Universal Hospice Care

“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 and interview. In 1 of 7 (14%) clinical records reviewed revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 3: Hospice benefit of election was 10/21/2025 with a primary diagnosis of Alzheimer’s Disease and a secondary diagnosis of Diabetes. The patient was on a sliding scale for insulin and Januvia daily . The initial plan of care dated 10/21/2025 and updated every two weeks did not document any interventions for diabetes. The nursing assessments documented 10/24/2025 with a blood sugar of 257 and additionally insulin given and again 10/29/2025 additional insulin needed for blood sugar of 257. The updated nursing assessment on 11/10/2025 documented orders received for Lantus insulin 100unit that 10 units be given at bedtime as blood sugars noted as too high. As of review 11/24/2025 there were no documented interventions on the plan of care for diabetes. During interview with the administrator on 11/24/2025 she stated that her nurse and clinical manager left the agency suddenly and had not completed the identified update for the plan.”

“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 1 of 6 (17%) clinical records reviewed, in which a hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 3: The initial comprehensive assessment documented on 10/21/2025 documented that the patient had a coccyx wound with a foam dressing as well as foam boots to be worn bilaterally. He was paralyzed from the waist down and used a Hoyer transfer. The hospice aide plan documented 10/21/2025 and updated 11/13/2025 did not document the transfer per Hoyer, it does direct transfer bed to chair but not specifically with a Hoyer. The dressing on the coccyx was not identified on the aide plan to report to nurse if off, saturated or signs or symptoms of infections. During interview with the administrator on 11/24/2025 stated that the nurse who created the aide instructions left the organization suddenly and the plan did not get corrected.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, in which a hospice aide supervisory visit was required, the agency did not ensure that the hospice aide was supervised by a Registered Nurse no less frequently than every 14 days. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 3: The hospice benefit of election was 10/21/2025 with a primary diagnosis of Alzheimer’s Disease. The first hospice aide visit was 10/24/2025 with supervision documented 10/27/2025 and then 11/14/2025 which was day 18 and was 4 days late. During interview with the administrator on 11/24/2025 stated that the clinical manager left suddenly and had not completed all the supervisions assigned.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed that required additional physician orders, it was revealed that the agency did not ensure that all required physician orders were documented. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 3: The hospice benefit of election was 10/21/2025 with a wound identified on the coccyx with a dressing that included calcium alginate and a foam covering. Additionally, the updated nursing assessment documented on 11/10/2025 that orders were received for Tylenol suppository 650 milligram every 4 hours for elevated fever and Lantus 100unit administer 10 units at bedtime for elevated blood sugars. The medication profile was updated but there was no documented physician order for these medications and treatments. During interview with the administrator on 11/24/2025 she stated that the facility had the order and they would have to obtain a copy of this.”

“It is required that a hospice must routinely provide substantially all core services directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by review of the agency’s clinical records and interviews with the Administrator and Director of Nursing which revealed the following issues: Failed to ensure that nursing care and services were provided, as written in the plan of care, in 2 of 22 (9%) clinical records [HCDT.6.I/L591/418.64(b)(1)]; Failed to ensure that medical social services were provided according to plan of care and per the patient and family needs in 5 of 21 (24%) clinical records [HCDT.9.I/L594/418.64(c)]; Failed to ensure bereavement services were available and provided to the families in 4 of 4 (100%) of bereaved records [HCDT.22.I/L596/418.64(d)(1)(iv)]; and Failed to ensure that spiritual counseling was provided to meet the spiritual needs of the patient and family in 6 of 16 (38%) of clinical records [HCDT.11.I/L598/418.64(d)(3)(ii)]. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice services from the agency.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record reviews and interviews with the Administrator and Director of Nursing, which revealed the following: Failed to ensure the skills competency assessment for the aide was completed prior to providing unsupervised direct patient care in 2 of 2 (100%) personnel records reviewed of hospice aides [HSRM.9.I/L615/418.76(c)(1)]; Failed to ensure the hospice aide was provided specific written patient care instructions in 6 of 19 (32%) clinical records reviewed [HCDT.15.I/L625/418.76(g)(1)]; Failed to ensure that hospice aides provided services as ordered by the Interdisciplinary Group in 3 of 19 (16%) of clinical records reviewed [HCDT.16.I/L626/418.76(g)(2)(i)]; Failed to ensure the hospice aide reported changes related to the plan of care to the Registered Nurse in 3 of 19 (16%) of clinical records reviewed [HCDT.18.I/L628/418.76(g)(4)]; and Failed to ensure hospice aides were supervised by a registered nurse no less frequently than every 14 days in 2 of 19 (11%) clinical records reviewed [HSRM.25.I/L629/418.76(h)(1)(i)]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including: Participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. b) If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to: A second full-scale exercise that is community-based or a facility-based functional exercise; or A mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness documents revealed the agency did not ensure the annual testing of the emergency plan was documented. Review of the Emergency Preparedness Binder revealed no documented tests or exercises of the emergency preparedness system in 2023, 2024, or 2025. They did do a practice fire drill in September of 2025 but no other documented testing of their emergency preparedness system. During an interview on 10/08/2025 the Administrator stated that the office had been broken into, a few months ago and documents were removed, she validated this with police reports. She had no other documented activity but was planning an exercise in 2025. Review of the Emergency Preparedness Binder revealed no documented tests or exercises of the emergency preparedness system in 2023, 2024, or 2025. They did do a practice fire drill in September of 2025 but no other documented testing of their emergency preparedness system. During interview with the administrator on 10/08/2025 stated that the office had been broken into and documents were removed, she validated this with police reports. She had no other documented activity but was planning an exercise in 2025.”

