons. Upon further review, the post-death bereavement services failed to include one of the patient’s sons. The hospice failed to ensure a Bereavement Plan of Care was developed to address the needs of all who would be affected by the patient’s death. The Administrator (Staff-A) and the Director of Hospice (Staff-B) reviewed and acknowledged the above findings during an interview on 7/22/26 at 3:35 PM. Patient #6 (P-6) was admitted to hospice on 3/7/25 with a terminal diagnosis of Chronic Systolic Congestive Heart Failure. During the record review on 7/22/26 at 3:00 PM, it was noted that the patient expired on 5/12/25. The patient’s personal contacts listed the patient’s son and daughter. The Initial Bereavement Assessment dated 3/10/25 only included the patient’s daughter. Upon further review, the “Counselor Visit Note” (BC Initial Visit), Bereavement Visit-After Death visit note dated 5/12/25 only included the patient’s daughter as the person who would be affected by the patient’s death. The section titled “Support System: Family Members” listed the patient’s son, as a person available to provide comfort on an intermittent basis through the week. The patient’s son had not been included in the assessment as a person who would be affected by the patient’s death and did not receive any post-death bereavement services. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 3:40 PM.”

“Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aides provided specific guidance, safety precautions and care instructions on the needs of the patient for 13 (P-2, P-3, P-7, P-8, P-9, P-10, P-11, P-13, P-14, P-16, P-17, P-18, P-19) of 13 records with Hospice Aide services ordered, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #13’s (P-13) Start of Care (SOC) was dated 6/3/26. The Plan of Care (POC) identified a terminal diagnosis of Colon Cancer. During record review on 7/20/26 at 3:50 PM, it was noted that the POC contained the following safety measures: Energy Conservation, Fall precautions, Standard Precautions, Skin breakdown prevention, Bleeding Precautions, Home emergency plan, No driving, Evacuation Plans, Bath Tub Safety Bars, Ambulation Precautions, Avoid Constricting Clothing, Proper use of safety equipment, Properly functioning equipment. The Aide care plan contained the following safety measures: Fall precautions, Standard precautions. The Aide care plan failed to contain all of the patient’s safety measures.Patient #14’s (P-14) Start of Care (SOC) was dated 4/9/25. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/21/26 at 12:15 PM, it was noted that the POC contained the following safety measures: Safe tranfers, Energy Conservation, Fall precautions, Standard Precautions, 24 Hour supervision, Head of bed elevated, Skin breakdown prevention, Bleeding Precautions, Home emergency plan, Transfer Precautions, Infection control, Evacuation Plans, Ambulation Precautions, keep Pathways Clear, Proper use of safety equipment, Properly functioning equipment. The Aide care plan contained the following safety measures: Fall precautions. The Aide care plan failed to contain all of the patient’s safety measures.Patient #16’s (P-16) Start of Care (SOC) was dated 6/28/25. The Plan of Care (POC) identified a terminal diagnosis of Pancreatic Cancer. During record review on 7/21/26 at 3:15 PM, it was noted that the POC contained the following safety measures: Aspiration precautions, Transfer Precautions, Skin breakdown prevention, Safe transfers, Evacuation Plans, Fall precautions, Standard Precautions, Ambulation Precautions, Energy Conservation, Keep Pathways Clear, Lock wheelchair w/transfers, Proper use of safety equipment, Properly functioning equipment. The Aide care plan contained the following safety measures: Fall precautions. The Aide care plan failed to contain all of the patient’s safety measures. Additionally, the aide care plan was not patient specific and stated, “7. Hygiene-Bath-Bed. 8. Hygiene Bath-Complete. 9. Bath-Partial. 10. Bath-Shower. 11. Bath-Shower Chair.” The bathing options were not patient specific and failed to provide clear instructions to the Aide.Patient #17’s (P-17) Start of Care (SOC) was dated 4/11/25. The Plan of Care (POC) identified a terminal diagnosis of Sarcopenia. During record review on 7/21/26 at 4:00 PM, it was noted that the POC contained the following safety measures: Ambulation Precautions, Transfer Precautions, Skin breakdown prevention, Safe transfers, Aspiration Precautions, Bleeding Precautions, Energy Conservation, Evacuation Plans, Fall precautions, Keep Pathways Clear, Lock wheelchair w/transfers, Bath Tub Safety Bars, Proper use of safety equipment, Properly functioning equipment, Standard Precautions. The Aide care plan contained the following safety measures: Fall precautions, Standard precautions. The Aide care plan failed to contain all of the patient’s safety measures.Patient #18’s (P-18) Start of Care (SOC) was dated 7/7/26. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 7/21/26 at 4:40 PM, it was noted that the POC contained the following safety measures: Safe transfers, Skin breakdown prevention, Transfer Precautions, Ambulation Precautions, Oxygen Precaution, Standard Precautions, Evacuation Plans, Fall precautions, Infection control, Keep Pathway Clear, Lock wheelchair w/transfers. The Aide care plan contained the following safety measures: Fall precautions, Oxygen precautions, Standard precautions. The Aide care plan failed to contain all of the patient’s safety measures.Patient #19’s (P-19) Start of Care (SOC) was dated 6/16/26. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/22/26 at 12:15 PM, it was noted that the POC contained the following safety measures: Safe transfers, Oxygen Precaution, Transfer Precautions, Ambulation Precautions, Bleeding Precautions, Energy Conservation, Evacuation plans, Fall precautions, Infection control, Keep Pathways Clear, , Proper use of safety equipment, Properly functioning equipment, Skin breakdown prevention, Standard Precautions. The Aide care plan contained the following safety measures: Fall precautions, Oxygen precautions. The Aide care plan failed to contain all of the patient’s safety measures.The Administrator (Staff-A) and Director of Hospice Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/22/26 at 1:40 PM. Patient #7 (P-7) was admitted to the agency for the diagnosis of sarcopenia (loss of muscle mass and strength). During record review on 7/21/2026 at 12:58 PM, it was noted that the plan of care (POC) for episode 5/14/2026 through 8/1/2026 documented safety measures that included energy conservation, safe use of equipment, and ambulation, fall, and transfer precautions. The review of the “Aide Care Plan” noted the interventions did not include energy conserving or safe use of equipment measures. Patient #8 (P-8) was admitted to the agency with the diagnosis of left breast cancer. During record review on 7/21/2026 at 2:52 PM, it was noted that the POC for episode 6/4/2026 through 9/1/2026, documented safety measures that included energy conservation, safe use of equipment, and skin breakdown prevention. The review of the “Aide Care Plan” noted the interventions did not include energy conserving, safe use of equipment, and skin breakdown prevention measures.Patient #9 (P-9) was admitted to the agency with the diagnosis of Alzheimer’s. During record review on 7/21/2026 at 3:41 PM, it was noted that the POC for episode 7/8/2026 through 9/5/2026, documented safety measures that included energy conservation, safe use of equipment, skin breakdown prevention, and “lock wheelchair with transfer”. It also included aspiration, fall, and standard precautions. The review of the aide intervention noted in the POC did not include measures to conserve energy, prevent skin breakdown, or “lock wheelchair with transfer”. It is noted that thickened liquids is an invention for the aide, however no aspiration precautions were noted.Patient #10 (P-10) was admitted to the agency with the diagnosis of congested heart failure (CHF). During record review on 7/22/2026 at 9:34 AM, it was noted that the POC for episode 7/8/2026 through 9/5/2026, documented safety measures that included energy conservation, safe use of equipment, skin breakdown prevention, and “lock wheelchair with transfer”. It also included ambulation, fall, oxygen, and standard precautions. The review of the aide intervention noted in the POC did not include measures to prevent skin breakdown, the safe use of equipment, “lock wheelchair with transfer” or ambulation precautions.Patient #11 (P-11) was admitted with the diagnosis of coronary artery disease (blocked blood flow of the heart arteries). During record review on 7/22/2026 at 11:31 AM, it was noted that the POC for episode 6/21/2026 through 8/19/2026, documented safety measures that included energy conservation, safe use of equipment, skin breakdown prevention, and infection control. It also included ambulation, bleeding, fall, standard and universal precautions. The review of the “Aide Care Plan” noted no interventions that aligned with the POC safety measures. The administrator (Staff-A) and the director of hospice services (Staff-B) reviewed and acknowledged the findings above during an interview on 7/22/2026 at 3:13 PM. Patient #2 (P-2) was admitted to hospice on 7/30/25. The benefit period of review was 5/26/26 through 7/22/26 with a terminal diagnosis of Sarcopenia. During the record review on 7/21/26 at 1:25 PM, it was noted that the Plan of Care (POC) listed the following safety measures: safe transfers, skin breakdown prevention, energy conservation and bleeding precautions. These precautions were not added to the aide care plan. Additionally, the aide care plan was non-specific and listed “hygiene-bath-bed; bath-complete; bath-partial; bath-shower; bath-shower chair...” There were no clear instructions to guide the aide in rendering care. The Administrator (Staff-A) and the Director of Hospice (Staff-B) reviewed and acknowledged these findings during an interview on 7/22/26 at 11:48 AM. P-3 was admitted to hospice on 6/24/26 with a terminal diagnosis of Congestive Heart Failure. During the record review on 7/21/26 at 10:45 AM, it was noted that the POC listed an oil emulsion dressing and bleeding precautions. This information had not been added to the aide care plan. Additionally, the aide care plan mentioned both, bed bath and shower. There was no specific guidance to direct the aide in the provision of care. Further, there was no instruction provided on what measures to take in the event the wound dressing should become soiled or removed during care. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 7/22/26 at 12:05 PM.”