Hope Hospice and Palliative Care, LLC

“Based on record review, interview and policy review, the hospice agency failed to inform four of six sampled patients (Patient (P)2, P3, P4, and P5) were informed of his/her rights, and the hospice must protect and promote the exercise of these rights. Findings include: 1.Failed to provide written information regarding its advance directive policies, including applicable State law, to two of six sampled patients (Patient (P)1 and P4). (Refer to L502) 2.Failed to ensure four of six sampled patients (Patient (P)1, P2, P3, and P4) were informed of and afforded the right to choose their attending physician upon admission to hospice services. (Refer to L515) 3.Failed to inform one of six sampled patients (Patient (P)4) of a medication that was not covered under the election of the hospice benefit. (Refer to L518)”

“Based on record review, interview, and policy review, the hospice agency failed to obtain and complete an initial Certificate of Terminal Illness (CTI) for four of six sampled patients (Patient (P)2, P3, P4, and P5) and failed to obtain written recertification of terminal illness for two of six sampled patients (Patient (P)2 and P5). Findings include: 1.Failed to obtain and complete an initial Certificate of Terminal Illness (CTI) for four of six sampled patients (Patient (P)2, P3, P4, and P5). (Refer to L667) 2.Failed to obtain written recertification of terminal illness for two of six sampled patients (Patient (P)2 and P5). (Refer to L668)”

“Based on record review, interview, and policy review, the agency failed to provide written information regarding its advance directive policies, including applicable State law, to two of six sampled patients (P1 and P4). This failure had the potential for the two patients not to be able to make informed decisions concerning their healthcare preferences and advance directive rights. Findings include: 1.Review of P1’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P1 was admitted on 06/23/26 to the hospice agency with the terminal illness of malignant neoplasm of the colon. Review of P1’s “Election of Benefits” located under the “MISC” tab in the EMR indicated it was signed by the patient on 06/22/26. During an interview on 07/01/26 at 11:20 AM, P1 stated he had not received an admission booklet when he was admitted to hospice services. P1 also stated that he was not presented with any information from the hospice agency concerning Advance Directives. During an interview on 07/01/26 at 1:00 PM, the Administrator stated P1 had not received his admission packet because P1 had signed his consents using Docusign. The Administrator also stated he had made plans to take the admission booklet to P1 on 06/29/26 but this did not occur. During an interview on 07/01/26 at 3:52 PM, the Patient Care Coordinator/Registered Nurse (PCC/RN) stated patients are typically provided the admission booklet and admission packet upon admission to hospice services. The PCC/RN further stated it was not his/her responsibility for providing these materials to the patients. 2.Review of P4’s “Patient Profile” located under the “View” tab in the EMR indicated P4 was admitted on 08/12/25 to the hospice agency with the terminal illness of senile degeneration of the brain.Review of P4’s “Admission Consents” located under the “MISC” tab in the EMR revealed the consents were not signed by the patient and/or caregiver at the time of admission. Further review revealed there was no documentation P4 or family/caregiver was provided with an admission booklet on admission.During an interview on 07/01/26 with the Administrator, Alternate Administrator, who attended in person and the Director of Patient Care Services (DPCS) who attended by phone beginning at 9:00 PM; the Administrator was asked who is responsible admitting a patient to hospice services. The Administrator stated the Community Liaison was the person responsible for obtaining the consents and also for providing the admission packet to the patient at that time. The Administrator also confirmed P4’s consents were not signed by the patient and/or family/caregiver at the time of admission. Review of the agency’s “Admission Booklet”, provided by the hospice agency, revealed information on how to formulate an Advance Directive if the patient had not done so, and the agency’s policy on Advance Directives. Review of the agency’s policy “Admission Criteria and Process” dated November 2022 indicated “… If eligibility criteria is met the patient and family/caregiver will be provided with a hospice brochure and various educational materials providing sufficient information on: … Advance Directives…” Review of the agency’s policy “Community Liaison” dated November 2022 indicated, “ … K. Educating patients, families, and referral sources regarding hospice eligibility criteria, benefits, services, patient rights, and the admission process. L. Conducting hospice admissions and signing up eligible patients for hospice services by obtaining required consents, election statements, and admission documentation in accordance with organizational policies and regulatory requirements. Review of the “Hospice Employee Roster” provided by the agency on 06/29/26 revealed no employee identified with the title of Community Liaison, despite the Administrator identifying the Community Liaison as responsible for conducting admissions and providing admission materials to patients.”

“Based on record review, interview, and agency policy review, the agency failed to ensure four of six sampled patients (Patient (P)1, P2, P3, and P4) were informed of and afforded the right to choose their attending physician upon admission to hospice services. This failure had the potential to limit patients’ participation in care decisions, affect continuity of care, and result in care being directed by a physician not selected by the patient. Findings include: 1. Review of P1’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P1 was admitted on 06/23/26 to the hospice agency with the terminal illness of malignant neoplasm (cancer) of the colon. During an interview on 07/01/26 at 11:20 AM, P1 was asked if he/she was informed of their right to choose an attending physician when admitted to hospice services. P1 replied, “No, I was not.” Review of P1’s “Election of Hospice Benefit (EOB)” located under the “MISC” tab in the EMR revealed under the section of “Right to Choose My Attending Physician” indicated a box to either be checked for “I do not wish to choose an attending physician” and “My choice for my attending physician is.” The boxes were left blank and were not marked as to a choice was made of an attending physician by the patient. 2.Review of P2’s “Patient Profile” listed under the “View” tab in the EMR indicated P2 was admitted to the agency on 02/21/25 with the terminal illness of senile degeneration of the brain. Review of P2’s “EOB” dated 02/19/25 and located under the “MISC” tab in the EMR revealed under the section of “Right to Choose My Attending Physician” indicated a box to either be checked for “I do not wish to choose an attending physician” and “My choice for my attending physician is.” The boxes were left blank and were not marked as to a choice that was made of an attending physician by the caregiver who signed this consent. During a phone interview on 06/30/26 at 5:15 PM, the caregiver of P2 was asked if he/she had been given the right to choose an attending physician while under hospice services and the caregiver stated, “No, I was not.” 3. Review of P3’s “Patient Profile” listed under the “View” tab in the EMR indicated P3 was admitted to the agency on 12/06/24 with the terminal illness of unspecified severe protein-calorie malnutrition. Review of P3’s “EOB” dated 12/06/24 and located under the “MISC” tab in the EMR revealed under the section of “Right to Choose My Attending Physician” indicated a box to either be checked for “I do not wish to choose an attending physician” and “My choice for my attending physician is.” The boxes were left blank and were not marked as to a choice that was made of an attending physician by the legal guardian who signed this consent. 4. Review of P4’s “Patient Profile” listed under the “View” tab in the EMR indicated P4 was admitted to the agency on 08/12/25 with the terminal illness of senile degeneration of the brain. Review of P4’s “EOB” located under the “MISC” tab in the EMR revealed all admission consents including the EOB were left blank and was not signed by the patient/family/caregiver/legal guardian. During an interview on 07/01/26 at 9:00 PM with the Administrator, Alternate Administrator, who attended in person, and the Director of Patient Care Services (DPCS) who attended by phone beginning at 9:00 PM; the Administrator confirmed the boxes on the EOB were left blank in the section under the section of “Right to Choose My Attending Physician” for P1, P2, P3, and P4. The Administrator confirmed P4’s admission consents and EOB were left blank and were not signed by the patient/family/caregiver/legal guardian. The Administrator stated patients are to be offered the choice of their attending physician when admitted to hospice services and all admission consents and EOB are to be signed by the patient/family and/or legal guardian. Review of the agency’s policy “Community Liaison” dated November 2022 indicated, “… Conducting hospice admissions and signing up eligible patients for hospice services byobtaining required consents, election statements, and admission documentation in accordancewith organizational policies and regulatory requirements …” Review of the agency’s “Admission Booklet” provided by the hospice agency indicated on page 13, Section 3 “Patient Rights and Responsibilities” stated, “Decision Making – You Have the Right To: Choose your attending physician and other health care providers …””

“Based on record review, interview, and agency policy review, the agency failed to inform one of six sampled patients (Patient (P)4) of a medication that was not covered under the election of the hospice benefit. This failure had the potential to result in P4 being unaware of their financial responsibility for services or medications not covered by the hospice benefit. Findings include: Review of P4’s “Patient Profile” listed under the “View” tab in the EMR indicated P4 was admitted to the agency on 08/12/25 with the terminal illness of senile degeneration of the brain. Review of P4’s Election of Hospice Benefit (EOB)” located under the “MISC” tab in the EMR indicated the “Yes” or “No” boxes next to “I elect to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs” were left blank. Review of P4’s “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” consent located under the “MISC” tab in the EMR indicated the form was blank with no patient/caregiver/legal guardian signatures. Review of P4’s “Plan of Care” located under the “IDG/POC” tab in the EMR for the benefit period of 08/12/25 through 11/09/25 revealed Eliquis five milligrams (mg) take one tablet daily with the documented indication for use being “blood thinner.” This medication had the documentation of “Not Covered” under the listing of this medication. During an interview on 07/01/26 at 9:00 AM, the Administrator and Alternate Administrator attended in person, and the Director of Patient Care Services (DPCS) attended by phone. The Administrator confirmed admission consents, the Election of Hospice Benefit (EOB), and the Patient Notification of Hospice Non-Covered Items, Services, and Drugs should be completed by the nurse, explained to the patient/representative, and signed by the patient/representative on admission to hospice services and be made aware of in writing of any non-covered services or medications that would not be covered under the hospice benefit. Review of the agency’s policy “Admission Criteria and Process” dated November 2022 indicated, “… the patient and family/caregiver will be provided with a hospicebrochure and various educational materials providing sufficient information on: … Costs to be borne by the patient, if any, for care …” Review of the “Admission Booklet” provided by the agency indicated on page 14 under the section of “Financial Information – You Have The Right To: … Receive a Patient Notification of Hospice Non-Covered Items, Services, and Drugs if there are conditions, items, services and drugs that the hospice determines to be unrelated to your terminal illness and related conditions and would not be covered by the Medicare hospice benefit …””