“The written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who exercised their right to request the “Patient Notification of Hospice Non-Covered Items” document, it was revealed that the agency did not ensure the information was provided to the patient within 5 days, as required. CLINICAL RECORD 3: The patient elected the hospice Medicare benefit on 08/01/2025, and on that date requested the election statement addendum, “Patient Notification of Hospice Non-Covered Items.” As of the date of the review, 10/09/2025, the record lacked evidence that the information had been provided to the patient. CLINICAL RECORD 5: The patient elected the hospice Medicare benefit on 07/30/2025, and on that date requested the election statement addendum, “Patient Notification of Hospice Non-Covered Items.” As of the date of the review, 10/09/2025, the record lacked evidence that the information had been provided to the patient. During interview with the Hospice Liaison on 10/10/2025 and the Administrator on 10/10/2025 the Liasson stated that two copies of the addendum are left with every patient on obtaining signing of the benefit of election. She stated that they are blank, and the nurse was supposed to complete them. The administrator stated that they will educate the nurses about completion and leaving a completed copy with the patient and bringing the other back to the office.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with laboratory monitoring. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed the agency did not ensure that the medication profile was accurate for all medications and active medications that the patient was taking and could not correctly review all medications for potential interactions. CLINICAL RECORD 4: The hospice election of benefit was 12/10/2024 with a primary diagnosis of Alzheimer’s Disease. The medication profile documented Cipro that was ordered 09/21/2025 for infection to be administered for one week (09/28/2025). The medication remained listed as an active medication on the profile and was not discontinued per the physician order. CLINICAL RECORD 22: The hospice benefit of election was on 07/01/2025 with a primary diagnosis of Alzheimer’s Disease and secondary of hypertension. The nursing assessment completed on 08/06/2025 documented the use of oxygen but as of the date of death 08/28/2025 the oxygen was not added to the medication profile. During the interview, on 10/09/2025, the Director of Nursing stated the medication profiles were not accurate.”

“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 12 of 22 (55%) clinical records reviewed the agency did not ensure documentation of a pre bereavement assessment. CLINICAL RECORD 5: The initial comprehensive assessment was completed on 07/30/2025. As of the review (10/09/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 8: The initial comprehensive assessment was completed on 09/12/2025. As of the review (10/10/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 10: The initial comprehensive assessment was completed on 09/17/2025. As of the review (10/10/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 13: The initial comprehensive assessment was completed on 12/10/2024. As of the review (10/09/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 14: The initial comprehensive assessment was completed on 06/27/2025. As of the review (10/09/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 15: The initial comprehensive assessment was completed on 08/01/2025. As of the date of the revocation (08/17/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 16: The initial comprehensive assessment was completed on 07/06/2025. As of the date of the revocation (07/25/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 17: The initial comprehensive assessment was completed on 06/18/2025. As of the date of death (07/18/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 18: The initial comprehensive assessment was completed on 06/16/2025. As of the date of death (07/12/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 19: The initial comprehensive assessment was completed on 06/19/2025. As of the date of death (06/30/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 20: The initial comprehensive assessment was completed on 03/28/2024. As of the date of review (10/09/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. CLINICAL RECORD 22: The initial comprehensive assessment was completed on 07/01/2025. As of the date of death (08/28/2025), the record lacked documented evidence that the initial comprehensive assessment included the bereavement risk assessment. During interview with the Director of Nursing and the Administrator on 10/09/2025 they stated that the initial bereavement assessments were not documented.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 6 of 13 (46%) clinical records in which an LVN ( a Licensed Vocational Nurse) provided visits, the agency did not ensure that a registered nurse provided a comprehensive assessment of care every 15 days. CLINICAL RECORD 2: The initial comprehensive nursing assessment was completed on 07/06/2025. The nursing frequency was one time a week. There was a Registered Nurse (RN) visit on 07/22/2025 and the next RN visit was 09/18/2025; in between all weekly visits were completed by an LVN. There were 57 days between the updated comprehensive assessment being completed by an RN. CLINICAL RECORD 4: The initial comprehensive nursing assessment was 12/10/2024. The plan of care, dated 08/07/2025 to 10/05/2025, included skilled nurse frequency once per week. An RN comprehensive assessment was completed on 08/28/2025 and the next was 09/18/2025 with weekly visits in between completed by the LVN. There were 21 days between the updated comprehensive assessments being completed by an RN. CLINICAL RECORD 6: The initial comprehensive assessment was completed by a registered nurse on 04/04/2025. The plan of care, dated 08/12/2025 to 10/10/2025, included a skilled nursing visit frequency order of one time a week. An RN completed a comprehensive assessment on 08/05/25 and the next RN visit was documented on 09/29/2025; in between all weekly visits were completed by an LVN. There were 55 days between the updated comprehensive assessments being completed by an RN. CLINICAL RECORD 13: The initial comprehensive assessment was completed by the RN on 08/28/2025. The nursing visit frequency was ordered at 1-2 times a week per quarter. As of 10/06/2025 which was 40 days and not every 15 days. CLINICAL RECORD 14: The initial comprehensive assessment was completed by an RN on 06/27/2025. The plan of care dated 06/27/2025 to 09/24/2025 included the skilled nurse visit frequency orders of 1-2 per week. Following the initial visit on 06/27/2025 the next RN visit was documented on 07/25/2025, this was 30 days later. An RN visit was documented on 08/02/2025 and the next one on 09/12/2025 which was 40 days between updated comprehensive assessments. CLINICAL RECORD 17: The initial comprehensive assessment was completed by a Registered Nurse on 06/18/2025. With a nursing frequency of 1-2 times a week. Following the initial visit on 06/18/2025 the next RN visit was documented on 07/18/2025, this was 30 days before the updated comprehensive assessment was documented. During an interview the Administrator and Director of Nursing stated that many staffing changes contributed to fewer Registered Nurses for a time.”

