Moments Hospice

“Based on observations, interviews, record review, and agency policy review, the agency failed to provide the patient and/or representative with written notice of the patient’s rights and responsibilities for three patients (Patients (P)1, P2, and P7) of four home folders reviewed. This failure had the potential to result in the patients and/or their representatives not knowing, or understanding, their rights under the hospice benefit. Findings include: 1. Review of P1’s “Face Sheet” located in the “Face Sheet” tab of the electronic medical record (EMR) revealed a Start of Care (SOC) date of 10/31/25 for a diagnosis of interstitial lung disease. On 04/29/26 at 12:48 PM, a visit was made to P1’s home. The hospice folder was reviewed with P1’s Spouse. There was no documentation to show that P1 or his/her representative was provided with a written copy of the rights and responsibilities under the hospice benefit. During an interview on 04/29/26 at 12:50 PM, P1’s Spouse stated that he/she was not aware of any information regarding his/her rights and responsibilities having been provided to P1. 2. Review of P2’s “Face Sheet” located in the “Face Sheet” tab of the EMR revealed a SOC date of 03/07/25 for a diagnosis of congestive heart failure. On 04/29/26 at 10:00 AM, a visit was made to P2’s home. The hospice folder was reviewed with P2’s Representative. There was no documentation to show that P2 or his/her representative was provided with a written copy of the rights and responsibilities under the hospice benefit. During an interview on 04/29/26 at 10:05 AM, P2’s Representative stated that he/she was not aware of any information regarding his/her rights and responsibilities having been provided to P2. 3. Review of P7’s “Face Sheet” located in the “Face Sheet” tab of the EMR revealed a SOC date of 04/16/26 for hypertensive heart disease with heart failure. On 04/29/26 at 2:15 PM, a visit was made to P7’s home. The hospice folder was reviewed with P7 and his/her spouse. There was no documentation to show that P7 or his/her spouse was provided with a written copy of the rights and responsibilities under the hospice benefit. During an interview on 04/29/26 at 12:28 PM, P7 stated that he/she was not aware of any information regarding his/her rights and responsibilities having been provided. During an interview on 04/30/23 at 9:34 AM, the Alternate Administrator stated, “It is the responsibility of the staff member who obtains the consents to place them in the home folders. All patients should have them in their folders.” Review of an undated Hospice agency procedure titled, “Admission Criteria and Process,” revealed, “. . . The purpose of the initial visit will be to . . . Explain the hospice philosophy of palliative care with the patient and family/caregiver as unit of care . . . Explain the patient’s rights and responsibilities and grievance procedure . . . Provide the patient with a copy of [agency] notice of privacy practices . . .””

“Based on observations, interviews, and record review, the Hospice agency failed to ensure two of four patients whose home folders were reviewed (Patients (P) 1 and P2), received information about all hospice services and non-covered services to include documentation of the Election of Benefits (EOB), the legal document required to initiate hospice services. This failure placed the patients and caregivers at risk of not fully understanding the hospice benefit, including available, and non-covered, services. Findings include: 1. Review of P1’s “Face Sheet” located in the “Face Sheet” tab of the electronic medical record (EMR) revealed a Start of Care (SOC) date of 10/31/25 for a diagnosis of interstitial lung disease. On 04/29/26 at 12:48 PM, a visit was made to P1’s home. The hospice folder was reviewed with P1’s Spouse. There was no documentation to show P1, and his/her spouse was provided with a written copy of the EOB. During an interview on 04/29/26 at 12:50 PM, P1’s Spouse stated there had been no copy of the EOB provided to him/her. 2. Review of P2’s “Face Sheet” located in the “Face Sheet” tab of the EMR revealed a SOC date of 03/07/25 for a diagnosis of congestive heart failure. On 04/09/26 at 10:00 AM, a visit was made to P2’s home. The hospice folder was reviewed with P2’s Representative. There was no documentation to show that P2 or his/her representative was provided with a written copy of the EOB. During an interview on 04/29/26 at 10:05 AM, P2’s Representative stated that he/she was not provided with a copy of the EOB. During an interview on 04/30/26 at 9:34 AM, the Alternate Administrator stated, “That is the responsibility of either Registered Nurse Case Manager or whoever obtains the signed consents. All patients should have them in their home folders. We also do a 24-hour follow-up visit, and they could be placed in the folders at that time, but they should be getting them.””

