Harrison County Hospice

“Based on record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Observation and interview on 10/28/2025 showed the following discrepancies between the provider’s current medication profile, dated 09/25/2025 to 11/232025, and the patient’s home medication bottles:- The patient was taking Vitamin B12 (supplement) 500 mcg take one daily. The provider’s profile failed to include this medication. The patient’s spouse stated the patient had been taking the medication for about five months. During an interview on 10/29/2025 beginning at 3:17 PM, RNC stated that he/she expected the clinicians to ask if any med changes at every visit and would expect it to be on the medication profile. Findings included:The provider failed to provide a Drug Regimen Review (start of care and on-going) policy prior to exit. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child.Observation and interview on 10/27/2025 at 3:00 PM, showed the following discrepancies between the provider’s medication profile and the patient’s home medications:- The provider’s profile showed loratadine (antihistamine) 10 milligrams (mg), one tablet daily as needed. The patient failed to have the medication;- The provider’s profile showed pantoprazole sodium (acid reflux) 40 mg, one tablet twice a day. The patient failed to have the medication;- The provider’s profile failed to show the following medications:* Famotidine (stomach acid) 20 mg, one tablet, two times per day * Black seed oil (supplement), ½ teaspoon, once a day * Selenium (supplement) 200 micrograms (mcg), one tablet per day* Vitamin E (supplement) 180 mg, one softgel per day* Vitamin C (supplement) 1000 mg, one tablet per day* Milk thistle (supplement) 150 mg, two capsules per day* Cat’s claw (supplement) 500 mg, two capsules per day. Patient stated that he/she took one per day* Quercetin-LipoMicel (supplement) 250 mg, one softgel per day* Zinc (supplement) 50 mg, one capsule per day * Turmeric (supplement) 500 mg, one capsule per day - The patient stated that he/she took the above medications daily. He/She was not aware if the hospice nurse knew it or not.During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that the nurse asked about medication at every visit and updated the medication list.”

“Based on policy review, record review, and interview, the bereavement assessment failed to identify the bereaved in, but not limited to, five of seven records reviewed for bereavement (Records/Patients #1, #2, #3, #5, and #10) and the hospice provider failed to incorporate the needs of the bereaved in the bereavement plan of care in one of seven records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Bereavement Services,” revised 06/2024, showed in part the following:- The program provided bereavement services to the families and caregivers of hospice patients both before and up to 13 months after the patient’s death in accordance with the plan of care;- On admission, the registered nurse (RN) completed the “pre-bereavement” section of the assessment; and- The social worker did a more extensive grief assessment during his/her visit within five days. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Review of the initial bereavement assessment dated 01/28/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/17/2025 with a terminal diagnosis of end stage renal disease (ESRD) (a severe condition where the kidneys have permanently lost most of their ability to function). The patient resided at a long-term care facility (LTCF). Review of the initial bereavement assessment dated 09/17/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. During an interview on 10/29/2025 at 3:08 PM, the registered nurse coordinator, stated that the assessment does not have a name documented of who the bereavement assessment was completed on. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child. Review of the admission assessment dated 09/30/2025, showed the family was not available for the pre-bereavement assessment. Review of the social services assessment dated 10/01/2025, showed the following: - The adult child lived with the patient and was the primary caregiver; and - The patient believed the situation was having an emotional impact on him/her.Review of the spiritual care assessment dated 10/02/2025, showed the following: - The adult son was not available; - The patient shared that family was well prepared for his/her approaching death; - The patient did not feel that there was a high degree of bereavement risk for the family; and - The assessment failed to identify the caregiver for the bereavement risk.Review of the nursing note dated 10/23/2025, showed the following: - The adult child/primary caregiver was present for the visit; and - The RN failed to complete a bereavement risk assessment. During an interview on 10/29/2025 at 11:55 AM, RNC stated that since the caregiver was not present during the admission visit, he/she would have expected the RN to complete the bereavement risk assessment during the visit on 10/23/2025. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia(a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at his/her parent’s home with the patient’s parents. Review of the chaplain patient missed visit on 03/13/2025, showed the initial evaluation was delayed due to inability to contact the patient.Review of the spiritual care assessment dated 03/19/2025, showed the following:- Some anger and pain was evident in the caregivers’ lives;- The patient was blocking access to his/her parents/caregivers; and- The assessment failed to identify the caregiver for the bereavement risk.RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and significant other had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; - The patient and family were in denial of the severity of the diagnosis;- The patient and family were not able to openly discuss the pending death; - Possible grief process complications due to dependency; - Bereavement risk factors with children/adolescents in the home; and - The bereavement assessment failed to include the children in the home and the bereaved family member identified on the bereavement plan of care dated 07/06/2025.Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter (previously identified as significant other); - Moderate risk level; and - Spiritual care visit would be offered monthly for the next two months.Review of the bereavement plan of care updated 09/05/2025, failed to show a plan to offer spiritual care visits in October and November.During an interview on 10/29/2025 at 11:55 AM, RNC stated that the social worker completes the initial bereavement assessment at the time of admission. He/She would expect the person that was assessed to be identified. If the social worker was not available, then the nurse would complete the bereavement assessment. He/She would expect the bereavement plan of care to be updated and it would be put on a different form. During an interview on 10/29/2025 at 3:10 PM, RNC stated that the caregivers received the initial bereavement assessment and caregivers in the home. If there are several children or other family members, they would receive mailings about bereavement services after the death of the loved one. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child. Review of the admission assessment dated 09/30/2025, showed the family was not available for the pre-bereavement assessment. Review of the social services assessment dated 10/01/2025, showed the following: - The adult child lived with the patient and was the primary caregiver; and - The patient believed the situation was having an emotional impact on him/her.Review of the spiritual care assessment dated 10/02/2025, showed the following: - The adult son was not available; - The patient shared that family was well prepared for his/her approaching death; - The patient did not feel that there was a high degree of bereavement risk for the family; and - The assessment failed to identify the caregiver for the bereavement risk.Review of the nursing note dated 10/23/2025, showed the following: - The adult child/primary caregiver was present for the visit; and - The RN failed to complete a bereavement risk assessment. During an interview on 10/29/2025 at 11:55 AM, RNC stated that since the caregiver was not present during the admission visit, he/she would have expected the RN to complete the bereavement risk assessment during the visit on 10/23/2025. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks requiring treatment. The patient resided in a LTCF. Review of the initial bereavement assessment (known to the provider as the pre-bereavement assessment) dated 10/20/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Review of the initial bereavement assessment dated 01/28/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 08/21/2025 with a terminal diagnosis of acute exacerbation (a sudden worsening) of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the initial bereavement assessment dated 10/20/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/17/2025 with a terminal diagnosis of end stage renal disease (ESRD) (a severe condition where the kidneys have permanently lost most of their ability to function). The patient resided at a long-term care facility (LTCF). Review of the initial bereavement assessment dated 09/17/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia(a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at his/her parent’s home with the patient’s parents. Review of the chaplain patient missed visit on 03/13/2025, showed the initial evaluation was delayed due to inability to contact the patient.Review of the spiritual care assessment dated 03/19/2025, showed the following:- Some anger and pain was evident in the caregivers’ lives;- The patient was blocking access to his/her parents/caregivers; and- The assessment failed to identify the caregiver for the bereavement risk. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and significant other had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; - The patient and family were in denial of the severity of the diagnosis;- The patient and family were not able to openly discuss the pending death; - Possible grief process complications due to dependency; - Bereavement risk factors with children/adolescents in the home; and - The bereavement assessment failed to include the children in the home and the bereaved family member identified on the bereavement plan of care dated 07/06/2025.Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter (previously identified as significant other); - Moderate risk level; and - Spiritual care visit would be offered monthly for the next two months.Review of the bereavement plan of care updated 09/05/2025, failed to show a plan to offer spiritual care visits in October and November. During an interview on 10/29/2025 at 11:55 AM, registered nurse coordinator (RNC) stated that the social worker completes the initial bereavement assessment at the time of admission. He/She would expect the person that was assessed to be identified. If the social worker was not available, then the nurse would complete the bereavement assessment. He/She would expect the bereavement plan of care to be updated and it would be put on a different form. During an interview on 10/29/2025 at 3:10 PM, RNC stated that the caregivers received the initial bereavement assessment and caregivers in the home. If there are several children or other family members, they would receive mailings about bereavement services after the death of the loved one.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure all care and services furnished to patients and their families follow an individualized, written plan of care (POC) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” last revised “06/24,” showed in part: - Hospice care and services furnished to patients and their families were to follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient’s needs; and- Care provided to the patient would be in accordance with the plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment. The patient resided in a long-term care facility (LTCF). Review of the hospice POC with a start of care (SOC) date of 10/16/2025 showed under the integumentary (skin) section: Integumentary interventions: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/perineal area (peri area - the area on the body between the genitals and anus) daily, start effective date: 10/16/2025. Review of the document titled, “Interdisciplinary Group (IDG) Meeting Review,” dated 10/23/2025, showed, under the integumentary (skin) section: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/peri area daily, start effective date: 10/16/2025. Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed he/she:- Cleansed the patient’s buttock and peri area with disposable cleansing wipes; and- Applied 1.5% dimethicone cream; and- Failed to follow the POC treatment to the buttock/peri area.Review of a skilled nursing note dated 10/28/2025 showed redness/shearing (a mechanical force where layers of tissue move in opposite directions, causing damage beneath the skins surface) was noted to bilateral outer gluteal cleft (the natural groove or fold between the buttocks). Moisture ointment applied to buttock following peri care; - Moisturizing ointment applied to the patient buttock as patient stated that he/she was allergic to zinc. New order placed. (The RN failed to contact the physician during the observation visit for new orders prior to applying the dimethicone). During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that he/she knew the staff were supposed to follow the POC.”