“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 and interview. In 13 of 22 (59%) clinical records reviewed, it was revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 1/HOME VISIT 1: The hospice election of benefit was 01/31/2025 with a primary diagnosis of congestive heart failure. The initial comprehensive assessment documented a wound on the right heel. During the home visit on 10/07/2025, the Registered Nurse (RN) was observed performing wound care on the right heel, the right forefoot and the left heel. The initial plan of care and updated plans of care did not document specific interventions for wound care. The patient was observed to have oxygen in the home, and the plan of care documented no interventions for the oxygen or respiratory care. CLINICAL RECORD 2: The hospice election of benefit was 07/06/2025 with a primary diagnosis of hydrocephaly. The initial plan of care and plans of care updated every two weeks did not document interventions for the primary diagnosis or the additional diagnosis of Dementia. The interdisciplinary meeting documented 09/29/2025 for nutritional needs but the plan was not updated for any interventions related to nutrition. CLINICAL RECORD 3: The hospice election of benefit was 08/01/2025 with a primary diagnosis of Alzheimer’s Disease. The initial plan of care and plans of care updated every two weeks did not include interventions for neurological needs, fall risk identified in the initial comprehensive assessment or incontinence interventions documented in the initial comprehensive assessment. CLINICAL RECORD 4: The hospice election of benefit was 12/10/2024 with a primary diagnosis of Alzheimer’s Disease and a comorbidity of Diabetes with insulin per sliding scale. The initial plan of care and plans of care updated every two weeks did not include interventions for diabetic management or monitoring of blood sugars. The nursing clinical visit notes documented orders for Augmentin 08/13/2025 and Cipro 09/21/2025 but the plans of care were not updated with any interventions for the defined infections as of review 10/07/2025. CLINICAL RECORD 5: The hospice election of benefit was 07/30/2025. The initial comprehensive assessment completed the same day included a primary diagnosis of prostate cancer and a comorbidity of dementia. The initial plan of care documented 08/01/2025 did not include any interventions for cancer or neurological needs. CLINICAL RECORD 6: The hospice election of benefit was 08/23/2023. The initial comprehensive assessment completed the same day documented congestive heart failure as primary diagnosis. The initial plan of care and plans of care updated every two weeks do not document any cardiac interventions. The certificate of terminal illness (dated 08/07/2025-10/05/2025) documented a wound on the left hip, and the nursing clinical visits documented the wound care, but the plan of care documented no interventions for skin integrity. The wound continued as of review 10/07/2025. CLINICAL RECORD 7: The hospice election of benefit was 10/01/2024 with a primary diagnosis of Alzheimer’s Disease. The initial comprehensive assessment (10/01/2024) documented a fall risk of “7” (greater than “4” was a fall risk). There were no fall interventions on the plan of care dated 10/01/2024 to the date of review 10/10/2025. The nursing assessment visit dated 11/01/2024 documented redness and skin breaks on hips but no interventions on the updated plans of care 11/15/2024, 11/29/2024, or 12/27/2024. The plan of care was not updated with skin integrity interventions until 03/07/2025. CLINICAL RECORD 8: The hospice election of benefit was 09/12/2025 with the primary diagnosis of Prostate Cancer and a comorbidity of Dementia. The initial nursing comprehensive assessment dated 09/12/2025, documented difficulty with swallowing and using nectar and thickened liquids. The initial plan of care documented 09/15/2025 and updated 09/19/2025 and 10/03/2025 did not include any interventions for nutrition or swallowing deficits. CLINICAL RECORD 9: The hospice election of benefit was 09/18/2025 with the primary diagnosis of stomach cancer. The initial comprehensive assessment documented shortness of breath and oxygen started at 2 liters per minute per nasal cannula. The initial plan of care dated 09/18/2025 and updated 10/03/2025 documented no interventions for respiratory status and no oxygen interventions. The patient revoked the hospice benefit on 10/08/2025. CLINICAL RECORD 10: The hospice election of benefit was 09/17/2025 with the primary diagnosis of lymphocytic cancer with a comorbidity of diabetes. The initial comprehensive assessment dated 09/17/2025 documented that the patient used a nebulizer routinely but there were no documented interventions for the respiratory problem. CLINICAL RECORD 13: The hospice election of benefit was 08/28/2025 with a primary diagnosis of Alzheimer’s disease and a comorbidity of hypertension. The initial plan of care documented on 08/28/2025 and updated every two weeks did not include any interventions for Alzheimer’s or for cardiac problems. The initial comprehensive assessment also documented a fall risk of “5” (greater than “4” was a fall risk). There were no documented interventions for falls. CLINICAL RECORD 17: The hospice election of benefit was 06/18/2025 with a primary diagnosis of Alzheimer’s Disease. A nursing assessment dated 06/30/2025 documented problems with constipation. The initial plan of care was documented on 06/18/2025 and was updated every two weeks, but none of the updated plans of care, starting 07/11/2025 included any interventions for constipation. CLINICAL RECORD 22: The hospice election of benefit was 07/01/2025 with a primary diagnosis of Alzheimer’s Disease. The initial plan of care was documented on 07/01/2025 with a problem related to the PEG (percutaneous endoscopic gastronomy) tube that lacked individualized interventions for flushing the tube or dressing or cleaning around the tube. The referral orders documented that the tube should be flushed with water 75 milliliters before and after each bolus feeding three times a day. Additionally on the nursing comprehensive visit on 07/11/2025 the nurse documented that the coccyx was red, the penis was red, and the heels were red, with the addition of barrier cream and to float the heels. The plans of care updated every two weeks did not update with any interventions for skin integrity. On 08/06/2025 the nursing comprehensive assessment documented use of oxygen but there were no updated respiratory interventions on the plan of care, as of date of death 08/28/2025. During an interview with the Administrator and Director of Nursing, on 10/09/2025, they stated that interventions and plans of care were a focus area.”

