Compassus - Bay City

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, observation, document review, and interviews with the Leadership team, which revealed the hospice: Failed to ensure that the patient’s plan of care (POC) included the necessary drugs and treatments to meet the patient’s needs in 7 of 19 (37%) clinical records reviewed [HCPC.21.I/L549/418.56(c)(4)]; Failed to ensure that each patient’s written plan of care included the medical supplies and appliances necessary to meet the patient’s needs in 5 of 19 (26%) clinical records reviewed [HCPC.21.I/L550/418.56(c)(5); Failed to ensure that each patient’s written plan of care included planned Interventions to manage pain and symptoms based on problems identified in the comprehensive assessments in 10 of 19 (53%) clinical records reviewed [HCPC.21.I/L546/418.56(c)(1); and Failed to ensure that each patient’s written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments in 4 of 19 (21%) clinical records reviewed [HCPC.21.I/L545/418.56(c)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation, CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed of patients admitted for greater than five (5) days, the agency did not ensure that the patient’s initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 7: The patient elected hospice care on 07/23/2025. The Chaplain coordination note dated 07/24/2025 documented that a message was left for the spouse to call back to schedule an initial assessment visit. A missed visit was documented on 07/24/2025. The Interdisciplinary Group meetings dated 09/03/2025, 09/17/2025, 10/01/2025, and 10/15/2025 did not include documentation of further attempts or team input regarding the patient’s spiritual needs. A clinical record review revealed no documentation of the patient’s or family’s declination of spiritual services. CLINICAL RECORD 17: The patient elected hospice care on 11/27/2024. On 12/04/2024, the Social Worker (SW) conducted a phone call to schedule an appointment for the comprehensive assessment, with seven (7) days outstanding. The SW documented that the patient stated they were not feeling well and would like to postpone. The patient was transferred to another hospice on 12/05/2025. During an interview and a joint record review on 10/23/2025, the leadership team confirmed the findings and stated that the assessments were not documented.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. Agency policy #HOS-C_15C “Medication Reconciliation and Management” (review date 04/09/2025) stated in part, “Nursing Facility - each scheduled nursing visit after admission, review the current MAR at the medication cart for the hospice patient, note whether there are any new medications or medication order changes documented on the MAR. if so, document on the nursing visit note what the medication changes are, review the hospice patient’s facility medical record and look for the orders to support the medication changes noted by the nurse, if the orders are signed, make a copy. If the medication lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders and the medication reconciliation process is completed.” In 2 of 3 (67%) home visits observed of patients in a facility, the agency did not ensure that the comprehensive assessment included a drug profile containing the patient’s current medications. HOME VISIT 2/CLINICAL RECORD 2: The patient elected hospice care on 07/08/2025 with a diagnosis of Alzheimer’s Disease. The patient resided in a facility. During the home visit with the Registered Nurse Case Manager (RNCM) [Personnel Record 3] on 10/22/2025, the hospice medication profile was compared to the patient’s facility medication profile. The hospice medication profile documented prochlorperazine as needed for nausea. The facility’s medication profile did not include prochlorperazine. HOME VISIT 3/CLINICAL RECORD 3: The patient elected hospice care on 10/03/2025 with a diagnosis of end-stage congestive heart failure (CHF). The patient resided in a long-term care facility (LTCF). During the home visit with the Chaplain (SC) [Personnel Record 5] on 10/22/2025, the hospice medication profile and the LTCF medication profile were compared. The LTCF medication profile documented: Tylenol Extra Strength oral tablet 500 mg, for pain/fever “crush” via PEG (percutaneous endoscopic gastrostomy) tube. The hospice medication profile documented Acetaminophen Suppository. Morphine concentrate was documented on the hospice medication profile as “oral.” The LTCF medication profile documented “sublingually.” Additionally, the hospice medication profile documented Pro-Stat AWC (Advanced Wound Care) 17 G, 30 milliliters, 4 times/day “Oral,” and the facility medication profile documented Jevity 240 ml, 4 times/day, with 180 ml of water. During an interview on 10/23/2025, the leadership team confirmed the findings and stated that they would check with the facility, as they may document some items on a different form.