“Based on record review, interview, and policy review, the agency failed to ensure the Social Worker completed a comprehensive assessment within the five calendar days after the election of hospice care for two of two patients reviewed (Patient (P)1 and P5) out of a total of six sampled patients. This failure had the potential for the patients’ psychosocial, emotional, financial, and/or discharge planning needs to not be identified and addressed timely. Findings include: 1. Review of P1’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P1 was admitted on 06/23/26 to the hospice agency with the terminal illness of malignant neoplasm of the colon. Review of P1’s “Election of Benefits” located under the “MISC” tab in the EMR indicated it was signed by the patient on 06/22/26. There was documentation to indicate the start of care for P1 would be 06/23/26. During an interview on 07/01/26 at 11:20 AM, P1 was asked what members of the hospice team had visited with him/her thus far. P1 stated the nurse, and the chaplain has come to visit. When asked if the social worker had come to make an initial visit after being admitted to hospice and P1 stated, “No.” The Patient care Coordinator/Registered Nurse (PCC/RN) was also in attendance of the home visit with P1 stated, “[P1] didn’t have any psychosocial needs at the time of admission.” Review of the “RN Initial Assessment” dated 06/23/26, documentation indicated, “Patient does not have any MSW [Medical Social Worker] … needs at present …” During a phone interview on 07/01/26 at 3:52 PM, the PCC/RN was asked if he/she was qualified to assess P1 for psychosocial, psychosocial, emotional, financial, and/or discharge planning needs. PCC/RN stated, “Of course I am.” 2.Review of P5’s “Patient Profile” located under the “View” tab in the EMR indicated P5 was admitted on 09/12/24 to the hospice agency with the terminal illness of senile degeneration of the brain. Review of P5’s “Election of Benefits” located under the “MISC” tab in the EMR indicated it was signed by the guardian on 09/06/24. There was documentation to indicate the start of care for P5 would be 09/12/24. Review of P5’s “MSW Medical Social Worker” documentation located under the “MSW” tab in the Resident Manager section of the EMR revealed the initial assessment completed by the social worker was dated 09/18/24. During a phone interview on 07/01/26 at 2:15 PM, Social Services/Bereavement Coordinator (SS/BC) stated, “The social worker initial assessment is to be completed within five days from the start of care.” The SS/BC confirmed he/she did not do an initial assessment on P1. The SS/BC also stated he/she would make a note in the medical record if the patient or family requested the visit to be completed after the five days but could not recall if this was done for P5. The SS/BC continued, “I was not notified that one [P1] was needed to be completed. The agency will text me on my cell phone to alert me that a visit is needed to be made, and I did not receive anything from them about this.” During an interview on 07/01/26 at 9:00 PM with the Administrator, Alternate Administrator, who attended in person and the Director of Patient Care Services (DPCS) who attended by phone was asked if a Registered Nurse (RN) was qualified to assess a patient for psychosocial, psychosocial, emotional, financial, and/or discharge planning needs. The DPCS stated the RN was not qualified to assess for these things and those assessments were the responsibility of the social worker. The Administrator stated, “The social worker is to make their first visit with the patient within five days of admission to hospice unless the patient refuses for this visit to occur.” Review of the agency’s policy “Psychosocial Services” dated November 2022 indicated, “… Assessment activities of the social worker will include but not limited to: A. The emotional factors related to the terminal illness B. The patient and family/caregiver psychosocial status, potential for risk of suicide … C. Environmental resources and obstacles to maintain patient safety … G. Need for counseling related to risk assessment for pathological grief, suicide and/or abuse or neglect … I. Support systems available to reduce stress and facilitate coping with end of life care J. Evaluation for long term care when appropriate and determining the patient’s and family/caregiver’s ability to accept the change in level of care …””

“Based on interview and policy review, the agency failed to ensure the social worker, a member of the Interdisciplinary Group (IDG), attended all IDG meetings. This failure had the potential to affect the coordination and oversight of care for current patients, future patients, and discharged patients. Findings include: During a phone interview on 07/01/26 at 2:15 PM, the Social Services/Bereavement Coordinator (SS/BC) was asked if he/she attended all the IDG meetings. The SS/BC stated, “Because I work somewhere else full time, there are times that I cannot attend the IDG meetings. If that occurs, I send in the information needed for the meeting to [Director of Patient Care Services (DPCS)] and the information is presented from what I provided.” When asked if he/she knew the exact dates of when this had occurred in the past and the SS/BC stated, “No, I didn’t keep a record for the dates of the meetings I did not attend.” During an interview on 07/01/26 at 9:00 PM with the Administrator, and Alternate Administrator, who attended in person and the DPCS who attended by phone. The DPCS stated, “If the social worker is not able to attend the IDG meetings, I am provided with information for the patients that the social worker is seeing at the time and I will present this information in that meeting.” Asked if he/she kept a record of the dates that this had occurred in the past and the DPCS stated that he/she did not keep a record of the dates when this had occurred. The SS/BC date of hire was 02/26/23. Review of the agency’s policy “ Interdisciplinary Group Membership and Responsibilities” dated November 2022 indicated, “… The hospice interdisciplinary group membership includes at a minimum: A. Physician B. Registered Nurse C. Social Worker D. Pastoral or other counselor(s) …””

“Based on record review, interview, and policy review, the agency failed to ensure the Interdisciplinary Group (IDG) reviewed and updated the plan of care no less frequently than every 15 calendar days for three of six sampled patients (Patients P2, P3, and P5) reviewed. This failure had the potential to delay identification of changes in patients’ needs, coordination of services, and updates to the patients’ plans of care. Findings include: 1. Review of P2’s “Patient Profile” listed under the “View” tab in the electronic medical record (EMR) indicated P2 was admitted to the agency on 02/21/25 with the terminal illness of senile degeneration of the brain. Review of P2’s “IDG Meeting” notes, located under the “IDG/POC” tab in the EMR, revealed the last IDG meeting was documented as conducted on 11/05/25. P2 was discharged from hospice services on 03/16/26. The EMR contained no documentation that the IDG reviewed or updated P2’s plan of care at least every 15 calendar days from 11/05/25 through discharge. 2.Review of P3’s “Patient Profile” located under the “View” tab in the EMR indicated P3 was admitted to hospice services on 12/06/24 with the terminal illness of unspecified severe protein-calorie malnutrition. Review of P3’s “IDG Meeting” notes, located under the “IDG/POC” tab in the EMR, revealed the last IDG meeting was documented as conducted on 11/05/25. The next documented IDG meeting was conducted on 04/08/26, approximately 154 days later. The EMR contained no documentation that the IDG reviewed or updated P3’s plan of care at least every 15 calendar days from 11/05/25 until 04/08/26. 3.Review of P5’s “Patient Profile” located under the “View” tab in the EMR indicated P5 was admitted to hospice services on 09/12/24 with the terminal illness of senile degeneration of the brain. Review of P5’s “IDG Meeting” notes, located under the “IDG/POC” tab in the EMR, revealed the last IDG meeting was documented as conducted on 11/06/24. The next documented IDG meeting was conducted on 02/12/25, approximately 98 days later. A subsequent documented IDG meeting was conducted on 03/12/25, approximately 28 days later. The EMR contained no documentation that the IDG reviewed or updated P5’s plan of care at least every 15 calendar days between 11/06/24 and 02/12/25, or between 02/12/25 and 03/12/25. During an interview on 07/01/26 at 9:00 PM, the Administrator and Alternate Administrator attended in person, and the Director of Patient Care Services (DPCS) attended by phone. They were informed of the lack of documented IDG meetings at least every 15 calendar days for P2, P3, and P5, including the dates and timeframes of the gaps identified for each patient. The DPCS stated he/she could not explain why the gaps occurred and confirmed he/she was responsible for documenting each IDG meeting. The Administrator stated he/she did not understand why the IDG meetings were not appearing in the EMR if the DPCS had documented them. The Administrator stated he/she would contact the EMR company to determine whether there was an issue with the records. Review of the agency’s policy “Interdisciplinary Group Coordination of Care” dated November 2022 revealed, “… The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days …””

“Based on observation, interview, and review of the agency’s policy, the agency failed to implement accepted standards of infection prevention and control during one of one home visit with Patient (P)1 by the Patient Care Coordinator/Registered Nurse (PCC/RN). This deficient practice had the potential to increase the risk of transmission of infections or communicable diseases to P1 and future hospice patients receiving agency services. Findings include: Review of P1’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P1 was admitted on 06/23/26 to the hospice agency with the terminal illness of malignant neoplasm (cancer) of the colon. While conducting a home visit with P1 on 07/01/26 at 11:00 AM, the PCC/RN placed his/her nursing bag directly on the carpet in P1’s living room without first placing a barrier between the bag and the floor. The PCC/RN then applied hand sanitizer and removed a blood pressure machine from the nursing bag. The PCC/RN obtained P1’s blood pressure, auscultated lung sounds using a stethoscope, and obtained an oxygen saturation reading using a pulse oximeter. After completing the assessment, the PCC/RN placed the blood pressure machine, stethoscope, and pulse oximeter into a plastic storage bag and returned the items to the nursing bag without first cleaning or disinfecting the reusable patient care equipment. During an interview on 07/01/26 at 3:52 PM, the PCC/RN stated reusable patient care equipment was cleaned before beginning daily visits and after returning home, rather than immediately following patient use. The PCC/RN stated disinfecting wipes used to clean the equipment were personally purchased. PCC/RN stated, “I have never asked the office for hand sanitizer or cleaning wipes.” The PCC/RN confirmed he/she currently had only P1 on caseload. On 07/01/26 at 4:30 PM, an observation was made of the supply room in the hospice agency with the Administrator. There were no cleaning wipes or hand sanitizers located in the supply room for the staff to use. The Administrator confirmed this finding and stated these items will have to be ordered. Asked the Administrator when the last order was placed for these items and he/she stated he did not know. During an interview on 07/01/26 at 9:00 PM with the Administrator, and Alternate Administrator, who attended in person and the Director of Patient Care Services (DPCS) who attended by phone. The DPCS confirmed the nurse should first place a barrier down then place their nursing bag on top of the barrier. When asked where the nurses should obtain the hand sanitizer from and the DPCS confirmed the hospice agency supplies that for the nurses and it would be located in the supply room. The DPCS was asked when the nurses are instructed to clean their reusable equipment and he/she stated, “Prior to use of the equipment in the patient’s home and after use of the equipment and before they place the equipment back in their bag at the end of the visit.” Review of the agency’s policy “Bag Technique” dated November 2022 indicated, “… The bag will be placed on a clean surface … Prior to administering care, alcohol-based hand rub or soap and paper towels will be removed, and hands will be washed … When the visit is over, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution … supplies will be returned to the bag … If paper towels/newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded.””