“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, a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 22 (18%) clinical records reviewed, it was revealed that the agency did not ensure that the plans of care documented the scope and frequency of services specific to meet the patient and family needs. CLINICAL RECORD 2: The hospice election of benefit was 01/31/2025 with a primary diagnosis of congestive heart failure. The initial plan of care (POC) dated 01/31/2025 included Registered Nurse (RN), Social Worker (MSW), and Chaplain frequencies all had PRN visits ordered without an indication or defined number of PRN visits they could make. CLINICAL RECORD 3: The hospice election of benefit was 08/01/2025 with a primary diagnosis of Alzheimer’s Disease. The plan of care, dated 08/01/2025, included Registered Nurse (RN), social worker (MSW), and Chaplain visit frequencies that had PRN visits ordered without an indication or defined number of PRN visits they could make. CLINICAL RECORD 5: The hospice election of benefit was 07/30/2025 with a primary diagnosis of Prostate Cancer. The plan of care, effective 07/30/2025, included Registered Nurse (RN), social worker (MSW), and Chaplain visit frequencies that had PRN visits ordered without an indication or defined number of PRN visits they could make. CLINICAL RECORD 17: The plan of care documented 06/18/2025 and updated every 2 weeks included Physician, Registered Nurse (RN), Social Worker (MSW), and Chaplain visit frequencies that had PRN visits ordered without an indication or defined number of PRN visits they could make. During the interview, on 10/09/2025, the Director of Nursing stated that the number of PRN visits was not documented and agreed ranges for aides was not correct.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed, the agency did not ensure that all outcomes included in the plan of care were measurable. CLINICAL RECORD 15: The hospice election of benefit was 08/01/2025 with a primary diagnosis of Bowel Cancer. The plan of care (POC), dated 08/01/2025 and the subsequent updates to the POC, included the goal, “Patient will consistently meet pain goals when assessed.” The pain goal was not defined; the outcome was not measurable. CLINICAL RECORD 21: The hospice election of benefit was 03/11/2024 with a primary diagnosis of respiratory failure. The plan of care (POC), dated 03/11/2024, and the subsequent updates to the POC, included the goal, “Patient will consistently meet pain goals when assessed.” The pain goal was not defined; the outcome was not measurable. During interview with the Director of Nursing and Administrator, on 10/09/2025, they stated that the outcomes were not measurable.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as, hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 5 (20%) home visit observations it was revealed that the agency did not ensure staff adherence with the infection control policies. Agency Policy PC.136, Infection control – PPE (Personal Protective Equipment), stated in part, “Gloves should be worn when it can be reasonably anticipated that there may be hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin and when handling or touching contaminated items or surfaces. 6. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment.” Agency Policy PC.125, Hand Hygiene, stated in part, “Hospice staff must wash hands: b. before performing clean/aseptic procedures; c. after performing tasks that involve risk of exposure to body fluids; e. before and after wearing gloves...” HOME VISIT 1: During the home visit, on 10/07/2025, the Registered Nurse (RN) (Personnel Record 1) was observed providing wound care to 4 different wound sites, (1- Left posterior hand, 2- left lateral heel, 3- right anterior side of foot, 4- top of left second toe), the nurse removed the dressing from wound 1 with her gloved hands and disposed of the gloves and the dressing. She donned gloves without performing hand hygiene/using hand sanitizer and proceeded to provide care to left posterior hand. The RN reached in and out of the bag which held clean dressing supplies several times without sanitizing hands. After completing the dressing change for wound 1, the RN proceeded to provide wound care to wounds 2, 3, and 4, while still donning the same pair of gloves. Throughout the dressing changes for the remaining wounds the RN was observed reaching into the visit bag for additional supplies. The nurse used a Sani-Wipe to clean her scissors and tweezers between each wound care (there was only one Sani-Wipe used during the visit). The same Sani-Wipe opened to reclean the scissors and tweezers was used to clean her gloves in between dressing changes. During interview with the nurse on 10/07/2025 stated the Sani-Wipe does say ‘wet surface for 2 minutes’ I did not know that but will practice that in the future.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed, it was revealed that the agency did not ensure that nursing care was provided as ordered by the physician in the plan of care. CLINICAL RECORD 11: The plan of care dated 05/13/2025 to 07/11/2025 included skilled nursing visit frequency orders for once per week. From 05/13/2025 until 06/10/2025 there were no nursing visits documented, which was 27 days. The clinical record lacked documentation for why the visits were not made. CLINICAL RECORD 20: The plan of care dated 05/22/2025 to 07/20/2025 included skilled nursing visit frequency orders for once per week. The week of 07/13/2025 - 07/19/2025 no nursing visits were documented. The clinical record lacked documentation for why the visits were not made. During interview with the Director of Nursing who stated the documentation is not there.”