“Based on interview and document review, the agency failed to coordinate care with non-hospice providers, including the primary care provider and the assisted living nursing staff for 1 of 3 patients (P1) reviewed for coordination of care. Findings include: P1’s hospital discharge summary, dated 5/5/24 , indicated P1 had a history of anxiety and was prescribed lorazepam (a medication for anxiety) 0.5 milligram (mg) twice daily. P1’s POC for certification period 6/13/25 through 8/11/25. indicated P1 was admitted to hospice on 6/18/24. P1 had diagnoses of alcoholic cardiomyopathy (a condition where the heart is damaged as a result of chronic alcohol consumption), alcohol-induced dementia, major depressive disorder, anxiety, and borderline personality disorder. The POC directed hospice nurse to coordinate plan of care with facility staff. A nurse visit note, dated 7/14/25, identified P1 was drowsy. The note identified registered nurse case manager (RNCM)-A was not able to locate assisted living facility (ALF) staff to determine recent sleep and activity, however the note identified she contacted the nurse manager and a nursing assistant at the ALF. The note identified medication counts were not completed at the visit. Further, the note lacked evidence of communication with P1’s attending nurse practitioner (NP). A recertification note, dated 7/16/25, indicated facility staff were frequently utilizing as needed lorazepam to help with patient when she becomes agitated, restless, and on edge, unchanged from last certification period. The note identified medication counts were not completed at the visit. A nurse visit note, dated 7/17/25, identified P1 was sleeping more and had no recent medication changes. The note lacked indication the ALF nurse, or NP were consulted regarding P1’s symptoms and plan for treatment. An email, dated 7/18/25, from the ALF licensed practical nurse (LPN) , includes a request to RNCM-A for a refill of P1’s lorazepam, as P1 had eight tablets remaining. RNCM-A responded to the email indicating P1 was receiving more lorazepam than expected and she planned to discuss this with the provider. A nurse visit note, dated 7/21/25, identified medication counts were not completed at the visit. In addition, the note lacked evidence of communication with P1’s NP. A nurse visit note, dated 7/23/25, indicated P1 was irritable throughout cares and threatened to strike staff. The note lacked evidence the ALF nurse or NP were consulted regarding P1’s symptoms and plan for treatment. The note also identified the medication counts were not completed at the visit.A nurse visit note, dated 7/25/25, indicated P1 was agitated, physician was consulted for lethargy with recommendations to decrease risperidone to 0.25mg at bedtime. The note lacked evidence the ALF nurse or the NP were consulted regarding P1’s symptoms and plan for treatment. The note also identified a medication count was not completed at the visit.A physician order written by the hospice medical director (MD), dated 7/28/25, directed to discontinue risperidone (an antipsychotic medication) 0.5 mg at bedtime and start risperidone 0.25 mg at bedtime. It also directed to discontinue lorazepam (medication used to treat anxiety) 0.5 mg every 4 hours as needed for terminal agitation and start lorazepam 0.5mg every 8 hours as needed for terminal agitation. A nurse visit note, dated 7/28/25, identified new orders to reduce risperidone to 0.25mg at bedtime and reduce lorazepam to every 8 hours. The note lacked evidence the ALF nurse or the NP were consulted regarding P1’s symptoms and plan for treatment. An email, dated 7/29/25, from the ALF LPN identified P1 often experienced agitation in the evenings and overnight, which was when the lorazepam was most often administered. On 8/7/25, at 1:45 p.m., RNCM-A stated she had concerns the ALF was over-using P1’s lorazepam, due to P1’s drowsiness. RNCM-A stated the ALF was administering P1’s lorazepam on a routine basis. RNCM-A stated necessary drugs and treatments were decided for patients by collaborating with the hospice medical director, the family, and sometimes the facility. RNCM-A seldom collaborated with P1’s NP and the NP was updated by fax after orders were written by hospice. RNCM-A stated, “I collaborate with the hospice doctor and inform the attending provider.”On 8/8/25, at 10:05 a.m., the hospice vice president of operations (VP) stated medication counts should be done at all nurse visits, to monitor use and quantity of medication remaining.On 8/8/25, at 10:42 a.m., the hospice team director (TD)-A stated nurses should complete medication counts and consult with facility/ALF nurses at every visit. She stated RNCM-A had access to the attending NP’s portal for communication and collaboration. On 8/8/25, at 11:28 a.m., the