Ecumen Hospice

“Based on interview and document review, the hospice failed to thoroughly investigate an allegation of abuse for 1 of 3 patient (P1) reviewed for abuse. The hospice’s investigation was limited to an interview with the alleged perpetrator (AP) and attempts to obtain information from the assisted living facility where P1 resided. The hospice failed to review and reconcile its own clinical documentation related to the incident, interview other hospice staff or individuals who may have had relevant information, or assess whether there were similar concerns involving other patients who received services from the AP. This failure prevented the hospice from completing a thorough investigation to determine the circumstances surrounding the allegation and whether additional patients may have been at risk. Findings include:P1’s hospice plan of care dated 7/17/26, indicated P1 was admitted to hospice services on 7/17/26 with a diagnosis of Alzheimer’s disease. A chaplain visit note dated 8/13/26, indicated the chaplain visited P1 for approximately 45 minutes. The note indicated P1’s arms were flailing during the visit.A death visit note dated 8/13/26, indicated P1 passed away on 8/13/26. The hospice’s investigation related to the 8/13/26, allegation was reviewed. The investigation consisted of an interview with the alleged perpetrator (AP) and documentation of a meeting with the assisted living facility. The investigation did not include interviews with other hospice staff or other individuals who may have had relevant information regarding P1’s condition, behaviors, care, or the circumstances surrounding the allegation. The investigation did not include evidence the hospice reviewed and reconciled its own clinical documentation with the information obtained during the investigation. In addition, the investigation did not include evidence the hospice assessed other patients who received services from the AP to determine whether there had been similar concerns or a potential pattern of conduct.During an interview on 8/18/26 at 12:09 p.m., the senior director of people services and the director of hospice operations stated the hospice became aware of the allegation on 8/13/26, after the assisted living facility notified the hospice it intended to file a report with the state agency. The senior director of people services and the director of hospice operations stated hospice leadership met with human resources and the AP’s direct supervisor, interviewed the AP, and placed the AP on administrative leave.The senior director of people services and the director of hospice operations stated the hospice had not been able to complete a thorough investigation because it had not received the requested information from the assisted living facility. The director of hospice operations stated the hospice had “half the story” and wanted additional information regarding how P1 was found, whether P1 had been agitated or restless, and what medications P1 had received. The senior director of people services stated the hospice was waiting for the assisted living facility to obtain approval from its corporate office to release additional documentation. The AP remained on administrative leave pending further information.During an interview on 8/18/26 at 12:33 p.m., the AP stated P1 was actively dying and minimally responsive during the 8/13/26 visit. The AP stated two assisted living staff entered P1’s room during the visit, administered medication, provided personal care, repositioned P1, and checked whether P1 needed to be changed while the AP remained in the room and documented on an electronic device. The AP stated P1 was calm, quiet, clothed, and covered with blankets when the AP left the room at approximately 2:00 p.m. The AP stated patients at the end of life could become restless and remove their clothing.During a follow-up interview on 8/18/26 at 12:45 p.m., the director of hospice operations stated the documentation provided to the State Agency represented the hospice’s full investigation. They confirmed the hospice had not contacted other patients who had received services from the AP to determine whether the patients felt comfortable or safe with the AP. The senior director of people services and hospice director reiterated the hospice was waiting to receive additional information from the assisted living facility.During an interview on 8/19/26 at approximately 9:15 a.m., the director of hospice operations stated the assisted living facilities was not going to send them any information from P1’s chart and the hospice agency was considering their investigation closed. The director of hospice operations stated they had done nothing more for the investigation since we spoke yesterday, 8/18/26. The agency’s undated policy, titled Abuse, Neglect, Mistreatment, and Exploitation directed that any allegation of abuse was to be immediately reported to the administrator and thoroughly investigated.”

“Based on interview and document review, the agency failed to ensure the medical director or physician designee reviewed or provided written certification the hospice patient’s life expectancy was 6 months or less for 1 of 14 patients (P5) reviewed. P5’s plan of care (POC) 11/30/23 to 1/28/23. identified a start of care (SOC) date 11/30/23, with a primary diagnoses of heart and kidney disease. Services included skilled nurse visits, hospice aide, chaplain, music therapy and social worker visits. The admission visit was completed by a registered nurse (RN) and licensed social worker (LSW) on 11/30/23 and a plan of care (POC) was initiated. P5’s medical record lacked the required certification of terminal illness from P5’s primary care provider and the hospice medical director, including documentation of clinical justification for admission to hospice. During interview on 12/11/23, at 2:10 p.m., clinical director (CD)-A verified P5’s medical record lacked the required certificate of terminal illness and stated the certification should be in the medical record within 48 hours of admission. During joint interview on 12/12/23, at 2:30 p.m. with the hospice director (HD) and CD-C, HD-B stated P5 certification had been missed. Patients were assigned to a hospice provider based on geographic location and P5 had been assigned to the wrong provider. Each of the two providers thought the other was completing the certification. All new admission records were audited by the health information specialist within five days of admission, but P5’s lack of certification had been overlooked during the audit as well. It was the agency’s practice to have the completed and signed certification of terminal illness in the patients medical record within three to five days after their admission to hospice. The agency’s undated policy Certification of Terminal Illness identified the Initial Certification of Terminal Illness form specified the patient’s prognosis was for a life expectancy of six months or less if the terminal illness ran it’s normal course. If the hospice physician and the patient’s attending physician did not sign the Initial Certification of Terminal Illness form within two calendar days of the start of care date, an oral certification would be obtained from both physicians within the two days and would be documented in the patient’s clinical record.”