“It is required that medical social services are provided by a qualified social worker, based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 5 of 21 (24%) clinical records in which the medical social worker (MSW) was accepted, the agency did not ensure visits were provided as ordered by the physician. CLINICAL RECORD 5: The Initial Plan of care was dated 07/30/2025 and included orders for the Social Worker (MSW) visit frequency of one time a month. A visit was documented on 07/31/2025 then a subsequent visit was documented on 09/12/2025. No visit was documented in the month of August 2025 and the clinical record lacked documentation for why the visit was not made. CLINICAL RECORD 7: The plan of care (POC) for the benefit period, dated 03/20/2025 to 05/28/2025, included MSW orders for visit frequency of 1 time a month. On the updated plans of care dated 04/14/2025, 04/18/2025, 05/02/2025 and 05/16/2025 the social worker documented to continue monthly visits. The only MSW visit documented for that plan of care date range was on 05/14/2025; the record lacked documentation as to why there were no documented visits through the end of March or the month of April. The plan of care for the benefit period, dated 05/29/2025 to 07/27/2025, included MSW orders for visit frequency of 1 time a month. The updated plans of care dated 05/30/2025, 06/13/2025, 06/27/2025, 07/11/2025 and 07/25/2025 the MSW documented to continue monthly visits. There were no visits documented the entire benefit period (05/29/2025 to 07/27/2025). The clinical record lacked documentation for why the visits were not made and there were no order changes written to decrease or stop the MSW visits. CLINICAL RECORD 13: The plan of care for first benefit period 08/28/2025 to 11/25/2025 included orders for the MSW to visit once per month. A social work visit was documented on 08/29/2025 with no further visits documented. The clinical record lacked documentation for why the visits were not made and there were no order changes written to decrease or stop the MSW visits. CLINICAL RECORD 14: The plan of care for first benefit period 06/27/2025 to 09/24/2025 included orders for the MSW to visit once per month. A social work visit was documented on 07/01/2025 with no further visits documented. The clinical record lacked documentation for why the visits were not made and there were no order changes written to decrease or stop the MSW visits. CLINICAL RECORD 17: The plan of care for the first benefit period, effective 06/18/2025 included the MSW visit frequency was 1 time a week. The MSW documented a visit on 06/19/2025 for the initial assessment and no further visits were documented as of the date of death (07/22/2025). The clinical record lacked documentation for why the visits were not made and there were no order changes written to decrease or stop the MSW visits. During an interview on10/10/2025, the Administrator and Director of Nursing stated staff changes had been made as this was an identified problem.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 4 (100%) clinical records reviewed of patients who have died, it was revealed the agency did not ensure the bereavement services were provided and documented in accordance with agency policy. Agency Policy, PC.B10 Bereavement Care Planning, stated in part, “The Bereavement Coordinator is notified of all deaths and initiates the bereavement discussion and care planning at the first IDG meeting following the patient’s death. At this time the bereavement plan of care is developed and information from the initial bereavement assessment is considered.” CLINICAL RECORD 17: The date of death was 07/22/2025 with the last IDG (interdisciplinary group) meeting was documented on 07/25/2025. The clinical record lacked documentation of a post death bereavement assessment or a bereavement plan of care with frequency of services, or a declination of bereavement services. CLINICAL RECORD 18: The date of death was 07/12/2025 with the last IDG meeting documented on 07/25/2025. The clinical record lacked documentation of a post death bereavement assessment or a bereavement plan of care with frequency of services, or a declination of bereavement services. CLINICAL RECORD 19: The date of death was 06/30/2025 with the last IDG meeting 07/11/2025. The clinical record lacked documentation of a post death bereavement assessment or a bereavement plan of care with frequency of services, or a declination of bereavement services. CLINICAL RECORD 22: The date of death was 08/28/2025 with no documented bereavement contact as of review 10/09/2025 or an IDG meeting that reviewed the death of the patient. The clinical record lacked documentation of a post death bereavement assessment or a bereavement plan of care with frequency of services, or a declination of bereavement services. During interview with the Bereavement Coordinator, on 10/07/2025, stated that he was new to the position and has just started with all deaths to send a sympathy card and call all bereaved and has planned mailings but was not sure how to document in the software yet.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 6 of 16 (38%) clinical records in which spiritual counseling was identified and not documented as declined, the agency did not ensure that spiritual care services were provided. CLINICAL RECORD 5: The hospice election of benefit was 07/30/2025 with a primary diagnosis of Prostate Cancer. The initial comprehensive assessment was completed on 07/30/2025 by the nurse who documented a spiritual assessment. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. CLINICAL RECORD 13: The hospice election of benefit was 08/28/2028 for Alzheimer’s Disease. The initial comprehensive assessment completed by the nurse documented a spiritual assessment. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. CLINICAL RECORD 16: The hospice election of benefit was 07/06/2025 for prostate cancer. The initial comprehensive assessment completed by the nurse documented a spiritual assessment. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. CLINICAL RECORD 17: The hospice election of benefit was 06/18/2025 with a primary diagnosis of Head and Neck Cancer. The initial comprehensive assessment completed by the nurse documented a spiritual assessment. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. CLINICAL RECORD 18: The hospice election of benefit was 06/16/2025 with a primary diagnosis of Head and Neck Cancer. The initial comprehensive assessment completed by the nurse documented a spiritual assessment. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. CLINICAL RECORD 22: The hospice election of benefit was 07/01/2025 with a primary diagnosis of Alzheimer’s Disease. The initial comprehensive assessment was completed on 07/01/2025 with a documented spiritual assessment that stated there were spiritual concerns but did not document refusal of spiritual care or offering of this service. The clinical record lacked documentation of patient/family contact by the Chaplain or if the spiritual care services were accepted or refused. During interview with the Director of Nursing and the Administrator on 10/09/2025 they stated that the identified patients had refused spiritual care but agreed that it was not documented in the clinical record.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed competency evaluations. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The competency evaluation addresses each of the following subject areas and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; Reading and recording temperature, pulse, and respiration; Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed of a hospice aide, it was revealed that the agency did not ensure that a competency evaluation was completed by a Registered Nurse prior to providing unsupervised direct patient care. PERSONNEL RECORD 7: The hospice aide was hired 06/23/2025 and left the agency in September 2025 but provided patient care during the other 3 months. There was no documented competency on hire that any skills were observed by a Registered Nurse prior to patient care being provided. PERSONNEL RECORD11: The hospice aide was hired 02/11/2025. The aide continued to provide care as of review 10/09/2025. There was no documented competency on hire that any skills were observed by a Registered Nurse prior to patient care being provided. During interview with the Director of Nursing on 10/10/2025 they provided an aide competency form that they had used in the past with the correct requirements and said they will start to use this again.”