“Based on record review, interview, and policy review, the hospice agency failed to ensure nursing visits were completed as ordered by the wound care physician for one of six sampled patients (P)2. This failure resulted in missed wound care services and had the potential to compromise wound management, delay healing, and increase the risk of wound deterioration. Findings included: Review of P2’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P2 was admitted to hospice services on 02/21/25 with the terminal illness ofsenile degeneration of the brain. Review of P2’s “RN-Skilled Nursing Visit” located under the “Nursing” tab in the EMR and dated 02/05/26 indicated, “… Noted on (L) [left] upper hip, abrasion, reddish in color…” On 02/09/26, the nurse documented, “… (L) upper hip, Less reddish appearance … Educated family on the wedge to prevent pressure ulcers …” On 02/20/26, the nurse documented, “… Noted (L) hip has fifty cent size wound. No draining. No odor … Wound doctor notified … Family educated regarding … prevention of increasing wounds.” Review of P2’s “Orders” located under the Orders” tab in the EMR revealed an order dated 03/05/26 for “Unstageable Right Hip region Cleanse wound with Dankins solution, Apply Santyl to wound bed, cover with 4 x [by] 4 gauze and ABD [abdominal pad] QOD [every other day] in PM [afternoon].” Review of P2’s “Plan of Care” located under the “IDG/POC” tab in the EMR revealed the skilled nursing visits did not increase after the order dated 03/05/26 was written by the wound care physician. During a phone interview on 07/01/26 at 3:52 PM, Patient Care Coordinator/Registered Nurse (PCC/RN) stated, “I remember that I had found a reddish area on [P2’s] left hip the beginning of February. I educated the family on using the wedge to prevent pressure ulcers from beginning and taught them to turn her every two hours. Then the family had called the office and cancelled a couple of visits and when I went back at the end of February, the area was the size of a fifty-cent piece. There was no drainage or odor. I notified the wound care doctor of this and asked for a home visit to be completed to evaluate the wound. I had to go out of town for a little while and I didn’t see her anymore.” During an interview on 07/01/26 at 9:00 PM with the Administrator, and Alternate Administrator, who attended in person and the Director of Patient Care Services (DPCS) who attended by phone. The DPCS confirmed he/she was seeing P2 while the PCC/RN was out of town. Asked if he/she was aware of the wound care orders that were in P2’s chart and dated 03/05/26 for wound care to be performed every other day. The DPCS stated, “I knew the wound doctor was going out to see the patient, but I was not aware there were new orders received in the office.” Asked what the process was when new orders were received in the office. The DPCS stated, “If the orders are faxed, they are uploaded into the medical record and then whoever uploads the document will notify the nurse there are new orders.” Review of the agency’s policy “Plan of Care” dated November 2022 indicated, “… Any new change in the patient’s condition must result in a change in the plan of care …””

“Based on record review, interview, and policy review, the hospice agency’s Governing Body failed to ensure effective oversight of the agency’s day-to-day operations and the provision of hospice services. This was evidenced by multiple deficient practices identified during the survey, including failures related to inform patients of their rights to be informed and the ability to exercise those rights for five of six sampled patients (Patient (P)1, P2, P3, P4, and P5) and failure to have written documentation of initial certification and recertification of terminal illness for four of six sampled patients (Patient (P)2, P3, P4, and P5. These failures had the potential to adversely affect the one current patient (Patient (P)1), five former patients (P2, P3, P4, P5, and P6), and all future patients served by the agency. (Cross reference to L502, L515, L518, L667 and L668) Findings include: Review of the “Governing Body Meeting” minutes dated 01/14/26 revealed, “… Reviewed by members the following:-Clinical Record Review: Election of Hospice Benefit Form signed prior to Admission Consent, Comprehension Assessment completed with 2 days of Election Hospice Services, MSW [Medical Social Worker] and Spiritual assessments completed within 5 days of Admission, Plan of Care completed within 5 days for all disciplines services identified.-IDG [Interdisciplinary Group] requirements q [every] 15 days … Discussion regarding accreditation process and follow up required post notification of agency readiness …” Requested the Governing Body meeting minutes from 2024 and the Administrator provided a binder labeled “Governing Body.” Review of this binder revealed there was no documentation of the Governing Body holding a meeting for the year of 2024. During an interview on 07/01/26 at 8:15 PM, the Alternate Administrator, who is a member of the Governing Body, stated the Governing Body meets annually and is able to call an emergency meeting anytime the Administrator feels it is necessary to discuss ongoing issues with the hospice agency. During on interview on 07/01/26 at 9:00 PM in which the Administrator and the Alternate Administrator attended in person and the Director of Patient Care Services (DPCS) attended by phone. The DPCS was asked how often chart audits were performed and what were the findings of the audits. The DPCS stated that he/she performed the chart audits approximately quarterly and could not remember having issues with the Certificates of Terminal Illness, and the Recertifications for the current patients at the time the audits were conducted. Asked if he/she had copies of the audits in his/her office that someone could get since he/she was not in the office and the DPCS stated, “They are in my office, but I wouldn’t know where to tell someone to go and look for them.” The Alternate Administrator stated this survey brought to light areas of improvements that were needed to ensure patient’s consents were signed on admission which would include the Election of Hospice Benefits and the non-covered items, supplies, and medications once the staff becomes aware of this for their patients, and areas of staff education that was needed to correct these concerns. The Administrator and Alternate Administrator confirmed the binder labeled “Governing Body” did not contain documentation of the 2024 Governing Body meeting minutes. Review of the agency’s policy “Governing Body” dated November 2022 indicated, “The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services … All actions taken by the Governing Body will be documented in meeting minutes, which will be retained by the organization for a minimum of five (5) years …””

“Based on record review, interview, and policy review, the hospice agency failed to obtain and complete an initial Certificate of Terminal Illness (CTI) for four of six sampled patients (P2, P3, P4, and P5). This deficient practice had the potential to delay or compromise the assessment, planning, and provision of hospice services necessary to meet the patients’ end-of-life care needs. Findings include: 1.Review of P2’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P2 was admitted to hospice services on 02/21/25 with the terminal illness of senile degeneration of the brain. Review of P2’s Benefit Period dated 02/21/25 to 05/21/25 and located under the “Orders” tab in the EMR revealed no documentation of initial CTI for the benefit period. 2. Review of P3’s “Patient Profile” listed under the “View” tab in the EMR indicated P3 was admitted to the agency on 12/06/24 with the terminal illness of unspecified severe protein-calorie malnutrition. Review of P3’s Benefit Period dated 12/06/24 to 03/05/25 and located under the “Orders” tab in the EMR revealed no documentation of initial CTI for the benefit period. 3. Review of P4’s “Patient Profile” listed under the “View” tab in the EMR indicated P4 was admitted to the agency on 08/12/25 with the terminal illness of senile degeneration of the brain. Review of P4’s Benefit Period dated 08/12/25 to 03/05/25 and located under the “Orders” tab in the EMR revealed no documentation of initial CTI for the benefit period. 4. Review of P5’s “Patient Profile” located under the “View” tab in the EMR indicated P5 was admitted on 09/12/24 to the hospice agency with the terminal illness of senile degeneration of the brain. Review of P4’s Benefit Period dated 09/12/24 to 12/10/24 and located under the “Orders” tab in the EMR revealed no documentation of initial CTI for the benefit period. The Administrator was notified on 06/30/26 at 4:45 PM, the surveyor needed to interview the Medical Director on 07/01/26 at his convenience. The Administrator stated he/she would contact the Medical Director and see when a convenient time for this interview would be for him/her. During an interview on 07/01/26 at 1:00 PM, the Administrator stated he/she would reach back out to the Medical Director to see when this could take place. During an interview on 07/01/26 at 5:00 PM, the Administrator revealed the Medical Director would call after he/she finished with rounding on his/her patients. The Administrator was given the phone number for the Medical Director and was told the surveyor would be available anytime tonight no matter how late it is to complete the interview. During an interview on 07/01/26 at 9:00 PM with the Administrator, Alternate Administrator, who attended in person, and the Director of Patient Care Services (DPCS) who attended by phone. The Administrator was notified of the initial CTIs that were not completed for P2, P3, P4, and P5 when admitted to hospice services. The Administrator confirmed the initial CTIs were not in the patient’s EMR. The Administrator stated the Medical Director could complete the CTIs either electronically or by handwriting them. If they were handwritten the Administrator stated an office staff person would go to the Medical Director’s office to pick them up and them upload them into the EMR. No phone calls were received from the Medical Director prior to the exit conference on 07/01/26 at 11:15 PM.”

“Based on record review, interview, and policy review, the hospice agency failed to obtain written recertification of terminal illness for two of six sampled patients reviewed (Patients P2 and P5). This failure had the potential for the patients’ hospice eligibility and ongoing care needs to not be appropriately assessed and documented. Findings include: 1. Review of P2’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) indicated P2 was admitted to hospice services on 02/21/25 with the terminal illness of senile degeneration of the brain. Review of P2’s “Benefit Periods” with the following dates and located under the “Orders” tab in the EMR revealed no documentation of the recertification of terminal illness: 05/22/25 to 08/19/25, 08/20/25 to 10/18/25, and 06/12/26 to 06/25/26. 2. Review of P5’s “Patient Profile” located under the “View” tab in the EMR indicated P5 was admitted on 09/12/24 to the hospice agency with the terminal illness of senile degeneration of the brain. Review of P5’s “Benefit Periods” with the following dates and located under the “Orders” tab in the EMR revealed no documentation of the recertification of terminal illness: 12/11/24 to 03/10/25 and 03/11/25 to 05/09/25. The Administrator was notified on 06/30/26 at 4:45 PM, the surveyor needed to interview the Medical Director on 07/01/26 at his convenience. The Administrator stated he/she would contact the Medical Director and see when a convenient time for this interview would be for him/her. On 07/01/26 at 1:00 PM, the Administrator asked if he/she has been able to set up a time for the interview with the Medical Director. The Administrator stated he/she would reach back out to the Medical Director to see when this could take place. On 07/01/26 at 5:00 PM, the Administrator came into the conference room and asked if the Medical Director could call after he/she finished with rounding on his/her patients. The Administrator was given the phone number the Medical Director could call, and the surveyor would be available anytime tonight no matter how late it is to complete this interview. During an interview on 07/01/26 at 9:00 PM with the Administrator, Alternate Administrator, who attended in person, and the Director of Patient Care Services (DPCS) who attended by phone. The Administrator was notified of the recertification of terminal illness was not completed for P2 and P5. The Administrator confirmed the recertifications were not in the patient’s EMR. The Administrator stated the Medical Director can complete the recertifications either electronically or by handwriting them. If they are handwritten the Administrator stated an office staff person will go to the Medical Director’s office to pick them up and them upload them into the EMR. Review of the agency’s policy “Physician Services – Medical Director Role” dated November 2022 revealed, “… Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation … Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods …” No phone calls were received from the Medical Director prior to the exit conference on 07/01/26 at 11:15 PM.”

“Based on record review, interview, and policy review, the hospice agency failed to obtain a signed Election of Hospice Benefits form upon admission for one of six sampled patients (Patient (P)4). This failure resulted in the lack of documented evidence that P4 was informed of and consented to the election of hospice services and had the potential to compromise the patient’s understanding of hospice benefits, rights, and services. Findings include: Review of P4’s “Patient Profile” located under the “View” tab in the EMR indicated P4 was admitted on 08/12/25 to the hospice agency with the terminal illness of senile degeneration of the brain. Review of P4’s “Consent for Election of Medicare/Medicaid Hospice Benefit” located under the “MISC” tab in the EMR revealed the Election of Hospice Benefits consent was not signed by the patient and/or caregiver at the time of admission. During an interview on 07/01/26 at 9:00 PM, with the Administrator, Alternate Administrator, who attended in person and the Director of Patient Care Services (DPCS) who attended by phone; the Administrator was asked who is responsible admitting a patient to hospice services. The Administrator stated the Community Liaison was the person responsible for obtaining the Election of Hospice Benefits consent. The Administrator also confirmed P4’s Election of Hospice Benefits consent was not signed by the patient and/or family/caregiver at the time of admission. Review of the agency’s policy “Admission Criteria and Process” dated November 2022 indicated, “… Allow the patient and family/caregiver to ask questions and facilitate a decision for hospice services especially provided under the Medicare/Medicaid hospice benefit. Review appropriate forms and subsequently sign forms by patient and family/caregiver once agreement for the hospice program has been decided …” Review of the agency’s policy “Community Liaison” dated November 2022 indicated, “ … K. Educating patients, families, and referral sources regarding hospice eligibility criteria, benefits, services, patient rights, and the admission process. L. Conducting hospice admissions and signing up eligible patients for hospice services by obtaining required consents, election statements, and admission documentation in accordance with organizational policies and regulatory requirements …” Review of the “Hospice Employee Roster” provided by the agency on 06/29/26 revealed no employee identified with the title of Community Liaison, despite the Administrator identifying the Community Liaison as responsible for conducting admissions and providing admission materials to patients.”