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 16 (19%) clinical records reviewed of patients admitted for greater than five (5) days, an initial bereavement risk assessment was not documented. CLINICAL RECORD 9: The patient elected hospice care on 09/18/2025. The skilled nursing (SN) initial comprehensive assessment was completed on 09/18/2025. A clinical record review revealed no evidence that an initial bereavement risk assessment had been completed as of 10/22/2025, with 35 days outstanding. CLINICAL RECORD 13: The patient elected hospice care on 08/02/2024. A clinical record review revealed no evidence that an initial bereavement risk assessment had been completed as of 10/23/2025, with 447 days outstanding. CLINICAL RECORD 15: The patient elected hospice care on 02/04/2025 and died on 04/25/2025. A clinical record review revealed no evidence that an initial bereavement risk assessment had been completed, with 85 days outstanding. A post-bereavement risk assessment was documented on 04/30 2025. During an interview and a joint record review on 10/23/2025, the leadership team confirmed the finding and stated that the initial bereavement risk assessment was not documented.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview, and observation. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the plan of care (POC) included planned interventions based on problems identified in the initial or updated comprehensive assessment. CLINICAL RECORD 6: The patient elected hospice care on 07/05/2025 with a primary diagnosis of lung cancer. On 8/19/2025, the physician ordered wound care for the patient’s right armpit, including a silver alginate dressing, and to start cephalexin 500mg for 7 days. A clinical record review on 10/21/2025 revealed that the plan of care was not updated to include planned interventions to address the patient’s identified problems with skin integrity and infection. The physician’s order dated 10/07/2025 ordered nystatin for the patient’s left armpit due to a yeast infection. The plan of care was not updated to include planned interventions to address the patient’s identified yeast infection. The POC dated 07/20/2025 documented that the patient was using oxygen, oxygen was entered on the medication profile, and the plans of care dated 07/19/2025 through 10/16/2025 and 10/17/2025 through 01/14/2025. The plans of care did not document planned interventions to address the patient’s oxygen use and the safety precautions related to it. CLINICAL RECORD 9: The patient elected hospice care on 09/18/2025 with a diagnosis of respiratory failure. The initial skilled nursing (SN) comprehensive assessment, dated 09/18/2025, documented that the patient is a “full code.” The POCs dated 09/18/2025, which were updated every two weeks, did not include interventions related to the patient’s advanced directives. The Interdisciplinary Group (IDG) note dated 10/01/2025 documented that “patient now on BiPAP (bilevel positive airway pressure).” The POC did not document interventions to address the BiPAP machine use. CLINICAL RECORD 12: The patient elected hospice care on 09/15/2025 with a diagnosis of heart failure. The initial skilled nursing (SN) comprehensive assessment, dated 09/15/2025, documented that the patient used a CPAP (continuous positive airway pressure) machine. The plan of care dated 09/15/2025, updated 10/01/2025, and 10/15/2025 did not include documentation of interventions to address CPAP machine use. On 10/20/2025, the physician ordered Keflex (antibiotic) for cellulitis of the left arm. The POC was not updated to include documentation of interventions to address the patient’s infection/cellulitis. CLINICAL RECORD 18: The patient elected hospice care on 12/29/2024 with diagnoses of congestive heart failure (CHF) and prostate cancer. On 12/31/2024, the physician ordered wound care to the patient’s left and right heels with a dressing. On 01/06/2025, the physician ordered wound care for the patient’s coccyx with a dressing. The POCs dated 12/29/2024, which were updated every two weeks, did not include interventions to address the patient’s skin integrity related to the wounds. A physician order dated 01/12/2025 ordered Zithromax (antibiotic) for the patient’s respiratory infection. The updated plan of care did not include interventions addressing the respiratory infection. The patient died 01/15/2025. During the interview and joint record review on 10/23/2025, the leadership team confirmed the findings, stating that the care plans did not include individualized interventions for all identified problems.