“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 19 (32%) clinical records reviewed, in which a hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 2: The hospice election of benefit was 01/31/2025 with a primary diagnosis of congestive heart failure. The initial plan of care dated 01/31/2025 documented a hospice aide frequency and duration that was written as 1-3 times a week and PRN (as needed). The aide was not provided instructions for the range or the as needed visits. CLINICAL RECORD 3: The hospice benefit of election was 08/01/02025 with a primary diagnosis of Alzheimer’s Disease. The initial plan of care dated 08/01/2025 included the hospice aide visit frequency written as 1 to 2 times a week and PRN (as needed). The updated plans every two weeks documented the same frequency as of 10/09/2025. The aide was not provided instructions for the range or the as needed visits. CLINICAL RECORD 5: The hospice benefit of election was 07/30/2025 with a primary diagnosis of Prostate Cancer. The initial plan of care dated 07/30/2025 included the hospice aide visit frequency written as 1 to 3 times a week. The updated plans every two weeks documented the same frequency as of 10/09/2025. The aide was not provided instructions for the range or the as needed visits. CLINICAL RECORD 17: The hospice benefit of election was 06/18/2025 with a primary diagnosis of head and neck cancer. The initial plan of care dated 06/18/2025 included the hospice aide visit frequency written as 1 to 3 times a week. The updated plans every two weeks documented same frequency as of 10/09/2025. The aide was not provided instructions for the range. CLINICAL RECORD 18: The hospice benefit of election was 06/16/2025 with a primary diagnosis of head and neck cancer. The initial plan of care dated 06/16/2025, through the date of death (07/12/2025) included the hospice aide visit frequency order of 1 to 3 times a week; the aide was not provided instructions for the range. The same aide plan of care did not include that the patient had a PEG (percutaneous endoscopic gastrostomy) tube or that he had a dressing around the PEG tube and what to do if the dressing became wet or dislodged. CLINICAL RECORD 22: The hospice benefit of election was 07/01/2025 with a primary diagnosis of Alzheimer’s disease. The hospice aide plan of care dated 07/01/2025 through the date of death (08/28/2025) did not document that the patient had a PEG tube in place. It also was not updated on 07/11/2025 with the nursing direction to float the heels that was documented on the nursing assessment. The same plan of care included orders for the aide visit frequency of 1 to 3 times a week; the aide was not provided instructions for the range. During an interview on 10/10/2025, the Director of Nursing and the Administrator stated they would have to work on the aide plans of care.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, in which a hospice aide provided care, the agency did not ensure that the hospice aide provided services as ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 3: The hospice aide frequency documented on the plan on 08/01/2025 was 2 times a week. The weeks of 09/07/2025, 09/14/2025, and 09/21/2025 the aide documented 3 visits per week; the clinical record lacked orders for the additional visits or documentation for why the additional visits were made. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025 with the hospice aide frequency ordered at 3 times a week. The week of 08/10/2025 there were no hospice aide visits documented and no reason for the missed visits documented. The week of 08/17/2025 there was one aide visit documented and no documented reasons for the other 2 visits not made. The week of 08/24/2025 there were no hospice aide visits documented and no reason for why the visits were not made was documented. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/10/2024 with the hospice aide frequency ordered at 2 times a week. The week of 09/21/2025 - 09/27/2025 there were no aide visits documented and no reason for why the visits were not made. During an interview on 10/08/2025, the Administrator stated the aide was no longer with the agency.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, in which hospice aide services were provided, the agency did not ensure that the hospice aide reported changes to the Registered Nurse as they related to changes in the visit frequency ordered in the plan of care. CLINICAL RECORD 3: The hospice aide frequency ordered on the plan of care effective 08/01/2025 was 1- 2 times a week. The weeks of 09/07/2025, 09/14/2025, and 09/21/2025 the aide documented 3 visits per week. There was no documented communication with the Registered Nurse (RN) that the additional visits were made, or the RN approved the increase in visits. CLINICAL RECORD 5: The patient elected the hospice benefit on 07/30/2025 with the hospice aide frequency ordered at 1- 3 times a week. The week of 08/10/2025 there were no hospice aide visits documented and no reason for the missed visits documented. The week of 08/24/2025 there were no hospice aide visits documented and no reason for why the visits were not made was documented. There was no documentation that the RN was notified of the missed visits. CLINICAL RECORD 13: The patient elected the hospice benefit on 12/10/2024 with the hospice aide frequency ordered at 2 times a week. The week of 09/21/2025 - 09/27/2025 there were no aide visits documented and no reason for why the visits were not made. There was no documentation that the RN was notified of the missed visits. During an interview on 10/08/2025, the Administrator stated the aide was no longer with the agency.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, in which a hospice aide supervisory visit was required, the agency did not ensure that the hospice aide was supervised by a Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 1: During the benefit period 05/01/2025 - 07/29/2025 there was an aide supervisory visit documented on 05/12/2025 with the next one documented on 05/27/2025 which was 15 days and one day outstanding. Following the aide supervisory visit documented on 5/27/2025, the next one was documented on 6/11/2025, which was 15 days later and one day outstanding. During the benefit period 07/30/2025-09/27/2025 an aide supervisory visit was documented on 9/3/2025 and the next one was documented on 9/18/2025; 15 days later and one day outstanding. CLINICAL RECORD 2: During the benefit period 07/06/2025-10/03/2025 an aide supervisory visit was documented on 07/22/2025 the next aide supervisory visit was documented on 08/08/2025 which was 17 days later and two days outstanding. During an interview on 10/10/2025 the Administrator and Director of Nursing both stated that supervision was not done timely.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. In a review of the volunteer program documents it was revealed that the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff Review of operating budget reports for 2024 with volunteer cost savings documented each quarter. For the year of 2024: Quarter 1 was 2.5 %, Quarter 2 was 2.0%, Quarter 3 was 1.60%, Quarter 4 was 0.53% for a year end of 2024 was 1.6%. During the interview with the Administrator and Volunteer Coordinator on 10/09/2025 they both reported they are new with the organization, and they have been rebuilding the program. Review of operating budget reports for 2024 with volunteer cost savings documented each quarter. For the year of 2024: Quarter 1 - was 2.5 %, Quarter 2 - was 2.0%, Quarter 3 was 1.60%, Quarter 4 was 0.53% for a year end of 2024 was 1.6%. For 2025, quarter 1 was 0.0%, Quarter 2 was 8%, (the volunteer hours for quarter 2 were 162). Quarter 3 was incomplete for data yet. The current cost savings for 2025 was 8 %. During interview with the administrator and volunteer coordinator on 10/09/2025 who are both new with the organization, stated they have been rebuilding the program.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by personnel record review, document review, and interview. In 3 of 10 (30%) personnel records reviewed, for those hired within the last three years, it was revealed that the agency did not ensure a competency assessment was completed prior to providing care, per agency policy. Agency Policy HR.C10 titled, Competency Assessment, stated in part, “As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing care or assuming administrative responsibilities… The competency of staff and volunteers (including supervisors and management staff) is assessed through self-evaluation and checklists, supervised visits, interview, simulated practice and written tests.” PERSONNEL RECORD 2: The Medical Social Worker (MSW) was hired on 06/17/2025. The record lacked documented evidence that a competency was completed prior to providing care. PERSONNEL RECORD 3: The Chaplain was hired on 06/27/2025. The record lacked documented evidence that a competency was completed prior to providing care. PERSONNEL RECORD 6: The record for this Licensed Practical Nurse (LPN) hired on 07/14/2025 lacked documented competencies as of the date of this review (10/08/2025). During an interview on 10/10/2025, the Administrator and Office Manager stated they did not have clinical competency documentation, but they would find a format.”