“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, 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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 5 of 7 (71%) clinical records reviewed, of patients on census as of 06/28/2024, revealed that the agency did not ensure that the registered nurse (RN) completed a comprehensive assessment to assess the patient’s status no less frequently than every 15 days. Clinical Record 1: The patient elected hospice care on 06/20/2024 and died on 07/15/2024. The last RN comprehensive assessment was documented on 06/20/2024. There was no documented evidence of an updated comprehensive assessment by the RN as of 07/15/2024. Clinical Record 3: The patient elected hospice care on 01/10/2024. The last RN comprehensive assessment was documented on 06/28/2024. There was no documented evidence of an updated comprehensive assessment by the RN as of 07/18/2024. Clinical Record 5: The patient elected hospice care on 05/29/2024. The last RN comprehensive assessment was documented on 06/25/2024. There was no documented evidence of an updated comprehensive assessment by the RN as of 07/18/2024. Clinical Record 6: The patient elected hospice care on 05/23/2024. The last RN comprehensive assessment was documented on 06/19/2024. There was no documented evidence of an updated comprehensive assessment by the RN as of 07/18/2024. Clinical Record 7: The patient elected hospice care on 11/18/2023. The last RN comprehensive assessment was documented on 06/20/2024. There was no documented evidence of an updated comprehensive assessment by the RN as of 07/18/2024. During a joint review of the record and interview on 07/18/2024, the Director of Nursing stated, “I’m not seeing any comprehensive assessments by the RN for the periods identified, we missed these,” and agreed there was no documented evidence that the (RN) completed a comprehensive assessment to assess the patient’s status no less frequently than every 15 days. Additionally, during an interview on 07/18/2024, the Executive Director stated that the Licensed Practical Nurse had been making routine visits but “only the RN can do comprehensive visits.””

“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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by review of the agency’s action plan during this site visit on 07/16/2024-07/18/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 06/28/2024. Previous Evidence: “This standard was not met as evidenced by document review and interview. In the interview, the Volunteer Coordinator disclosed that the agency lacked a functional volunteer program. Currently, there were no active volunteers, and none had been engaged since the COVID period. The agency did not possess any recorded evidence of recruitment or retention initiatives. Furthermore, there was no documentation to suggest that volunteers were contributing to the agency’s daily operations.” This standard was not met as evidenced by review of the agency’s action plan during this site visit on 07/16/2024-07/18/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 06/28/2024. Previous Evidence: “This standard was not met as evidenced by document review and interview. In the interview, the Volunteer Coordinator disclosed that the agency lacked a functional volunteer program. Currently, there were no active volunteers, and none had been engaged since the COVID period. The agency did not possess any recorded evidence of recruitment or retention initiatives. Furthermore, there was no documentation to suggest that volunteers were contributing to the agency’s daily operations.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient’s record, if requested. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by review of the agency’s action plan during this site visit on 07/16/2024-07/18/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 06/28/2024. Previous Evidence: “This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were alive at discharge, it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the physician. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and was discharged on 04/08/2024. The RN documentation noted that the facility physician ordered for the patient to be discharged for the reason, “no longer terminally ill”. The RN later documented that the hospice encouraged them to revoke, and they “reluctantly” signed the revocation form. There was no discharge summary found in the patient record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023 and was a live discharge on 04/07/2024. It was documented that the patient was discharged for being no longer terminally ill. There was no discharge order, no discharge summary, and no evidence that the discharge summary was forwarded to the physician. In an interview with the Director of Nursing, she stated “The facility doctor said the patient was no longer terminally ill. There was no order written to discharge the patient they were encouraged to revoke.” There was also no revocation form found in the clinical record.” This standard was not met as evidenced by review of the agency’s action plan during this site visit on 07/16/2024-07/18/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 06/28/2024. Previous Evidence: “This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were alive at discharge, it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the physician. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and was discharged on 04/08/2024. The RN documentation noted that the facility physician ordered for the patient to be discharged for the reason, “no longer terminally ill”. The RN later documented that the hospice encouraged them to revoke, and they “reluctantly” signed the revocation form. There was no discharge summary found in the patient record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023 and was a live discharge on 04/07/2024. It was documented that the patient was discharged for being no longer terminally ill. There was no discharge order, no discharge summary, and no evidence that the discharge summary was forwarded to the physician. In an interview with the Director of Nursing, she stated “The facility doctor said the patient was no longer terminally ill. We did not agree with that. There was no order written to discharge the patient they were encouraged to revoke.” There was also no revocation form found in the clinical record.””

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. THIS IS A CMS CONDITION LEVEL DEFICIENCY NOT REVIEWED AT THE PRIOR SITE VISIT This CONDITION was not met as evidenced by document review and interview which revealed the agency failed to ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program [HQPI.5. I/L563], failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually [HSLG.2.I/L574], failed to ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations [HQPI.9. I/L572] and failed to implement and document any program activities that would demonstrate evidence of a quality improvement program [HQPI.6.I/L566]. 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 418.58: Quality Assessment & Performance Improvements. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. THIS IS A CMS CONDITION LEVEL DEFICIENCY NOT REVIEWED AT THE PRIOR SITE VISIT This CONDITION was not met as evidenced by document review and interview which revealed the agency failed to ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program [HQPI.5. I/L563], failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually [HSLG.2.I/L574], failed to ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations [HQPI.9. I/L572] and failed to implement and document any program activities that would demonstrate evidence of a quality improvement program [HQPI.6.I/L566]. 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 418.58: Quality Assessment & Performance Improvements. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY NOT REVIEWED AT THE PRIOR SITE VISIT. This CONDITION was not met as evidenced by document review and interview. Review of the agency’s volunteer program revealed no documented evidence that the agency had implemented a volunteer program. During the request for personnel records on 06/04/2024, the Administrator/Volunteer Coordinator stated the agency did not have any volunteers. It was confirmed that the agency did not have volunteers available for day to day administrative or direct care roles. The agency could not provide documentation of recruitment and retaining efforts, cost savings related to volunteer usage, and could not show proof that volunteers had been used in administrative and direct care roles. The cumulative effect of this deficiency could result in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.78: Volunteer Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. THIS IS A CMS CONDITION LEVEL DEFICIENCY NOT REVIEWED AT THE PRIOR SITE VISIT. This CONDITION was not met as evidenced by document review and interview. Review of the agency’s volunteer program revealed no documented evidence that the agency had implemented a volunteer program. During the request for personnel records on 06/04/2024, the Administrator/Volunteer Coordinator stated the agency did not have any volunteers. It was confirmed that the agency did not have volunteers available for day to day administrative or direct care roles. The agency could not provide documentation of recruitment and retaining efforts, cost saving s related to volunteer usage, and could not show proof that volunteers had been used in administrative and direct care roles. The cumulative effect of this deficiency could result in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.78: Volunteer Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL FINDING THIS CONDITON WAS NOT REVIEWED AT THE PRIOR SITE VISIT This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness [HCPC.4.I/L667] and failed to ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement [HCPC.6.I/L668]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. THIS CONDITON WAS NOT REVIEWED AT THE PRIOR SITE VISIT This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness [HCPC.4.I/L667] and failed to ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement [HCPC.6.I/L668]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the 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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary group competed an initial comprehensive assessment no later than 5 calendar days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit effective 11/18/2024. Review of the clinical record revealed that the Chaplain did not make an initial visit until 11/25/2023, seven (7) days after the election of hospice services. There was no documentation provided to account for this delay in care. Clinical Record 6: The patient elected the hospice benefit effective 05/23/2024. A review of the clinical record revealed that there were no visits documented by any discipline since the RN initial assessment dated 05/23/2023. Review of the clinical record was thirteen (13) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 8: The patient elected the hospice benefit effective 03/21/2024. A review of the clinical record revealed that the social worker’s initial visit did not occur until 03/28/2024, seven (7) days after the hospice services were elected. The Chaplain initial visit was not made until 04/01/2024, eleven (11) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 11: The patient elected the hospice benefit effective 02/19/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 02/25/2024, six (6) days after the hospice services were elected. No documentation was provided to account for this delay in care. Clinical Record 13: The patient elected the hospice benefit effective 02/14/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 03/02/2024, seventeen (17) days after the hospice services were elected. No documentation was provided to account for this delay in care. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary group competed an initial comprehensive assessment no later than 5 calendar days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit effective 11/18/2024. Review of the clinical record revealed that the Chaplain did not make an initial visit until 11/25/2023, seven (7) days after the election of hospice services. There was no documentation provided to account for this delay in care. Clinical Record 6: The patient elected the hospice benefit effective 05/23/2024. A review of the clinical record revealed that there were no visits documented by any discipline since the RN initial assessment dated 05/23/2023. Review of the clinical record was thirteen (13) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 8: The patient elected the hospice benefit effective 03/21/2024. A review of the clinical record revealed that the social worker’s initial visit did not occur until 03/28/2024, seven (7) days after the hospice services were elected. The Chaplain initial visit was not made until 04/01/2024, eleven (11) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 11: The patient elected the hospice benefit effective 02/19/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 02/25/2024, six (6) days after the hospice services were elected. No documentation was provided to account for this delay in care. Clinical Record 13: The patient elected the hospice benefit effective 02/14/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 03/02/2024, seventeen (17) days after the hospice services were elected. No documentation was provided to account for this delay in care.”

“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, 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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment was completed no less frequently than every 15 days. Clinical Record 5: The patient elected the hospice benefit on 11/18/2024 with a diagnosis of Multiple Myeloma. The plan of care for the certification period 05/16/2024 - 07/14/2024, ordered nursing visits two times per week. The last comprehensive assessment was dated 05/23/2024. There was no documented evidence of contact with the patient or family by any discipline since then to date. Clinical Record 9: The patient elected the hospice benefit on 01/10/2024. The plan of care for the certification period 05/19/2024 - 07/07/2024 lacked an order for nursing visit frequency. The last documented comprehensive assessment was dated 05/22/2024. As of 06/06/2024, there was no evidence of an updated comprehensive assessment. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment was completed no less frequently than every 15 days. Clinical Record 5: The patient elected the hospice benefit on 11/18/2024 with a diagnosis of Multiple Myeloma. The plan of care for the certification period 05/16/2024 - 07/14/2024, ordered nursing visits two times per week. The last comprehensive assessment was dated 05/23/2024. There was no documented evidence of contact with the patient or family by any discipline since then to date. Clinical Record 9: The patient elected the hospice benefit on 01/10/2024. The plan of care for the certification period 05/19/2024 - 07/07/2024 lacked an order for nursing visit frequency. The last documented comprehensive assessment was dated 05/22/2024. As of 06/06/2024, there was no evidence of an updated comprehensive assessment.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Review of the agency Quality binder revealed there was no documented evidence of patient care related data that was collected to be used in quality assessment and improvement activities to monitor the effectiveness and safety of services and quality of care. During interview with the Director of Nursing and the Administrator it was confirmed that there was no data collection to review. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Review of the agency Quality binder revealed there was no documented evidence of patient care related data that was collected to be used in quality assessment and improvement activities to monitor the effectiveness and safety of services and quality of care. During interview with the Director of Nursing and the Administrator it was confirmed that there was no data collection to review.”