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 10 of 19 (53%) clinical records reviewed, the agency did not ensure that the plan of care included interventions to manage pain and symptoms. CLINICAL RECORD 2: The patient elected hospice care on 07/08/2025 with a diagnosis of Alzheimer’s Disease. The plan of care (POC), dated 07/08/2025 and updated every two weeks, ordered oxygen at 2-5 liters “as needed” and morphine concentrate “as needed” for shortness of breath. The POC did not include documentation of parameters for when to administer morphine or use oxygen, or which medication to use first for shortness of breath. CLINICAL RECORD 3: The patient elected hospice care on 10/03/2025 with a diagnosis of end-stage congestive heart failure (CHF). The patient resided in a long-term care facility (LTCF). The POC dated 10/03/2025 and updated every two weeks ordered acetaminophen and morphine concentrate for pain. The POC did not document instructions for when to administer the acetaminophen or morphine, or for what level of pain. CLINICAL RECORD 4: The patient elected hospice care on 09/10/2025 with a diagnosis of congestive heart failure (CHF). The updated plan of care, dated 10/09/2025, ordered the following: acetaminophen 500mg daily, Tylenol PM Extra Strength 500mg, 2 tablets at bedtime, and acetaminophen suppository 650mg every 4 hours as needed for pain. The instructions did not include information on not exceeding the maximum allowable dose when combining all doses of acetaminophen. The POC ordered acetaminophen “as needed” for pain and morphine solution “as needed” for pain. The POC did not include documentation of instructions or parameters for when to administer acetaminophen or morphine for pain. The POC ordered oxygen PRN (“as needed”) for shortness of breath and morphine solution “as needed” for shortness of breath. The POC did not provide documentation of instructions for when to use the oxygen or administer the morphine for shortness of breath. CLINICAL RECORD 5: The patient elected hospice care on 10/18/2025 with a diagnosis of unspecified sequelae of cerebral infarction. The plan of care dated 10/18/2025 and updated every two weeks ordered MSIR (morphine sulfate immediate release) tablet 15mg (milligrams) every 4 hours as needed, and MSIR solution 0.5mg every 4 hours as needed for pain. The POC did not include documentation of what dose of MSIR to administer for what level of pain. CLINICAL RECORD 7: The patient elected hospice care on 07/23/2025 with a diagnosis of heart failure, unspecified. The initial plan of care, dated 07/23/2025 - 10/20/2025 and updated every two weeks, documented the medications: Tylenol 325mg, 2 tablets every 6 hours and as needed (prn) for pain and fever, and hydrocodone 7.5mg with acetaminophen 325mg every 6 hours prn for moderate pain. There were no documented instructions for when to give each medication or for what level of pain. CLINICAL RECORD 10: The patient elected hospice care on 05/28/2025 with a diagnosis of heart failure, unspecified. The plans of care dated 05/28/2025 through 07/26/2025, updated every two weeks, ordered Tylenol 650mg every 8 hours as needed and MSIR ( start date 05/28/2025) 0.25 ml every 4 hours as needed. The plans of care did not include documentation of the indications for administering Tylenol and MSIR, which included parameters for use or clarification of which medication to administer first. CLINICAL RECORD 11: The patient elected hospice care on 06/01/2025 with a diagnosis of malignant neoplasm of the brain. The patient resided in a LTCF. The plans of care for the benefit period dated 06/01/2025 through 08/29’/2025, updated every two weeks, ordered Tylenol, two (2) tablets every 4 hours as needed for pain, and MS (morphine sulfate) 0.5ml every 2 hours as needed for pain (ordered 09/30/2025). The plans of care did not include documentation of instructions for administering the MS or Tylenol or for managing specific levels of