hospice medical director (MD) stated she was unaware RNCM-A had not attempted to collaborate with P1’s attending NP. MD stated they “My expectation on is they come to me as a last resort.” The nurses should be going to the primary care provider (PCP), unless the PCP is unavailable or they have diverted to hospice. The MD stated she did not feel P1 had used a significant quantity of lorazepam when it was reviewed 60 tablets were issued on 5/13/25 and again on 7/28/25 (76 days between pharmacy refill), for a hospice patient with a mental health history and anxiety.On 8/8/25, at 11:52 a.m., P1’s attending NP stated she was not aware of concerns of increased sedation for P1. She stated the lorazepam was originally prescribed for her anxiety and was a long-term medication for P1. She stated she had not been consulted regarding P1’s medication changes on 7/28/25, nor had she been updated with the medication reductions ordered by the hospice MD. On 8/8/25, at 1:00 p.m., the TD-B confirmed P1 had 60 tablets of lorazepam 0.5 mg delivered to her from the pharmacy on 5/13/25. Her next delivery of 60 tablets was 7/28/25. An undated facility document, Interdisciplinary Group Coordination of Care, directed the hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner.3) It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status between interdisciplinary group members and the patient’s attending physician. 6) Written evidence of care coordination will be found in the plan of care and/or inter-disciplinary team meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician. An undated facility document, Care/Service Coordination, directed each patient will be assigned a Case Manager upon admission by the clinical director or clinical supervisor. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel. Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. 4) Care coordination will include, but not be limited to: F) Appropriate involvement of the patient and caregivers J) Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities. 8) Written evidence of care coordination may be found in the POC/service, case conference summary forms, clinical notes in the patient’s clinical record or IDG meeting notes.”

“It is required that each patient’s individualized written plan of care: reflects patient, and family goals and 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 2 of 23 (9%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 4: The patient elected hospice care on 10/24/2024 with the diagnosis of ischemic cardiomyopathy. The comprehensive assessment completed by the skilled nurse (SN) on 12/03/2024 documented, “Has patient had a recent fall? Yes... Date of recent fall 12/02/2024.” The comprehensive assessment completed by the SN on 01/02/2025 documented, “Has patient had a recent fall? Yes... Date of recent fall 01/01/2024.” The plan of care dated 05/17/2024 through 08/14/2024 and the plan of care update reports dated 12/16/2024, 12/30/2024, and 01/13/2025 did not include planned interventions and patient and family goals for the patient’s identified fall risk. Clinical Record 21: The patient elected hospice care on 06/25/2024 with the diagnosis of other cerebrovascular disease. The comprehensive assessment completed by the SN on 07/03/2024 documented, “Has patient had a recent fall? Yes... Date of recent fall 07/02/2024.” The plan of care dated 06/25/2024 through 07/31/2024 and the plan of care update reports dated 07/02/2024 and 07/16/2024 did not include planned interventions and patient and family goals for the patient’s identified fall risk. During a joint record review and an interview on 05/15/2025, the Vice President of Clinical Operations/Administrator confirmed that clinical record 4 and clinical record 21 did not include patient and family goals and planned interventions for fall risk.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009, “Hand Hygiene” (effective 09/07/2022), stated in part, “Hand decontamination using an alcohol-based hand rub should be performed after removing gloves.” In 2 of 6 (33%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. Home Visit 1: The patient elected hospice care on 07/23/2024 with a diagnosis of Alzheimer’s Disease. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 05/13/2025, the RN donned gloves and measured the left 2nd toe wound. The RN removed their gloves, donned new gloves, and cleansed the wound with betadine swabsticks. The RN did not perform hand hygiene after removing their gloves per agency policy. Home Visit 4: The patient elected hospice care on 10/24/2024 with a diagnosis of ischemic cardiomyopathy. During the home visit with the RN [Personnel Record 4] on 05/14/2025, the RN performed a routine nursing visit with wound care. The RN sanitized their hands with an alcohol rub and proceeded to obtain vital signs from the patient. After obtaining the vital signs, the RN donned gloves, removed the adhesive dressing from the patient’s left-hand wound (skin tear), removed their gloves, donned gloves, cleansed the wound with wound wash, removed their gloves, retrieved the adhesive dressing, donned gloves, and applied the adhesive dressing. The RN did not perform hand hygiene after removing their gloves per agency policy. During an interview on 05/15/2025, the Vice President of Clinical Operations/Administrator confirmed the findings and that hands should be cleansed between and after glove removal per the agency’s policy.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-031 “Responsibilities/Supervision of Clinical Services,” (effective date 09/08/2022), stated in part, “A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services. More frequent supervision may be required per state regulations.” In 1 of 10 (10%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN nursing services per agency policy. Clinical Record 8: The patient elected hospice care on 01/09/2025 with a diagnosis of Alzheimer’s Disease. The plan of care dated 01/09/2025 through 04/08/2025 ordered skilled nursing (SN) services once (1) weekly beginning 01/09/2025. The LPN completed nursing visits on 01/13/2025, 01/28/2025, and 02/12/2025. The Registered Nurse (RN) completed a supervisory visit on 03/31/2025. A clinical record review revealed no evidence that LPN supervisory visits were completed in January and February, per agency policy. In a joint record review and interview on 05/55/2025, the Vice President of Clinical Operations/Administrator confirmed that LPN supervisory visits were not completed per agency policy, not less than monthly.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed of patients with identified volunteer needs who accepted volunteer services, the agency did not ensure that volunteer services were provided and noted in the plan of care based on the patient’s needs as identified in the comprehensive assessment. Clinical Record 7: The patient elected hospice care on 12/20/2024 with a diagnosis of Alzheimer’s Disease. The comprehensive assessment completed by the skilled nurse (SN) on 12/20/2024 documented, “Were volunteer services offered- yes...Does client want volunteer services- yes.” The volunteer coordinator updated the volunteer request on 12/23/2023 and documented “recruiting a volunteer for patient’s request.” A clinical record review revealed no evidence that volunteer services were provided, additional follow-up was completed, or a care plan was initiated to address the patient’s volunteer needs. Clinical Record 9: The patient elected hospice care on 01/29/2025 with a diagnosis of chronic systolic heart failure. The comprehensive assessment completed by the skilled nurse on 01/29/2025 documented, “Were volunteer services offered- yes. Does client want volunteer services- yes.” The volunteer coordinator updated the volunteer request on 01/30/2025 and documented “recruiting a volunteer for request.” A clinical record review revealed no evidence that volunteer services were provided, additional follow-up was completed, or a care plan was initiated to address the patient’s volunteer needs. During the joint record review and interview on 05/15/2025, the Vice President of Clinical Operations/Administrator confirmed that the clinical records did not include evidence that volunteer services were implemented based on needs identified in the comprehensive assessment.”

“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. The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The “Volunteer Activity Report” report dated 05/01/2024 through 03/31/2025 was reviewed with the Volunteer Coordinator [Personnel Record 10] on 05/15/2025. The Volunteer Coordinator confirmed that 3.32% of volunteers provided day-to-day administrative and/or direct patient care services from 05/01/2024 through 03/31/2025, less than the required 5%. During an interview on 05/15/2025, the Vice President of Clinical Operations/Administrator confirmed that volunteer utilization was below the 5% requirement for 05/01/2024-03/31/2025. During an interview on 05/15/2025, the Volunteer Coordinator confirmed that volunteer utilization was below the requirement of 5% for 05/01/2024-03/31/2025 and stated in part, “We have made some staffing changes and are recruiting a volunteer coordinator to focus on the... area. With this change, we have seen an increase in our volunteer percentage (current volunteer coordinator focusing on ... and the regional volunteer coordinator focusing on ... until a new volunteer coordinator is onboarded). Both locations were above 5% for April.” The hospice agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”