“It is required that the Hospice performance improvement (PI) activities: Focus on high-risk, high-volume, or problem-prone areas. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Review of the agency Quality binder revealed the Hospice did not have any evidence of any performance improvement activities for the years 2022 and 2023. During interview with the Administrator and the Director of Nursing, the lack of PI activities was confirmed. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Review of the agency Quality binder revealed the Hospice did not have any evidence of any performance improvement activities for the years 2022 and 2023. During interview with the Administrator and the Director of Nursing, the lack of PI activities was confirmed.”

“It is required that documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served, represent the internal needs of the organization, reflect the scope, complexity, and past performance of the hospice’s services and operations. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by review of documents and interview. Review of the agency Quality binder revealed that the agency had not conducted any performance improvement projects (PIP) for the years 2022 and 2023. During interview with the Administrator and the Director of Nursing it was confirmed that there were no PIPs conducted and none currently in place. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by review of documents and interview. Review of the agency Quality binder revealed that the agency had not conducted any performance improvement projects for the years 2022 and 2023. During interview with the Administrator and the Director of Nursing it was confirmed that there were no PIPs conducted and none currently in place.”

“It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Upon reviewing the agency’s QAPI, there was no evidence to suggest that the agency has maintained a data-driven program. Additionally, there was no evidence of any current or past performance improvement plans. The program lacks a qualified individual to oversee it and there is no proof that the agency conducted an annual review of its program. During an interview, the Director of Nursing presented a binder containing minimal information, consisting mostly of policies and procedures. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. Upon reviewing the agency’s QAPI, there was no evidence to suggest that the agency has maintained a data-driven program. Additionally, there was no evidence of any current or past performance improvement plans. The program lacks a qualified individual to oversee it and there is no proof that the agency conducts an annual review of its program. During an interview, the Director of Nursing presented a binder containing minimal information, consisting mostly of policies and procedures.”

“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/IDF (intermediate care facility/intellectual disability facility) 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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were eligible to receive bereavement services, it was revealed that the agency did not ensure that bereavement services were available to the family and other individuals following the death of the patient. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024. An initial bereavement assessment was completed by the RN on the initial RN assessment dated 02/19/2024. The patient died 03/07/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024. An initial bereavement assessment was done by the RN on the initial RN assessment dated 01/31/2024. The patient died 02/12/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. In an interview conducted with the Bereavement Coordinator on 06/05/2024 she stated that after death she made some phone calls but did not document them. She also stated that she had not completed any mailings or consistent follow up for families post death. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were eligible to receive bereavement services, it was revealed that the agency did not ensure that bereavement services were available to the family and other individuals following the death of the patient. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024. An initial bereavement assessment was completed by the RN on the initial RN assessment dated 02/19/2024. The patient died 03/07/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024. An initial bereavement assessment was done by the RN on the initial RN assessment dated 01/31/2024. The patient died 02/12/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. In an interview conducted with the Bereavement Coordinator on 06/05/2024 she stated that after death she made some phone calls but did not document them. She also stated that she had not done any mailings or consistent follow up for families post death.”

“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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients receiving aide services, it was revealed that the agency did not ensure that the aide plan of care contained specific instructions for patient care. Clinical Record 2: The patient elected the hospice benefit on 12/05/2024 and accepted aide services. The plan of care dated 12/05/2023 ordered shampoo as needed and change linen as needed. The aide plan of care written by the RN did not give specific instructions to when these services were to be provided. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024 and accepted aide services. The RN assessment documented that the patient had an indwelling catheter and a gastrostomy tube. The aide plan of care dated 02/24/2024, written by the RN, did not include notifications or specific instructions for the aide to follow when providing personal care to care for the foley or gastrotomy tube. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and accepted aide services. The initial assessment by the RN documented that the patient had a suprapubic catheter. The aide plan of care dated 02/14/2024, written by the RN did not include any specific written instructions for the aide to follow for care of the suprapubic catheter during personal care or when to notify the nurse if there were issues that needed to be addressed. In an interview with the DON she confirmed that the aide plans of care were lacking specific instructions for patient care. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients receiving aide services, it was revealed that the agency did not ensure that the aide plan of care contained specific instructions for patient care. Clinical Record 2: The patient elected the hospice benefit on 12/05/2024 and accepted aide services. The plan of care dated 12/05/2023 ordered shampoo as needed and change linen as needed. The aide plan of care written by the RN did not give specific instructions to when these services were to be provided. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024 and accepted aide services. The RN assessment documented that the patient had an indwelling catheter and a gastrostomy tube. The aide plan of care dated 02/24/2024, written by the RN, did not include notifications or specific instructions for the aide to follow when providing personal care to care for the foley or gastrotomy tube. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and accepted aide services. The initial assessment by the RN documented that the patient had a suprapubic catheter. The aide plan of care dated 02/14/2024, written by the RN did not include any specific written instructions for the aide to follow for care of the suprapubic catheter during personal care or when to notify the nurse if there were issues that needed to be addressed. In an interview with the DON she confirmed that the aide plans of care were lacking specific instructions for patient care.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. The Administrator was the acting Volunteer Coordinator. In an interview with the Volunteer Coordinator/Administrator he stated that the agency did not have any active volunteers at this time. He stated that on occasion he would deliver supplies or sit with a patient during the day. There were no documented volunteer hours. When asked if there if there are any volunteer that help with in-direct care he also stated, “No, not at this time.” THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. The Administrator was the acting Volunteer Coordinator. In an interview with the Volunteer Coordinator/Administrator he stated that the agency does not have any active volunteers at this time. He stated that on occasion he would deliver supplies or sit with a patient during the day. There were no documented volunteer hours. When asked if there if there are any volunteer that help with in-direct care he also stated “No, not at this time.””

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. During review of the volunteer program activities with the Administrator/Volunteer Coordinator, it was stated that there were no volunteers and there was no documentation of recruitment efforts or planned activities for volunteer recruitment. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. During review of the volunteer program activities with the Administrator/Volunteer Coordinator, it was stated that there were no volunteers and there was no documentation of recruitment efforts or planned activities for volunteer recruitment.”

“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. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. In the interview, the Volunteer Coordinator disclosed that the agency lacked a functional volunteer program. Currently, there were no active volunteers, and none had been engaged since the COVID period. The agency did not possess any recorded evidence of recruitment or retention initiatives. Furthermore, there was no documentation to suggest that volunteers were contributing to the agency’s daily operations. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by document review and interview. In the interview, the Volunteer Coordinator disclosed that the agency lacks a functional volunteer program. Currently, there are no active volunteers, and none have been engaged since the COVID period. The agency does not possess any recorded evidence of recruitment or retention initiatives. Furthermore, there is no documentation to suggest that volunteers are contributing to the agency’s daily operations.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that each patient had a written certification of terminal illness as required. Agency policy titled, Certification of Terminal Illness, #1-007 stated in part, “At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record.” Clinical Record 1: The patient elected the hospice benefit on 05/29/2024. There was no documentation of a written narrative for the certification of terminal illness upon admission, and there were no physician signatures. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative regarding the certification of terminal illness at the time of admission, and for the benefit period beginning on 05/24/2024. There were no physician signatures. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. There was no documented evidence of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, and there were no physician signatures on record. Clinical Record 9: The patient elected the hospice benefit on 03/21/2024. There was no documented evidence that the physician provided a written narrative on the certification of terminal illness on admission. There were no physician signatures. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 13: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative by the physician certifying terminal illness at the time of admission. During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the written narratives on the certifications of terminal illness. During interview with the Medical Director, he stated calls and talks to the Director of Nursing. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that each patient had a written certification of terminal illness as required. Agency policy titled, Certification of Terminal Illness, #1-007 stated in part, “At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record.” Clinical Record 1: The patient elected the hospice benefit on 05/29/2024. There was no documentation of a written narrative for the certification of terminal illness upon admission, and there were no physician signatures. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative regarding the certification of terminal illness at the time of admission, and for the benefit period beginning on 05/24/2024. There were no physician signatures. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. There was no documented evidence of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, and there were no physician signatures on record. Clinical Record 9: The patient elected the hospice benefit on 03/21/2024. There was no documented evidence that the physician provided a written narrative on the certification of terminal illness on admission. There were no physician signatures. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 13: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative by the physician certifying terminal illness at the time of admission. During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the written narratives on the certifications of terminal illness. During interview with the Medical Director, he stated calls and talks to the Director of Nursing.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 4 of 6 (67%) clinical records reviewed that were eligible for recertification it was revealed that the agency did not ensure that there was a written and signed recertification of the terminal illness for each benefit period. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024. There was no documented proof of the physician’s written narrative regarding the certification of terminal illness at the time of admission. Additionally, physician signatures were missing. There was no evidence of a terminal illness certification for the period beginning on 05/24/2024. Clinical Record 5: The patient elected the hospice benefit on 11/18/2023. There was no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 02/16/2024 to 05/15/2024, and the certification period from 05/16/2024 to 07/14/2024. Additionally, the certification of terminal illness lacks the required physician signatures. Clinical Record 9: The patient elected the hospice benefit on 01/10/2023. There was no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 03/10/2024 to 05/08/2024 and the certification period from 05/09/2024 to 07/07/2024. Additionally, the certification of terminal illness lacked the required physician signatures. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023. There was no evidence of a terminal illness certification for the period beginning on 02/02/2024 or certification period beginning on 04/08/2024. Director of Nursing: During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the terminal illness certifications for recertification. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 4 of 6 = 67% clinical records reviewed that were eligible for recertification revealed that the agency did not ensure that there was a written and signed recertification of the terminal illness for each benefit period. Clinical Record 4: The patient elected the hospice benefit starting on 02/24/2024. However, there is no documented proof of the physician’s written narrative regarding the certification of terminal illness at the time of admission. Additionally, physician signatures are missing. Furthermore, there is no evidence of a terminal illness certification for the period beginning on 05/24/2024. Clinical Record 5: The patient elected the hospice benefit on 11/18/2023. However, there is no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 02/16/2024, to 05/15/2024, and the certification period from 05/16/2024 to 07/14/2024. Additionally, the certification of terminal illness lacks the required physician signatures. Clinical Record 9: The patient elected the hospice benefit on 01/10/2023. However, there is no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 03/10/2024 to 05/08/2024 and the certification period from 05/09/2024, to 07/07/2024. Additionally, the certification of terminal illness lacks the required physician signatures. Clinical Record 14: The patient elected the hospice benefit starting on 11/04/2023. There is no evidence of a terminal illness certification for the period beginning on 02/02/2024 or certification period beginning on 04/08/2024. Director of Nursing: During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the terminal illness certifications for recertification.”