pain. Additionally, Tramadol (an opioid pain medication) 50mg, two times a day as needed, for pain was ordered (07/05/2025). The plans of care did not indicate which pain medication was to be administered first for which level of pain. CLINICAL RECORD 12: The patient elected hospice care on 09/15/2025 with a diagnosis of heart failure. The plan of care dated 09/15/2025, and updated every two weeks, ordered acetaminophen as needed for pain, hydrocodone with acetaminophen as needed for pain, and morphine concentrate as needed for pain. The plan of care did not include documentation of instructions for administering each medication or for managing specific levels of pain. CLINICAL RECORD 14: The patient elected home health services on 08/05/2025 with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient resided in an assisted living facility (ALF). The initial plan of care dated 08/05/2025, and updated every two weeks ordered acetaminophen 325mg, two (2) tablets 2 times per day for mild pain, acetaminophen suppository 650mg every 4 hours as needed for pain/elevated temperature, hydrocodone with acetaminophen 325mg, one (1) tablet every 6 hours as needed for moderate pain, and morphine concentrate 0.25ml for pain, shortness of breath. The plan of care did not include documentation of what level of pain or when to use the suppository or oral acetaminophen. CLINICAL RECORD 15: The patient elected hospice care on 02/04/2025 with a diagnosis of colon cancer and died on 04/25/2025. The updated plan of care dated 04/23/2025, ordered Dilaudid (narcotic pain medication) 2 mg, IVP (intravenous push) as needed for “severe” pain, and morphine concentrate 10mg as needed for “severe” pain and shortness of breath. The POC did not include documentation of instructions, nor parameters to define when to administer Dilaudid or morphine, or which one to administer first. During an interview and a joint record review on 10/23/2025, the leadership team stated that the records were unclear regarding the directions for medications.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) included the necessary drugs and treatments to meet the patient’s needs. CLINICAL RECORD 3: The patient elected hospice care on 10/03/2025 with a diagnosis of end-stage congestive heart failure (CHF). The patient resided in a long-term care facility (LTCF). The initial skilled nursing (SN) comprehensive assessment dated 10/03/2025, documented that the patient had a PEG (percutaneous endoscopic gastrostomy) tube placed in the left upper quadrant (LUQ). The plans of care dated 10/03/2025, updated every two weeks, did not document interventions for the care of the PEG tube, including tube-feeding instructions, care of the insertion site, or whether the tube was to be flushed. CLINICAL RECORD 4/HOME VISIT 4: The patient elected hospice care on 09/10/2025 with a diagnosis of congestive heart failure (CHF). The initial plan of care was dated 09/10/2025 with a primary diagnosis of congestive heart failure. The initial SN comprehensive assessment, dated 09/10/2025, documented the presence of a Foley catheter. The POC dated 09/10/2025 documented that the caregiver will be able to verbalize an understanding of catheter care, and the patient’s goal: “Foley catheter will remain patent...caregiver will understand care and irrigation of the Foley as evidenced by teach back.” The POC did not document the size of the Foley catheter, the frequency of catheter changes, the method of drainage, or whether irrigation was required. During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 10/23/2025, the patient and caregiver stated that the catheter was changed monthly, that it was a 16 French coude catheter, and that it was attached to a leg bag during the day and a large bag at night; it had not been flushed. CLINICAL RECORD 10: The patient elected hospice care on 05/28/2025 with a diagnosis of heart failure, unspecified. The plans of care dated 05/28/2025 through 07/26/2025, updated every two weeks (2) ordered triamcinolone cream (ordered 06/04/2024) 0.5%, ‘apply to affected area’ two (2) times a day. The plans of care did not include documentation of instructions on the location of the affected area. CLINICAL RECORD 11: The patient elected hospice care on 06/01/2025 with a diagnosis of malignant neoplasm of the brain. The patient resided in a LTCF. The SN comprehensive assessment, dated 06/01/2025, documented that the patient had a PEG (percutaneous endoscopic gastrostomy) tube. The initial plan of care, dated 