“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. Each patient’s record includes, at a minimum, physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed, in which the patient chose an attending physician, the agency did not ensure that the clinical record included the initial certification for terminal illness signed by the attending physician. Per the Code of Federal Regulations: § 418.22 Certification of terminal illness. (c) Sources of certification: For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from—(i) The medical director of the hospice, the physician designee, or the physician member of the hospice interdisciplinary group; and (ii) The individual’s attending physician, if the individual has an attending physician. Agency Policy, PC.C05 Certification of Terminal Illness, stated in part, “When a patient is first admitted to hospice, the Medical Director or physician member of the IDG (interdisciplinary group) and the patients attending physician (if the patient has one) sign a written statement certifying that the patients prognosis is 6 months or less if the terminal illness follows its normal course.” CLINICAL RECORD 6: The hospice election of benefit dated 08/23/2023 documented the patient requested their attending physician. The initial Certification for Terminal Illness (CTI) was not signed by the identified attending physician. During interview on 10/09/2025 with the Administrator and Office Manager, the Office Manager stated that they have not sent or asked for the CTI from the attending because they “won’t fill it out.” The administrator stated they would work on the process.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed, it was revealed that the agency did not ensure that all required physician orders were documented. CLINICAL RECORD 4: The hospice election of benefit was 12/10/2024 with a primary diagnosis of Alzheimer disease. The nursing clinical visit note, dated 09/30/2025, documented that the patient was using Novolog sliding scale. There was no documented physician order for this and no detail of what the sliding scale should be. During the interview with the Director of Nursing on 10/09/2025 they reported that they did not have a documented physician order and would notify the nurse.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure documentation of a discharge summary. Agency Policy PC.D20, Discharge from Hospice, stated in part, “When the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient’s attending physician. This discharge summary is filed in the clinical record and includes: The reason for the discharge; a summary of the patient stay including treatment’s and symptom and pain management; a copy of the patients current plan of care, including the current drug profile, the patients latest physician orders and any other documentation that will assist in post discharge continuity of care.” CLINICAL RECORD 15: The date of revocation was 08/17/2025, to move out of the country. There was no documented evidence of a discharge summary within the record. CLINICAL RECORD 16: The date of revocation was 07/25/2025 to seek aggressive treatment. There was no documented evidence of a discharge summary within the record. During interview with the management team on 10/09/2025 they stated that they did not have the discharge summary for either record.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, of patients in a skilled nursing facility, the agency did not ensure the plan of care delineated which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 2: The hospice election of benefit was 07/06/2025 with a primary diagnosis of Hydrocephaly. The patient resided in a skilled nursing facility (SNF). The initial plan of care and plans of care updated every two weeks did not specify if the hospice or the SNF were responsible for specific care and services. On 10/09/2025, the Director of Nursing stated, in an interview, that the plan was not specific as to who would provide care.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident, physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) home visit observations to a patient in a skilled nursing facility, the agency did not ensure that all required documents were provided to the facility. HOME VISIT 2: The hospice election of benefit was 07/06/2025 with a primary diagnosis of Hydrocephaly. The patient resided in a skilled nursing facility (SNF). During the patient visit, on 10/07/2025 the facility binder, which contained the documentation provided by the hospice, lacked evidence of the initial CTI (certificate of terminal illness). Following the visit, the Office Manager who prints the paperwork to be taken to the facility, confirmed that she had not been sending the CTIs.”

“Based on record review and interview, the agency failed to provide services ordered in the plan of care for 3 records (P-1, 2, 3), from a total of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #1: (P-1) was admitted to the hospice on 7/1/25, with a terminal diagnosis of Alzheimer’s Disease. P-1 resided in their home. P-1’s record was reviewed from 9/16/25 through 9/17/25. P-1’s Plan of Care dated 7/1/25 had skilled nursing (SN) services ordered at a frequency of 1-2 visits per week. The home health aide (HHA) plan of care for 8/22/25 to 10/24/25 had services ordered at a frequency of 3 visits per week. During review of P-1’s record it was discovered that there were no HHA visits documented after 8/22/25. There was no note explaining the cause of the missed visits, P-1 passed away on 8/28/25. No HHA visits were provided during the week of P-1’s passing. Patient #2: (P-2) was admitted to the hospice on 7/6/25, with a terminal diagnosis of Communicating Hydrocephalus. P-2 was chosen for review due to having SN and HHA services ordered around the same time as P-1. P-2 resided in their home. P-2’s record was reviewed from 9/16/25 through 9/17/25. P-2’s Plan of Care dated 7/6/25 had SN services ordered at a frequency of 1-2 visits per week. The HHA plan of care had services ordered at a frequency of 2 visits per week. During review of P-2’s record it was discovered that there were no HHA visits documented for week 1, 7/6/25 to 7/12/25. SN had no visits documented for week 2, 7/13/25 to 7/19/2025. There was no note explaining the cause of the missed visits. Patient #3 (P-3) was admitted to the hospice on 3/28/24, with a terminal diagnosis of Alzheimer’s Disease. P-3 was chosen for review due to having SN and HHA services ordered around the same time as P-1. P-3 resided in their home. P-3’s record was reviewed from 9/16/25 through 9/17/25. P-3’s Plan of Care dated 7/9/25 had SN services ordered at a frequency of 1 visit a week. The HHA plan of care had services ordered at a frequency of 2 visits a week. During review of P-3’s record it was discovered that there were no HHA visits documented for week 1, 7/6/25 to 7/12/25. SN had no visits documented from 7/10/25 of the previous certification period until 7/31/25 of the current certification period. There was no note explaining the cause of the missed visits.During an interview on 9/17/25 at 3:45 PM, the administrator (Adm-1) acknowledged the above findings.The agency failed to provide SN and HHA services as ordered in the plan of care. (see 2567 for associated citations).”