“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. The 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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that record included a patient plan of care. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. During review of the clinical record there was no documented plan of care. The patient’s death was imminent on admission and expired on 06/02/2024. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024, with a diagnosis of severe caloric malnutrition. There was no plan of care found in the clinical record for this patient. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024, with a diagnosis Malignant neoplasm of unspecified part of unspecified bronchus or lung. There was no plan of care found in the clinical record for this patient. Clinical Record 14: The patient elected the hospice benefit on 11/04/2024 with Senile Degeneration of the Brain. There was no plan of care found in the clinical record for this patient. Director of Nursing: In an interview with the Director of Nursing there was no explanation provided why the plans of care were absent. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 4 of 14 = 29% clinical records reviewed revealed that the agency did not ensure that record included a patient plan of care. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. During review of the clinical record there was no documented plan of care. The patient was imminent on admission and expired on 06/02/2024. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024, with a diagnosis of severe caloric malnutrition. There was no plan of care found in the clinical record for this patient. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024, with a diagnosis Malignant neoplasm of unspecified part of unspecified bronchus or lung. There was no plan of care found in the clinical record for this patient. Clinical Record 14: The patient elected the hospice benefit on 11/04/2024 with Senile Degeneration of the Brain. There was no plan of care found in the clinical record for this patient. Director of Nursing: In an interview with the Director of Nursing there was no explanation provided why the plan of care were absent.”

“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 REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed it was revealed that the agency did not ensure that the patient record contained signed physician’s orders. Clinical Record 1: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of severe calorie malnutrition. In the RN initial assessment, it was documented that the patient had an open wound on her right heel. The RN documented that she cleaned the wound with water and applied Medi honey. There was no documented physician’s order found in the clinical record. Clinical Record 3: The patient chose the hospice benefit on 09/15/2023, with a diagnosis of Malignant Neoplasm of an Unspecified Part of the Bronchus or Lung. On 01/30/2024, a verbal order for Oxycodone HCl 10mg to be taken orally every 8 hours for pain was noted, but it lacked a physician’s signature. A home visit and patient interview confirmed that she actively uses this medication when her pain becomes unbearable. Clinical Record 4: The patient chose to receive hospice care on 02/24/2024, with a diagnosis of Senile Degeneration of the Brain. In the RN initial assessment dated 02/24/2024 the RN documented that the patient had two (2) open wounds that she was provided care for. There was no documentation of physician orders for wound care. During the nursing assessment on 05/31/2024, the nurse recorded flushing the patient’s Foley catheter with 120cc of normal saline. Additionally, the nurse noted that the patient was taking Bactrim DS suspension, 20mL twice daily for seven days. However, there were no physician’s orders for these treatments, nor were they included in the plan of care. Clinical Record 10: The patient elected the hospice benefit on 05/302024, with a diagnosis of severe caloric malnutrition. The initial RN assessment documented that the patient was undergoing wound care for seven open wounds. The RN’s documentation stated that the wounds were cleansed with Dakin’s solution and covered with Xeroform dressings. The record did not show any physician’s order for this treatment protocol. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024 with a diagnosis of Severe Protein Calorie Malnutrition. The initial RN assessment documented that the patient had a foley catheter and 2 open wounds. The RN documented wound care was being provided as follows, clean wound with wound cleanser then apply Dakins soaked gauze to wound and cover with boarder gauze. There was no evidence found of a physician’s order for wound care in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024 with a diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. In the certification of terminal illness, the physician noted that the patient had a plurex drain for treatment of shortness of breath due to fluid buildup. There was no physician order for plurex drain or care for the plurex drain found in the clinical record. Director of Nursing: In an interview with the director of nursing she talked through the process of getting physicians orders signed but had no explanation as to why there were not physician’s orders in these records. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 6 of 14 = 43% clinical records reviewed revealed that the agency did not ensure that the patient record contained signed physician’s orders. Clinical Record 4: The patient chose to receive hospice care on 02/24/2024, with a diagnosis of Senile Degeneration of the Brain. In the RN initial assessment dated 02/24/2024 the Rn documented that the patient had 2 open wounds that she was provided care for. There was no documentation of physician orders for wound care. During the nursing assessment on 05/31/2024, the nurse recorded flushing the patient’s Foley catheter with 120cc of normal saline. Additionally, the nurse noted that the patient was taking Bactrim DS suspension, 20mL twice daily for seven days. However, there were no physician’s orders for these treatments, nor were they included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of severe calorie malnutrition. In the RN initial assessment, it was documented that the patient had an open wound on her right heel. The RN documented that she cleaned the wound with water and applied Medi honey. There was no documented physician’s order found in the clinical record. Clinical Record 3: The patient chose the hospice benefit on 09/15/2023, with a diagnosis of Malignant Neoplasm of an Unspecified Part of the Bronchus or Lung. On 01/30/2024, a verbal order for Oxycodone HCl 10mg to be taken orally every 8 hours for pain was noted, but it lacked a physician’s signature. A home visit and patient interview confirmed that she actively uses this medication when her pain becomes unbearable. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024 with a diagnosis of Severe Protein Calorie Malnutrition. In the initial RN assessment, it was noted that the patient had a foley catheter and 2 open wounds. The RN documented wound care was being provided as follows, clean wound with wound cleanser then apply Dakins soaked gauze to wound and cover with boarder gauze. There was no evidence found of a physician’s order for wound care in the clinical record. Clinical Record 10: The patient elected the hospice benetif on 05/302024, with a diagnosis of severe caloric malnutrition. The initial RN assessment indicated that the patient was undergoing wound care for seven open wounds. The RN’s documentation stated that the wounds were cleansed with Dakin’s solution and covered with Xeroform dressings. However, the records did not show any physician’s order for this treatment protocol. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024 with a diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. In the certification of terminal illness, the physician noted that the patient had a plurex drain for treatment of shortness of breath due to fluid buildup. There was no physician order for plurex drain or care for the plurex drain found in the clinical record. Director of Nursing: In an interview with the director of nursing she talked through the process of getting physicians orders signed but had no explanation as to why there were not physician’s orders in these records.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 8 (100%) clinical records reviewed it was revealed that the agency did not ensure the authentication of the signature dates of the plans of care. Document 1: The abatement plan stated in part, “Education provided on interdisciplinary group responsibilities for ensuring each patient has a care plan on 06/08/2024. Plans of care were located in the Quality Manager box. Plans of Care were approved and moved to the Hospice Medical Director and will be signed by 06/10/2024. The Medical Director was notified on 06/08/2024 to complete electronic signatures for all patients. Clinical Record 1: Physician signature for the plan of care for benefit period 05/29/2024 - 08/26/2024 was dated 05/31/2024. Clinical Record 2: The physician’s signature for the plan of care for the benefit period 05/24/2024 - 08/21/2024 was dated 05/22/2024 with a nurse signature date of 05/24/2024. Clinical Record 3: The physician’s signature for the plan of care for the benefit period 06/02/2024 -07/31/2024 was dated 05/30/2024. Clinical Record 4: The physician’s signature for the plan of care for the benefit period 05/16/2024 -07/14/2024 was dated 05/09/2024. Clinical Record 5: The physician’s signature for the plan of care for the benefit period 05/23/2024- 08/20/2024 was dated 05/28/2024. Clinical Record 6: The physician’s signature for the plan of care for the benefit period 05/12/2024 - 07/10/2024 was dated 05/02/2024. Clinical Record 7: The physician’s signature for the plan of care for the benefit period 05/09/2024 - 07/07/2024 was dated 05/08/2024. Clinical Record 8: The physician’s signature for the plan of care for the benefit period 05/30/2024- 08/27/2024 was dated 06/05/2024. In an interview with Alternate Administrator and Director of Nursing on 06/24/2024, the Alternate Administrator acknowledged that that the plans of care were backdated because all of the dates of the physician signatures were prior to the plan of correction.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient’s record, if requested. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were alive at discharge, it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the physician. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and was discharged on 04/08/2024. The RN documentation noted that the facility physician ordered for the patient to be discharged for the reason, “no longer terminally ill”. The RN later documented that the hospice encouraged them to revoke, and they “reluctantly” signed the revocation form. There was no discharge summary found in the patient record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023 and was a live discharge on 04/07/2024. It was documented that the patient was discharged for being no longer terminally ill. There was no discharge order, no discharge summary and no evidence that the discharge summary was forwarded to the physician. In an interview with the Director of nursing she stated “The facility doctor said the patient was no longer terminally ill. We did not agree with that. There was no order written to discharge the patient they were encouraged to revoke.” There was also no revocation form found in the clinical record. THIS STANDARD WAS NOT REVIEWED AT THE PRIOR SITE VISIT This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were alive at discharge, it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the physician. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and was discharged on 04/08/2024. The RN documentation noted that the facility physician ordered for the patient to be discharged for the reason, “no longer terminally ill”. The RN later documented that the hospice encouraged them to revoke, and they “reluctantly” signed the revocation form. There was no discharge summary found in the patient record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023 and was a live discharge on 04/07/2024. It was documented that the patient was discharged for being no longer terminally ill. There was no discharge order, no discharge summary and no evidence that the discharge summary was forwarded to the physician. In an interview with the Director of nursing she stated “the facility doctor said the patient was no longer terminally ill. We did not agree with that. There was no order written to discharge the patient they were encouraged to revoke.” There was also no revocation form found in the clinical record.”

“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 CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by review of clinical records and interviews with the Director of Nursing, Administrator, and Medical Director, which revealed significant issues with the development and implementation of the patient’s interdisciplinary plan of care. In review of clinical records, it was revealed that the agency failed to ensure the Interdisciplinary Group (IDG) prepared a written plan of care for each patient in consultation with the patient’s attending physician [HCPC.19.I/L543], failed to ensure a hospice plan of care was developed with physician orders for medications and services necessary to meet the specific needs of the patient and family as identified in the comprehensive assessments [HCPC.21.I/L545], failed to ensure the IDG, in its entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family [HCPC1.I/L539], failed to ensure a Registered Nurse was designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care [HCPC.19.I/L540], failed to ensure the individualized plan of care was reviewed by the IDG no less frequently than every 15 calendar days [HCPC.22.I/L552. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. Policy No.1-013 Initial Assessment states in part, “ based on the initial assessment, the plan of care will be initiated on the day of admission.””