06/01/2025, and updated every two weeks, did not document specific interventions for the care of the PEG tube, the flushing of the PEG tube, or the skin around the PEG tube. CLINICAL RECORD 12: The patient elected hospice care on 09/15/2025 with a diagnosis of heart failure. The plan of care dated 09/15/2025, and updated every two weeks, ordered oxygen “as directed.” The POC did not include documentation of indications for the use of “as directed” oxygen. CLINICAL RECORD 13: The patient elected hospice care on 08/02/2024 with a diagnosis of Alzheimer’s disease. The skilled nursing (SN) assessment dated 08/25/2025 documented that the patient was diagnosed with a fractured left humerus and placed in a sling. The updated plan of care dated 09/03/2025 did not include documentation of interventions for the care of the fractured left humerus or the application of a sling. CLINICAL RECORD 17: The patient elected hospice care on 11/27/2024 with a diagnosis of organ-limited amyloidosis. The initial SN comprehensive assessment, dated 11/27/2024, documented that the patient used a BiPAP (bilevel positive airway pressure) machine. The plans of care, dated 11/27/2024, and updated every two weeks, did not include interventions for care and use of the BiPAP machine. During an interview and a joint record review on 10/23/2025, the leadership team confirmed the findings and stated that the records were unclear regarding the directions for medications and treatments.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included the medical supplies and appliances necessary to meet the patient’s needs. CLINICAL RECORD 5: The patient elected hospice care on 10/18/2025 with a diagnosis of unspecified sequelae of cerebral infarction. The initial skilled nursing (SN) comprehensive assessment dated 10/18/2025 documented that the patient used a neck brace and had a wound. The plan of care dated 10/18/202 did not document a neck brace and wound supplies in the supply list. CLINICAL RECORD 8: The patient elected hospice care on 04/04/2025 with diagnoses of heart failure, unspecified, and memory deficit following cerebral infarction. The patient resided in a long-term care facility (LTCF). On 04/07/2025, the physician ordered Accu-Chek readings four (4) times a day. For the benefit period dated 07/03/2025 through 09/30/2025, the recertification plan of care DME/supply list, updated on 09/17/2025, did not include a glucometer and supplies, as well as a small-volume nebulizer, as documented in the nursing assessments. CLINICAL RECORD 12: The patient elected hospice care on 09/15/2025 with a diagnosis of heart failure. The initial SN comprehensive assessment dated 09/15/2025, documented that the patient was receiving ipratropium/albuterol via a small volume nebulizer (SVN) and was using a CPAP (continuous positive airway pressure) machine. The plans of care DME/supply list, dated 09/15/2025, and updated plans of care dated 10/01/2025, and 10/15/2025, did not document the small-volume nebulizer or the CPAP machine. CLINICAL RECORD 13: The patient elected hospice care on 08/02/2024 with a diagnosis of Alzheimer’s disease. The skilled nursing (SN) assessment dated 08/25/2025 documented that the patient was diagnosed with a fractured left humerus and placed in a sling. The updated plan of care DME/supply list, dated 09/03/2025 and updated every two weeks, did not document the sling. CLINICAL RECORD 17: The patient elected hospice care on 11/27/2024 with a diagnosis of organ-limited amyloidosis. The initial SN comprehensive assessment dated 11/27/2024, documented that the patient had an oxygen concentrator, a BiPAP (bilevel positive airway pressure) machine, a bedside table, a wheelchair with a cushion, and a walker. The plans of care DME/supply list, dated 11/27/2024 and updated every two weeks, did not document the oxygen concentrator, BiPAP machine, bedside table, wheelchair with a cushion, or walker. The POC dated 11/27/2024 documented that there were no DME/supplies. The patient died 12/04/2024. During an interview and a joint record review on 10/23/2025, the leadership team confirmed the findings and stated that the supplies were not listed.