“Based on record review and interview, the agency failed to document communication with the physician for 3 records (P-1, 2, 3), from a total of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #1: (P-1) was admitted to the hospice on 7/1/25, with a terminal diagnosis of Alzheimer’s Disease. P-1 resided in their home. P-1’s record was reviewed from 9/16/25 through 9/17/25. P-1’s Plan of Care dated 7/1/25 had skilled nursing (SN) services ordered at a frequency of 1-2 visits per week. The home health aide (HHA) plan of care for 8/22/25 to 10/24/25 had services ordered at a frequency of 3 visits per week. During review of P-1’s record it was discovered that there were no HHA visits documented after 8/22/25. There was no note explaining the cause of the missed visits, and there was no documentation in the record that the physician was notified of the missed visits. P-1 passed away on 8/28/25. No HHA visits were provided during the week of P-1’s passing. Patient #2: (P-2) was admitted to the hospice on 7/6/25, with a terminal diagnosis of Communicating Hydrocephalus. P-2 was chosen for review due to having SN and HHA services ordered around the same time as P-1. P-2 resided in their home. P-2’s record was reviewed from 9/16/25 through 9/17/25. P-2’s Plan of Care dated 7/6/25 had SN services ordered at a frequency of 1-2 visits per week. The HHA plan of care had services ordered at a frequency of 2 visits per week. During review of P-2’s record it was discovered that there were no HHA visits documented for week 1, 7/6/25 to 7/12/25. SN had no visits documented for week 2, 7/13/25 to 7/19/2025. There was no note explaining the cause of the missed visits and there was no documentation in the record that the physician was notified of the missed visits. The agency failed to provide HHA and SN services as ordered in the plan of care.Patient #3 (P-3) was admitted to the hospice on 3/28/24, with a terminal diagnosis of Alzheimer’s Disease. P-3 was chosen for review due to having SN and HHA services ordered around the same time as P-1. P-3 resided in their home. P-3’s record was reviewed from 9/16/25 through 9/17/25. P-3’s Plan of Care dated 7/9/25 had SN services ordered at a frequency of 1 visit a week. The HHA plan of care had services ordered at a frequency of 2 visits a week. During review of P-3’s record it was discovered that there were no HHA visits documented for week 1, 7/6/25 to 7/12/25. SN had no visits documented from 7/10/25 of the previous certification period until 7/31/25 of the current certification period. There was no note explaining the cause of the missed visits and there was no documentation in the record that the physician was notified of the missed visits.During an interview on 9/17/25 at 3:45 PM, the administrator (Adm-1) acknowledged the above findings.The agency failed to communicate patient changes to the physician. (see 2567 for associated citations).”

“Based on record review and interview, the agency failed to maintain communication to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided for 1 (P-2) of 3 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 1/30/25 with the terminal diagnosis of heart failure. In addition, P-2 was being treated for pressure ulcers on her coccyx, left wrist, left outer foot, and right heel. During record review on 8/28/25, it was noted the plan of care dated 8/8/25 ordered skilled nursing services 2 times per week. Upon further review of the record, it was noted the patient did not receive any skilled nursing visits the week of 8/10/25. During an interview with the administrator (Adm-1) on 8/28/25 at 2:30 PM, Adm-1 was asked why the patient had not received any skilled nursing visits the week of 8/10/25. Adm-1 stated the nurse (RN-1) went on vacation that week and the family did not want another nurse to come. Adm-1 stated the information should be documented in the skilled nursing daily note and should and communicated during the interdisciplinary group (IDG) meeting.During review of the skilled nursing visit notes dated 8/6/25 and 8/8/25 (prior to RN-1’s vacation), it was determined there was no documentation regarding the skilled nurse not making visits the following week. Upon review of the IDG meeting notes dated 8/8/25, it was noted the skilled nursing frequency was also confirmed as 2 times per week. There was no documentation of the change in frequency or how it would be ensured the patient’s needs were met during RN-1’s absence. Additionally, upon review of the next IDG meeting notes dated 8/22/25 following return of RN-1, it was determined there was no documentation regarding the recent frequency change or nurse absence. The agency failed to ensure communication was maintained with the IDG to ensure care and services were provided as needed for this patient.A review of the section titled “Visit Frequencies - Nurses” in the “Hospice Quickflips ©” book (a booklet used by Adm-1 to teach staff agency expectations upon hire) indicated, “Remember to document the reason for any missed visits, notify the interdisciplinary team and physician, and update the Plan of Care if visit frequency needs to change.”Adm-1 reviewed the above findings and documentation and acknowledged the findings during a follow-up interview on 8/28/25 at 2:53 PM.”

“Based on record review and interview, the agency failed to ensure services were provided in accordance with the plan of care in 1 (P-2) of 3 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 1/30/25 with the terminal diagnosis of heart failure. During record review on 8/28/25, it was noted the plan of care (dated 8/8/25) ordered skilled nursing services 2 times per week. Upon further review of the record, it was noted the patient did not have any skilled nursing visits the week of 8/10/25.A review of the section titled “Visit Frequencies - Nurses” in the“Hospice Quickflips ©” book (a booklet used by the administrator (Adm-1) to teach staff agency expectations upon hire) indicated, “Remember to document the reason for any missed visits, notify the interdisciplinary team and physician, and update the Plan of Care if visit frequency needs to change.”There was no documentation regarding the reason for the missed visits, an attempt to reschedule the missed visits, communication with the interdisciplinary team, or communication with the doctor regarding the change in frequency on the plan of care. The agency failed to ensure the patient received services in accordance with the plan of care.Adm-1 reviewed and acknowledged the findings during an interview on 8/28/25 at 2:30 PM.”

“Based on observation, record review, and interview, the agency failed to ensure the ongoing sharing of information between all disciplines providing care in all settings in 1 (P-1) of 3 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #1 (P-1) was admitted to this hospice agency on 3/11/24 with the terminal diagnosis of chronic obstructive pulmonary disease (COPD).Following an attempted joint home visit with P-1 and the registered nurse (RN-1) on 8/28/25 at 11:55 AM, RN-1 was observed writing in the communication book at the skilled nursing facility where P-1 resided. Upon review of the communication log, it was noted the previous note was written on 8/21 (no year written) by another staff member and the note before that was written on 6/26/24 (more than 1 year ago).During an interview with Adm-1 on 8/28/25 at 1:29 PM, Adm-1 acknowledged the large gap in the communication log and stated this was one of the reasons she had to let so many staff members go when she started as the administrator in March 2025. Adm-1 state she visited several facilities and discovered this was a widespread agency issue. Adm-1 was asked about the agency expectation regarding documentation in the communication book at skilled nursing facilities. Adm-1 stated it is not written in a policy, but it is verbally expressed to staff repeatedly that the expectation is a communication note is written in the book after every visit.The agency failed to ensure ongoing communication between the hospice staff and the staff providing care for P-1 at the skilled nursing facility. Adm-1 acknowledged the findings at the time of interview.”