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview which revealed the agency failed to ensure that quality indicator data, including patient care data and other relevant data, was used in the Quality Assessment Performance Improvement (QAPI) program [HQPI.5. I/L563], failed to ensure it maintained documentary evidence of its quality assessment and performance improvement program that included how the program was defined, implemented, maintained, and evaluated annually [HSLG.2.I/L574], failed to ensure that performance improvement projects conducted represented the needs of the hospice population served, represented the internal needs of the organization, and reflected the scope, complexity, and past performance of the hospice’s services and operations [HQPI.9. I/L572] and failed to implement and document any program activities that would demonstrate evidence of a quality improvement program [HQPI.6.I/L566]. 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 418.58: Quality Assessment & Performance Improvements. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview. Review of the agency’s volunteer program revealed no documented evidence that the agency had implemented a volunteer program. During the request for personnel records on 06/04/2024, the Administrator/Volunteer Coordinator stated the agency did not have any volunteers. It was confirmed that the agency did not have volunteers available for day to day administrative or direct care roles. The agency could not provide documentation of recruitment and retaining efforts, cost saving s related to volunteer usage, and could not show proof that volunteers had been used in administrative and direct care roles. The cumulative effect of this deficiency could result in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.78: Volunteer Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by review of clinical records and interviews with the Director of Nursing, Administrator, and Medical Director, which revealed significant issues with the development and implementation of the patient’s interdisciplinary care plan. In 60% of records reviewed it was revealed that the organization failed provide oversight of organizational operations to ensure the hospice IDG delivered services to patients, caregivers, and families that provided palliation and management of their terminal illness and related conditions. The organization failed to ensure the provision of care and services followed individualized plans of care and physician orders and were obtained and implemented in compliance with state and federal regulations, [HSLG.2.I/L651] failed to ensure staff were oriented to their specific roles and job duties [HSRM.15.I/L662] and failed to ensure staff competencies were completed as outlined in organization policy [HSRM14.I/L663]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness [HCPC.4.I/L667] and failed to ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement [HCPC.6.I/L668]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the 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. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary group competed an initial comprehensive assessment no later than 5 calendar days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit effective 11/18/2024. Review of the clinical record revealed that the Chaplain did not make an initial visit until 11/25/2023, seven (7) days after the election of hospice services. There was no documentation provided to account for this delay in care. Clinical Record 6: The patient elected the hospice benefit effective 05/23/2024. A review of the clinical record revealed that there were no visits documented by any discipline since the RN initial assessment dated 05/23/2023. Review of the clinical record was thirteen (13) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 8: The patient elected the hospice benefit effective 03/21/2024. A review of the clinical record revealed that the social worker’s initial visit did not occur until 03/28/2024, seven (7) days after the hospice services were elected. The Chaplain initial visit was not made until 04/01/2024, eleven (11) days after the election of the hospice benefit. No documentation was provided to account for this delay in care. Clinical Record 11: The patient elected the hospice benefit effective 02/19/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 02/25/2024, six (6) days after the hospice services were elected. No documentation was provided to account for this delay in care. Clinical Record 13: The patient elected the hospice benefit effective 02/14/2024. A review of the clinical record revealed the social worker’s initial visit did not occur until 03/02/2024, seventeen (17) days after the hospice services were elected. No documentation was provided to account for this delay in care.”

“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, 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. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment was completed no less frequently than every 15 days. Clinical Record 5: The patient elected the hospice benefit on 11/18/2024 with a diagnosis of Multiple Myeloma. The plan of care for the certification period 05/16/2024 - 07/14/2024, ordered nursing visits two times per week. The last comprehensive assessment was dated 05/23/2024. There was no documented evidence of contact with the patient or family by any discipline since then to date. Clinical Record 9: The patient elected the hospice benefit on 01/10/2024. The plan of care for the certification period 05/19/2024 - 07/07/2024 lacked an order for nursing visit frequency. The last documented comprehensive assessment was dated 05/22/2024. As of 06/06/2024, there was no evidence of an updated comprehensive assessment.”

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed it was revealed that the agency did not ensure the IDG, in its entirety supervised the care and services provided to the patient. In all 14 records reviewed, there was no consistent evidence that the interdisciplinary team had come together to discuss and/or update the patient’s plans of care. IDG format was a template of yes/no questions. The IDG meeting notes that were documented, included an attendee list, but the notes were lacking multiple areas of information required: There was no consistent documentation of, updated assessments, discipline specific notes, review of medications and treatments, and orders. The dates for IDG meetings were not consistent across patient roster and multiple IDG meetings were missing. In multiple interviews about IDG meetings with the Director of Nursing she stated, “I forgot to close the meetings, that’s why they are not showing up.” The Interdisciplinary meeting took place on 05/22/2024 and was scheduled to be held on 06/0502024. The director of nursing cancelled the meeting stating, “there is too much going on we will maybe do it tomorrow.” By the end of business day on 06/06/2024 the IDG had not met. This was the 15th day. Clinical Records: [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14] In all 14 charts reviewed There was no consistent evidence that the interdisciplinary team had come together to discuss or update patient plans of care. The IDG meeting notes presented was lacking multiple areas of information required. The dates for IDT meetings were not consistent across patient roster and multiple IDT meetings were missing. In multiple interviews about IDG meetings with the Director of Nursing she stated, “I forgot to close the meetings, that’s why they are not showing up.” The Interdisciplinary meeting took place on 05/22/2024 and was scheduled to be held on 06/0502024. The director of nursing cancelled the meeting stating, “there is too much going on we will maybe do it tomorrow.” By the end of business day on 06/06/2024 the IDT still had not met. This was the 15th day.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed of patients actively receiving treatments, it was revealed that the agency did not ensure that a Registered Nurse was designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. [Records 1, 2, 10, 11 and 12] Clinical Record 1, 10, and 11: The records documented multiple open wounds. There was no documented evidence of delineation of who was responsible for wound care or dressing changes. Clinical Record 2 and 12: The records identified each patient had a pleurex drain. There was no documented evidence of delineation of who was responsible for using the drain or caring for the drain.”

“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 standard was not met as evidenced by clinical record review, document review and interview. In 6 of 14 (43%) clinical records reviewed it was revealed that the agency did not ensure that the interdisciplinary group prepared an individualized written plan of care for each patient. Agency policy No.1-013 titled, Initial Assessment, stated in part, “Based on the initial assessment, the plan of care will be initiated on the day of admission.” Clinical Record 6: The patient elected the hospice benefit on 05/23/2024. An initial assessment was done on 05/23/2024 by the RN. During record reviewed on 06/04/2024 there was no evidence of a written plan of care for the patient. Clinical Record 7: The patient elected the hospice benefit on 06/01//2024. An initial assessment was done on 06/01/2024 by the RN. The patient died on 06/02/2024. During record review on 06/06/2022 there was no evidence of a written plan of care for the patient. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024. An initial assessment was done on 03/21/2024 by the RN. During clinical record review on 06/06/2022 there was no evidence of a written plan of care for the patient. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024. An initial assessment was done on 05/30/2024 by the RN. During record review on 06/06/2024 there was no evidence of a written plan of care for the patient. Clinical Record 11: Patient elected hospice benefit on 02/19/2024. An initial assessment was done by the RN on 02/14/2024. During record review on 06/04/2024 there was no evidence of a written plan of care for the patient. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024. An initial assessment was done on 01/31/2024 by the RN. During record review on 06/05/2022 there was no evidence of a written plan of care for the patient. In an interview with the Director of Nursing on 06/04/2023, 06/05/2023, and 06/06/2023, she stated that the EMR sometimes does not generate the plan of care when they are put in the computer. She was unable to locate any plans of care for these patients during the site visit.”

“It is required that each patient’s individualized written plan of care reflects 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 14 (7%) records reviewed it was revealed that the agency did not ensure the plan of care orders included all services and treatments the patient was receiving. Clinical Record 2: The patient elected the hospice benefit on 12/05/2023 with a diagnosis of Malignant neoplasm of the brain. In the initial certification of terminal illness dated 12/05/2023, the physician documented that the patient has a malignant pleural effusion with chest tube present in right chest wall. There was no documented evidence on the plan of care for planned interventions to care for chest tube. No evidence of collaboration with the facility and no delineation of care for the chest tube. In an interview with the director of nursing she confirmed that there were no orders for care of the chest tube in the plan of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 10 of 10 (100%) active clinical records reviewed it was revealed that there was no consistent interdisciplinary group discussion or documentation to track the patient’s changing status. The IDG documentation that was found offered minimal information including only patient demographics and attendees. In multiple records it was found that there was only one plan of care for the entire benefit period. There was no documented evidence that existing plans of care were reviewed or updated. Clinical Records: [1, 2, 3, 4, 5, 6, 7, 8, 9, and 10] During interview with the Director of Nursing, she stated that they use a standard template for IDG documentation. She states that the reason the surveyor could not see IDG notes was due to her not closing the notes at the end of the meeting. In an interview with the Medical Director, he stated he attends IDG when he can and if he can’t he calls and talks to only the DON about the patients to get updates. During Review of the clinical records there was no documented evidence that existing plans of care were reviewed or updated. In all 14 clinical records there was no consistent interdisciplinary group discussion or documentation to track the patient’s changing status. Interview with the Director of Nursing she stated that they use a standard template for IDG documentation. She states that the reason the surveyor could not see IDG notes was due to her not closing the notes at the end of the meeting. The IDG documentation that was found offered minimal information including only patient demographics and attendees. In multiple records it was found that there was only one plan of care for the entire benefit period. In an interview with the Medical Director, he stated he attends IDG when he can and if he can’t he calls and talks to only the DON about the patients to get updates.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. This standard was not met as evidenced by document review and interview. Review of the agency Quality binder revealed there was no documented evidence of patient care related data that was collected to be used in quality assessment and improvement activities to monitor the effectiveness and safety of services and quality of care. During interview with the Director of Nursing and the Administrator it was confirmed that there was no data collection to review.”

“It is required that documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served, represent the internal needs of the organization, reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by review of documents and interview. Review of the agency Quality binder revealed that the agency had not conducted any performance improvement projects for the years 2022 and 2023. During interview with the Administrator and the Director of Nursing it was confirmed that there were no PIPs conducted and none currently in place.”

“It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview. Review of the agency’s QAPI, there was no evidence to suggest that the agency has maintained a data-driven program. Additionally, there was no evidence of any current or past performance improvement plans. The program lacks a qualified individual to oversee it and there is no proof that the agency conducted an annual evaluation of its program. During an interview, the Director of Nursing presented a binder containing minimal information, consisting of policies and procedures, and admission statistics. Upon reviewing the agency’s QAPI, there was no evidence to suggest that the agency has maintained a data-driven program. Additionally, there was no evidence of any current or past performance improvement plans. The program lacks a qualified individual to oversee it and there is no proof that the agency conducts an annual review of its program. During an interview, the Director of Nursing presented a binder containing minimal information, consisting mostly of policies and procedures.”

“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/IDF (intermediate care facility/intellectual disability facility) 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 and interview. In 2 of 2 (100%) clinical records reviewed of patients that were eligible to receive bereavement services, it was revealed that the agency did not ensure that bereavement services were available to the family and other individuals following the death of the patient. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024. An initial bereavement assessment was completed by the RN on the initial RN assessment dated 02/19/2024. The patient died 03/07/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024. An initial bereavement assessment was done by the RN on the initial RN assessment dated 01/31/2024. The patient died 02/12/2024. There was no documented evidence of a post death bereavement plan of care. There was no evidence of calls or mailings being made and no evidence of planned support for the family for the required 1 year based on any identified needs. In an interview conducted with the Bereavement Coordinator on 06/05/2024 she stated that after death she made some phone calls but did not document them. She also stated that she had not done any mailings or consistent follow up for families post death.”