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 15 (40%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected hospice care on 07/08/2025 with a diagnosis of Alzheimer’s Disease. The skilled nursing (SN) assessment dated 07/20/2025 documented that the patient removed their catheter. On 07/20/2025, the physician ordered that the patient’s Foley catheter be removed and left out. The HA care plan dated 07/09/2025 assigned the HA the task of catheter care. The HA care plan was updated on 10/01/2025 to include perineal care, with 83 days outstanding. CLINICAL RECORD 3: The patient elected hospice care on 10/03/2025 with a diagnosis of end-stage congestive heart failure (CHF). The patient resided in a long-term care facility (LTCF). The initial skilled nursing (SN) comprehensive assessment dated 10/03/2025 documented that the patient had a PEG (percutaneous endoscopic gastrostomy) tube in the left upper quadrant (LUQ). The HA care plan dated 10/05/2025 did not document instructions for the HA regarding the presence of a PEG tube, whether it should be washed around, or whether a dressing was in place around it. CLINICAL RECORD 4: The patient elected hospice care on 09/10/2025 with a diagnosis of congestive heart failure (CHF). The patient had a left heel wound requiring wound care and a dressing. The HA care plan dated 09/11/2025 did not document instructions for the HA regarding the care of the left heel dressing during bathing, should it become wet, soiled, or dislodged. CLINICAL RECORD 5: The patient elected hospice care on 10/18/2025 with a diagnosis of unspecified sequelae of cerebral infarction. The HA care plan dated 10/18/2025 assigned the HA the task for oxygen “prn” (as needed). The HA care plan did not include instructions for the HA regarding when the patient was to use the oxygen or the liter flow. Additionally, the plan of care dated 10/18/2025 ordered skilled nursing (SN) for wound care with a dressing. The HA care plan did not notify the HA that the patient had a wound with a dressing, nor did it document instructions for the HA regarding the wound dressing and what to do if the dressing became soiled, wet, or dislodged. CLINICAL RECORD 6: The patient elected hospice care on 07/05/2025 with a primary diagnosis of lung cancer. The HA care plan dated 07/22/2025 documented “O2 (Oxygen) as needed.” The HA care plan did not include instructions for the HA regarding when the patient was to use the oxygen or the liter flow. CLINICAL RECORD 8: The patient elected hospice care on 04/04/2025 with diagnoses of heart failure, unspecified, and memory deficit following cerebral infarction. The patient resided in a long-term care facility (LTCF). The HA care plan was last updated on 07/02/2025, assigned the HA the tasks of bed bath and shower every visit, and documented for the bed bath “perform bath if shower is unable to be completed due to patient condition or patient refusal” and documented for the shower “assist patient to shower (Hoyer lift with 2 Person).” There was no identified decision maker. During an interview and joint record review on 10/23/2025, the leadership team confirmed the findings and agreed that the HA instructions were not specific.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed for patients receiving Hospice Aide (HA) services, the agency did not ensure that the patient’s record included clinical notes, including the care and services provided. CLINICAL RECORD 14: The patient elected home health services on 08/05/2025 with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient resided in an assisted living facility (ALF). The first HA visit was dated 08/14/2025. The skilled nursing assessment dated 08/07/2025 included a HA supervisory visit note documenting that the plan was followed and that the patient’s needs were being met; however, the HA did not provide care until 08/14/2025. During an interview and joint record review on 10/23/2025, the leadership team confirmed the finding, stating that HA supervision was documented prior to the HA visits.”

“Based on record review and interview, the hospice failed to demonstrate that they ensured the patient received pain management and symptom control related to the terminal illness in 1 (Patient #1) of 3 records reviewed potentially resulting in unmanaged terminal symptoms and resulting in a poor family perception of end-of-life symptoms management. Findings include: On 9/24/25 at 4:02 PM, patient #1’s wife (Com-1) was interviewed during a phone call. During the interview, Com-1 stated that patient #1 (P-1) was signed up with the hospice agency at 9:30 PM on 7/25/25 at the skilled nursing facility (SNF) where P-1’s was residing. Com-1 explained the next day (7/26/25), she came to the SNF to sit with P-1 around 3:00 PM. Com-1 stated that P-1 seemed to be breathing very hard at that time, which she believed was a sign of discomfort. Com-1 said that she asked the SNF nurse to give P-1 some pain medicine that was prescribed by the hospice. Com-1 said the SNF nurse told her they (SNF nursing) were waiting to get a code needed from the pharmacy to get the medication out of their medication dispensing system. Com-1 said the SNF nurse told her hospice had been called for assistance. Com-1 stated that after hearing that, she called the hospice and told them that P-1 was not getting his pain medication. Com-1 also stated the SNF staff did give P-1 some medication but not pain medication. Com-1 said that P-1 did not get a dose of pain medicine until 11:00 PM and died soon after. When asked if she (Com-1) felt that P-1’s symptoms seemed to be managed, Com-1 explained that she felt P-1 was uncomfortable because he had initially been receiving scheduled pain medication and that schedule of medication had been interrupted. Com-1 did deny that P-1 had facial grimacing or made vocalizations of pain.P-1: This patient was admitted to the hospice agency on 7/25/25 with a terminal diagnosis of intracerebral hemorrhage (bleeding within the brain). The medical record was reviewed on 9/24/25. During review, the following information was noted in the medical record (including associated triage call logs):The plan of care dated for the certification period of 7/25/25 through 10/22/25 included physician orders for a scheduled opioid medication (Dilaudid, 2 mg orally every 2 hours for pain). There were no other opioid pain medication orders on P-1’s medication profile.On the start of care visit dated 7/25/25 which began at 9:30 PM, the registered nurse (RN-1) documented that P-1 was unresponsive. RN-1 also documented a respiratory assessment for P-1 which included that P-1 was screened for, and was found to have, shortness of breath. RN-1 selected types of treatment initiated for P-1’s shortness of breath which included “OPIOIDS” (unnamed in note). Oxygen was also being provided for respiratory symptoms.On the nursing visit dated 7/26/25 which began at 11:08 AM, the registered nurse (RN-2) documented that P-1 was lethargic and unresponsive. RN-2 also documented that P-1 was assessed for, and found to have, mild pain. Additionally, RN-2 documented that P-1’s respiratory status was assessed and found to be abnormally fast, and that P-1 was using accessory muscles to breathe (which indicated it was harder work for P-1 to breathe). RN-2 documented that opioid medication (unnamed in note) was utilized for P-1’s pain, and respiratory symptoms. Finally, RN-2 documented that the SNF nurse was advised to give “medication” (unnamed) for increased work of breathing; that P-1’s medications were reviewed with the SNF nurse; and that the SNF had a 7-day supply of all the medications (unnamed) on hand with no refills needed. The visit note status was completed at 11:41AM (indicating the end of the visit).A communication note was entered on 7/26/25 at 3:52 PM (4 hours and 11 minutes after the in-person nursing visit ended) by RN-2 stating that an SNF nurse called because the pharmacy was requesting clarification of P-1’s Dilaudid order (opioid pain medication). RN-2 documented that she called pharmacy to clarify the order for Dilaudid with pharmacist and called the SNF back to update the order.On 7/26/25 at 4:15 PM (23 minutes after communication note by RN-2)- a triage call was received from Com-1 and was handled by RN-2. The triage message details included the following questions and documented responses:Out of Medication? “No”Urgent RX (prescription) Refill? “No”Patient in Pain? “No”Message: “Patient has not received any medications as yet.” [sic]There were no additional communication notes, interventions offered, additional symptom management information (including respiratory status), or additional visits documented in the medical record regarding this call.On 7/26/25 at 9:18 PM (5 hours and 3 minutes after the last time Com-1 called)- a call was received from Com-1 and handled by a hospice agency nurse (RN-3). The triage message details included the following questions and documented responses:Out of Medication? “Yes”Urgent RX (prescription) Refill? “Yes”Patient in Pain? “Yes”Message: “PT’s (patient’s) pain medication hasn’t arrived.”There were no additional communication notes, interventions offered, additional symptom management information (including respiratory status), or additional visits documented in the medical record regarding this call. On 7/26/25, RN-3 entered