“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 3 of 13 (23%) clinical records reviewed of patients receiving aide services, it was revealed that the agency did not ensure that the aide plan of care contained specific instructions for patient care. Clinical Record 2: The patient elected the hospice benefit on 12/05/2024 and accepted aide services. The plan of care dated 12/05/2023 ordered shampoo as needed and change linen as needed. The aide plan of care written by the RN did not give specific instructions to when these services were to be provided. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024 and accepted aide services. The RN assessment documented that the patient had an indwelling catheter and a gastrostomy tube. The aide plan of care dated 02/24/2024, written by the RN, did not include notifications or specific instructions for the aide to follow when providing personal care to care for the foley or gastrotomy tube. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and accepted aide services. The initial assessment by the RN documented that the patient had a suprapubic catheter. The aide plan of care dated 02/14/2024, written by the RN did not include any specific written instructions for the aide to follow for care of the suprapubic catheter during personal care or when to notify the nurse if there were issues that needed to be addressed. In an interview with the DON she confirmed that the aide plans of care were lacking specific instructions for patient care.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. The Administrator was the acting Volunteer Coordinator. In an interview with the Volunteer Coordinator/Administrator he stated that the agency does not have any active volunteers at this time. He stated that on occasion he would deliver supplies or sit with a patient during the day. There were no documented volunteer hours. When asked if there if there are any volunteer that help with in-direct care he also stated “No, not at this time.” This was a renewal survey for this agency. Director of Nursing informed surveyor that the Administrator was the acting Volunteer Coordinator. In an interview with the Volunteer Coordinator/Administrator he stated that at this time they do not have any active volunteers at this time. He stated that on occasion he would deliver supplies or sit with a patient during the day. There is no documented volunteer hours. When asked if there if there are any volunteer that help with in-direct care he also stated “no, not at this time.” The recruitment for volunteers is lacking and there is no evidence documented of recruitment efforts.”

“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. This standard was not met as evidenced by document review and interview. In the interview, the Volunteer Coordinator/Administrator disclosed that the agency lacked a functional volunteer program. There was no documentation of active volunteers, and none had been engaged since the COVID pandemic. The agency did not possess any recorded evidence of recruitment or retention initiatives. There was no documentation of cost savings. There was no documentation to suggest that volunteers had contributed to the agency’s daily operations. In the interview, the Volunteer Coordinator disclosed that the agency lacks a functional volunteer program. Currently, there are no active volunteers, and none have been engaged since the COVID period. The agency does not possess any recorded evidence of recruitment or retention initiatives. Furthermore, there is no documentation to suggest that volunteers are contributing to the agency’s daily operations.”

“It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, and provision of care and services. This standard was not met, as evidenced by document review, and interview. The governing body did not provide oversight of the organizational operations to ensure the hospice interdisciplinary group (IDG) delivered services to patients and caregivers that provided palliation and management of their terminal illness and related conditions. There was no documented evidence that the governing body provided oversight and management of hospice operations to ensure the provision of care and services. The clinical records were missing initial hospice plans of care and updated plans of care (POC), verbal orders, plans of care signed by the physician or health care practitioner, medication orders, and completed certifications of terminal illness. The Administrator could not provide documentation to support that the hospice’s overall status of operations and provision of care and services had been reviewed and there was no documented quality plan. There was no documented evidence including no information pertaining to patient care coordination and issues such as missed comprehensive assessments, plans of care and updated plans of care, Interdisciplinary Group (IDG) review of plans of care, verbal orders and signed physician orders. During multiple interviews on 06/042024-06/06/2024, the Director of Nursing (DON) confirmed that care and services were being provided without verbal orders and physician-signed plans of care, treatment, and medication orders.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by personnel record review. In 3 of 6 (50%) personnel records reviewed it was revealed that the agency did not ensure that each employee was provided with information that addressed their specific job duties. Personnel Record 1: The social worker, with a bachelor’s degree in social work, was initially hired on 11/01/2017. A review of her personnel file revealed no documentation since 2021. The Director of Nursing indicated that she served as the acting bereavement coordinator, her personnel file lacked a job description or specific competencies for the bereavement coordinator role. Personnel Record 2: The supervising social worker, who holds an MSW, was first employed on April 30, 2019. There have been no updated competencies since 2020. The job description was not signed from hire to date. Personnel Record 3: The Director of Nursing was hired 07/14/2023, The personnel file revealed there was no evidence of any completed education that was job specific. There was no documented background check, and no job description.”

“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 and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 2 of 6 (33%) personnel records reviewed it was revealed that the agency did not ensure that skills and competencies of individuals providing care were assessed annually per agency policy. Personnel Record 2: The Master of Social Work (MSW) hired on April 30, 2019, to supervise the Bachelor of Social Work (BSW) qualified social worker, had no recorded competencies beyond the year 2020 to date. Personnel Record 1: The social worker (BSW), hired on 11/01/2017, who provided direct patient care, had no competencies documented in her record beyond the year 2021 to date. In an interview with the director of nursing she could not provide an explanation of why these were missing, and they could not be located.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that each patient had a written certification of terminal illness as required. Agency policy titled, Certification of Terminal Illness, #1-007 stated in part, “At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record.” Clinical Record 1: The patient elected the hospice benefit on 05/29/2024. There was no documentation of a written narrative for the certification of terminal illness upon admission, and there were no physician signatures. Clinical Record 4: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative regarding the certification of terminal illness at the time of admission, and for the benefit period beginning on 05/24/2024. There were no physician signatures. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. There was no documented evidence of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 8: The patient elected the hospice benefit on 03/21/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, and there were no physician signatures on record. Clinical Record 9: The patient elected the hospice benefit on 03/21/2024. There was no documented evidence that the physician provided a written narrative on the certification of terminal illness on admission. There were no physician signatures. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024. There was no documentation of the physician’s written narrative certifying terminal illness at the time of admission, nor were there any physician signatures on record. Clinical Record 13: The patient elected the hospice benefit on 02/24/2024. There was no documentation of a written narrative by the physician certifying terminal illness at the time of admission. During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the written narratives on the certifications of terminal illness. During interview with the Medical Director, he stated calls and talks to the Director of Nursing. In agency policy Certification of Terminal Illness policy #1-007 it states in part, “at the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record.””

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 4 of 6 (67%) clinical records reviewed of patients that were eligible for recertification, it was revealed that the agency did not ensure that there was a written and signed recertification of the terminal illness for each benefit period. Clinical Record 4: The patient elected the hospice benefit effective 02/24/2024. There was no written narrative regarding the certification of terminal illness at the time of admission, and no physician signatures. There was no evidence of a terminal illness certification for the benefit period effective 05/24/2024. Clinical Record 5: The patient elected the hospice benefit on 11/18/2023. There was no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 02/16/2024, to 05/15/2024, and 05/16/2024 to 07/14/2024. Clinical Record 9: The patient elected the hospice benefit on 01/10/2023. There was no documented certification narrative or physician’s signature on the certification of terminal illness for the recertification periods from 03/10/2024 to 05/08/2024 and the certification period from 05/09/2024, to 07/07/2024. Clinical Record 14: The patient elected the hospice benefit effective 11/04/2023. There was no evidence of a certificate of terminal illness certification for the period beginning on 02/02/2024 or the certification period beginning on 04/08/2024. During an interview and a joint review of clinical records with the Director of Nursing, no explanation was provided for the absence of the terminal illness certifications for recertification.”

“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. The 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 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the clinical record included a plan of care. Clinical Record 7: The patient elected the hospice benefit on 06/01/2024. There was no documented plan of care. The documentation reflected death was imminent on admission and the patient expired on 06/02/2024. Clinical Record 10: The patient elected the hospice benefit on 05/30/2024, with a diagnosis of severe caloric malnutrition. There was no documentation of a plan of care found in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024, with a diagnosis malignant neoplasm of unspecified part of unspecified bronchus or lung. There was no documentation of a plan of care found in the clinical record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2024 with a diagnosis of Senile Degeneration of the Brain. There was no documentation of a plan of care found in the clinical record. In an interview with the Director of Nursing there was no explanation provided for why there were no documented plans of care.”

“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 6 of 14 (43%) clinical records reviewed it was revealed that the agency did not ensure that the patient record contained physician’s orders. Clinical Record 1: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of severe calorie malnutrition. In the RN initial assessment, it was documented that the patient had an open wound on her right heel. The RN documented that she cleaned the wound with water and applied Medi honey. There was no documented physician’s order found in the clinical record for wound care. Clinical Record 3: The patient chose the hospice benefit on 09/15/2023, with a diagnosis of Malignant Neoplasm of an Unspecified Part of the Bronchus or Lung. On 01/30/2024, a verbal order for Oxycodone HCl 10mg to be taken orally every 8 hours for pain was noted, but it lacked a physician’s signature. A home visit and patient interview confirmed that she actively uses this medication when her pain becomes unbearable. Clinical Record 4: The patient chose to receive hospice care on 02/24/2024, with a diagnosis of Senile Degeneration of the Brain. The RN initial assessment dated 02/24/2024 documented that the patient had 2 open wounds that she was provided care for. There was no documentation of physician orders for wound care. The nursing assessment dated 05/31/2024, documented the nurse recorded flushing the patient’s indwelling catheter with 120cc of normal saline. Additionally, the nurse noted that the patient was taking Bactrim DS suspension, 20ml twice daily for seven days. There were no physician’s orders for these treatments, nor were they documented on the plan of care. Clinical Record 10: The patient elected the hospice benefit on 05/302024, with a diagnosis of severe caloric malnutrition. The initial RN assessment indicated that the patient was undergoing wound care for seven open wounds. The RN’s documentation stated that the wounds were cleansed with Dakin’s solution and covered with Xeroform dressings. The record did not show any physician’s order for this treatment protocol. Clinical Record 11: The patient elected the hospice benefit on 02/19/2024 with a diagnosis of Severe Protein Calorie Malnutrition. In the initial RN assessment, it was noted that the patient had an indwelling catheter and 2 open wounds. The RN documented wound care was being provided as follows: “Clean wound with wound cleanser then apply Dakins soaked gauze to wound and cover with boarder gauze”. There was no evidence found of a physician’s order for wound care in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 01/31/2024 with a diagnosis of Malignant neoplasm of unspecified part of unspecified bronchus or lung. In the certification of terminal illness, the physician noted that the patient had a plurex drain for treatment of shortness of breath due to fluid buildup. There was no physician order for plurex drain or care for the plurex drain found in the clinical record. In an interview with the director of nursing she talked through the process of getting physicians orders signed but had no explanation as to why there were not physician’s orders in these records.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that were alive at discharge, it was revealed that the agency did not ensure that a discharge summary was completed and forwarded to the physician. Clinical Record 13: The patient elected the hospice benefit on 02/14/2024 and was discharged on 04/08/2024. The RN documentation noted that the facility physician ordered for the patient to be discharged for the reason, “no longer terminally ill”. The RN later documented that the hospice encouraged them to revoke, and they “reluctantly” signed the revocation form. There was no discharge summary found in the patient record. Clinical Record 14: The patient elected the hospice benefit on 11/04/2023 and was a live discharge on 04/07/2024. It was documented that the patient was discharged for being no longer terminally ill. There was no discharge order, no discharge summary and no evidence that the discharge summary was forwarded to the physician. In an interview with the Director of nursing she stated “the facility doctor said the patient was no longer terminally ill. We did not agree with that. There was no order written to discharge the patient they were encouraged to revoke.” There was also no revocation form found in the clinical record.”