a visit note which was titled, Hospice Unattended Death at Facility. The assessment documentation included that at 11:30 PM, SNF staff reported that P-1 had died on 7/26/25 at 11:15 PM. On 9/25/25, the “Nursing Facility Hospice Services Agreement” (agreement between the hospice agency and the SNF), signed and dated on 7/25/25, was provided for surveyor review. On page 2., it stated “D… Hospice assumes responsibility for professional management, including, but not limited to, the planning, coordinating and prescribing, of the hospice services provided to and for determining the appropriate course of hospice care for the Patient…” On 9/25/25 at 1:40 PM, an interview was conducted with the hospice Administrator (ADM-1) and the Director of Clinical Services (DCS-1). ADM-1 and DCS-1 were asked if communication regarding triage calls was expected to be added to the medical record. ADM-1 stated yes. When asked who was responsible for ensuring the patient’s symptoms were managed, DCS-1 stated “both of us” referring to both the hospice agency and the SNF. When asked if P-1 received his scheduled Dilaudid, DCS-1 stated the only way the hospice would know if the patient was not receiving his medication is if the SNF told hospice. DCS-1 stated that RN-2 documented P-1 was getting his medication at the visit on 7/26/25. When asked if P-1 was getting the Dilaudid when 2 triage calls were received from Com-1, DCS-1 stated the hospice agency could have documented interventions better in the medical record. ADM-1 reported that a message was sent on the agency’s Microsoft Teams application from RN-3 to RN-2 (on 7/26/25) regarding the Dilaudid order that stated the SNF was advised by RN-2 during the call on 7/26/25 at 3:52 PM to give Dilaudid on hand at the SNF but this was not in P-1’s medical record and remains unclear. No other medication administration documentation was provided for review during the survey. The hospice failed to demonstrate in the medical record that P-1 received the scheduled pain medication Dilaudid, 2mg every 2 hours as ordered by the physician.”

“Based on record review and interview, the hospice failed to ensure nursing services provided an initial pain assessment to determine the patient’s related nursing needs and ensure nursing needs were met in 1 (P-1) of 3 records reviewed resulting in the potential for unmet care needs. Findings include: On 9/24/25, the hospice agency procedure titled “HOS-C_08A Pain Management”; (revised on 2/4/2025), was provided for surveyor review. On page 1-2., it stated “At the ADMISSION nursing visit, the nurse completes the comprehensive pain assessment and then establishes with the patient the level of pain severity which will require a change in current pain management strategy… Type of Pain Scales… Pain AD- most appropriate for patients with cognitive impairment and should be used for all patients with… conditions which impair speech”.P-1: This patient was admitted to the hospice agency on 7/25/25 with a terminal diagnosis of intracerebral hemorrhage (bleeding within the brain). The medical record was reviewed on 9/24/25.During review of the plan of care dated for the certification period of 7/25/25 through 10/22/25 it was noted physician orders included a scheduled opioid pain medication (Dilaudid, 2 mg orally every 2 hours for pain). During review of the start of care (SOC) assessment completed by an agency registered nurse (RN-1) on 7/25/25, in the section of the SOC assessment titled “Pain”, the following assessment questions and documented responses (provided by RN-1) were noted:Assessment question: “Was the patient screened for pain?”RN#1 selected the answer “NO”.Assessment question: “Indicate why pain/comfort was not assessed:”RN#1 documented “pt (patient) unresponsive”.Assessment question: “Is pain an active problem for the patient?”RN#1 selected the answer “NO”.Assessment question: “Are there additional comments regarding pain assessment?” RN#1 documented “NO”. The hospice failed to provide a pain assessment on the admission visit to establish the level of pain severity which will require a change in current pain management strategy. On 9/25/25 at 1:40 PM, an interview was conducted with the hospice Administrator (ADM-1) and the Director of Clinical Services (DCS-1). ADM-1 and DCS-1 were asked if an unresponsive patient could still be assessed for signs of pain. ADM-1 stated yes. When asked if RN-1 should have completed a pain assessment for this patient at the SOC assessment, ADM-1 stated yes.”