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) updated/revised the plan of care (POC) with new assessment findings/orders, in two of five full records reviewed (Records/Patients #2, and #4). This deficient practice has the potential to adversely affect coordination of care for all patients served by the provider. Findings included:Review of the provider’s policy titled, “Plan of Care,” last revised “06/24,” showed in part:-The POC was reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; and-Review of the POC was to be documented in the clinical record. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks requiring treatment. The patient resided in a long-term care facility (LTCF). Review of the hospice POC dated 10/16/2025, showed chaplain visits one time a week for one week starting 10/16/2025. Review of the spiritual assessment dated 10/16/2025 showed plan for next visit/contact: two times per month and as needed. Review of a physician’s order dated 10/17/2025 showed chaplain visits two times a month for three months starting 10/17/2025, and three as needed visits starting 10/17/2025 for emotional support. Review of the document titled, “Interdisciplinary Group (IDG) Meeting Review,” dated 10/23/2025, showed the POC update failed to include the chaplain services and their visit frequency. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that the chaplain discipline and visit frequency should have been on the IDG meeting note dated 10/23/2025. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 08/21/2025 with a terminal diagnosis of acute exacerbation (a sudden worsening) of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of a skilled nurse (SN) visit note dated 09/11/2025, showed:- An assessment of the back revealed an area at the site of a previous skin graft, with scar tissue noted. The area had rolled edges from shear (a mechanical force where layers of tissue move in opposite directions, causing damage beneath the skin’s surface) due to prolonged recliner use, with a small open area present; and- The patient’s physician was notified and orders were received. Duoderm (brand, an adhesive dressing) was applied as ordered to the area for protection and to promote healing. Review of a physician’s order dated 09/11/2025 showed apply hydrocolloid (Duoderm) dressing to previous skin graft site on mid back. Change every seven days. Review of an interdisciplinary group (IDG) meeting note dated 09/12/2025 showed the IDG failed to update the individualized plan of care to include the new open area to the mid back and the new treatment orders. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that the back wound and new treatment should have been addressed on the POC/IDG meeting note.”

“Based on policy review, record review, and interview, the provider failed to ensure medical social services were available in one of seven records reviewed (Record/Patient #10). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, ‘Plan of Care,” reviewed 06/2024, showed in part the following: - The registered nurse (RN) was to complete the initial assessment and initiate the development of the plan of care after the consent forms were signed; - The admitting RN was to notify the attending physician and a core member of the interdisciplinary group (IDG) of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs; and - The plan of care was to identify the patient’s needs and services to meet those needs.Review of the provider’s policy titled, “Suicide Threat,” reviewed 01/2020, showed in part the following: - When a patient was assessed to be suicidal (whether through behaviors or verbal statements) the patient would be placed on suicide precautions to promote safety and decrease/prevent the risk of self-inflicted injury; - Any patient who verbalized ideation involving thoughts of self-harm or suicide would be placed on suicide precautions as reviewed and ordered by the attending physician; - If verbalizations were given to or behaviors observed by hospice employees who were not registered nurses, the case manager or nursing supervisor would be notified immediately;- Suicide precautions were to be based on level of apparent risk of self-harm;- Nursing considerations for all levels included:* Remove from the environment anything the patient may use to inflict injury* Check the patient’s belongings for any unsafe items* One to one constant observation with well-defined documentation as per policy - Low risk-minimal danger of attempting suicide* Notify hospice interdisciplinary group (IDG) members, including on-call nurse* A referral would be made to the individual’s spiritual mentor, if there was a spiritual connection identified; and* Hospice social worker would make a support visit and a referral to local professional counseling, if patient was agreeable. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at home with his/her parents. Review of the admission assessment dated 03/10/2025, showed in part the following:- Other diagnoses included depression, anxiety disorder, nicotine dependence, and long term (current) use of opiate analgesics (a drug to relieve pain); - The patient was trying to protect his/her parents and did not let them listen to the hospice conversation; - Bereavement risk factors included a history of substance abuse and concern for teenage child;- Pain level was an eight (on a numerical pain scale where zero equals no pain and 10 equals the worst pain imaginable) due to the patient’s fall off the roof of their house a “few” days ago; and - The IDG members failed to include a medical social worker (The provider failed to have a social worker from 12/2024 to 05/2025).Review of the plan of care dated 03/17/2025, failed to show medical social services.Review of the nursing note dated 04/01/2025, showed the patient called the office requesting a visit related to anxiety. The patient talked with the RN about his/her spiritual turmoil and distress. The patient verbalized constant thoughts of suicide with no plan. The patient cried during the visit and was tearful discussing depression, end of life, suicide, and spiritual distress. The patient reported he/she had no plan or intentions to commit suicide which was why he/she made the phone call to the office for the visit. The patient reported decreased anxiety toward the end of the visit. The chaplain and physician were notified. The nurse failed to document notification of the medical social worker or the reason why medical social services were not notified.Review of the spiritual care note dated 04/02/2025, showed the chaplain phoned the patient at 7:30 PM. The patient discussed his/her thoughts and emotions.Review of the chaplain missed visit notes, dated 04/10/2025 and 04/17/2025, showed the patient postponed the visits.Review of the spiritual care visit note dated 04/23/2025 at 3:00 PM, showed the patient was intoxicated and was deeply emotional, expressed many negative feelings, and expressed thoughts about ending his/her life. The patient expressed a desire to become sober and not to do anything self-destructive. The patient admitted that he/she was having a mental health crisis and agreed to go to the hospital. The chaplain transported the patient to the emergency department and the patient checked himself/herself in.Review of the emergency department note from an outside hospital (OH)-1 dated 04/23/2025, showed the patient was treated for psychiatric symptoms of depression. The patient was discharged on 04/23/2025 with recommendations to follow up with psychiatry and an outpatient order for “Psych” (psychiatry) follow up was written and placed.Review of the spiritual care note dated 04/24/2025, showed the following spiritual issues:- Anxious about the future;- Isolation/withdrawal;- Depression;- Concern with death and dying;- Spiritual questioning;- Suicidal; and- The chaplain failed to notify the social worker (the provider failed to have a social worker at this time).Review of the hospice discharge summary dated 04/28/2025, showed in part the following:- The patient was hospitalized for facial fractures that occurred during an altercation with his/her family; - The patient was transferred from OH-2 to OH-3 for facial fractures and surgical procedures;- The patient was out of the hospice covered area;- The patient’s stay length was unknown to the patient and current caregivers; and- The patient verbalized to the RN his/her understanding of the reason for the discharge and agreed to discharge from current hospice services.Review of the care summary, on the hospice discharge summary, dated 04/28/2025, showed the patient struggled with pain control during hospice [services] and “compliance” (unspecified) was “unknown”. The RN was unable to enter the patient’s home and review the medications with the patient while on hospice [services]. The patient cancelled scheduled visits multiple times and verbalized alcohol use and increased depression. The patient refused therapy services and depression management that were offered to him/her. The patient agreed to discharge from current hospice services related to being out of the coverage area and his/her unknown course of upcoming treatment.During an interview on 10/29/2025 at 2:00 PM, the administrator stated that the provider advertised the (social worker) position via the local newspaper on 11/26/2024, social media on 11/30/2024, at a local college 12/09/2024, and on an employment website on 01/21/2025. The last day of employment for the social worker (MSW -master’s of social work) was 12/06/2024.During an interview on 10/29/2025 at 3:45 PM, registered nurse coordinator (RNC) stated that the provider did not have a social worker for about six months. If a patient needed social services, the chaplain or a registered nurse would fill in. The new social worker (BSW- bachelor’s of social work) started on 05/12/2025 and a contract with a MSW was dated 05/14/2025. Based on the diagnoses documented on the admission assessment, the RNC would have expected social services to be included in the plan of care.”

“Based on policy review, record review, and interview, the hospice provider failed to have an organized program for bereavement services and failed to ensure the needs of the bereaved and bereavement services provided were included in the bereavement plan of care (POC), in one of seven records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Bereavement Services,” revised 06/2024, showed in part the following: - The provider was to have an organized program for the provision of bereavement services under the supervision of a qualified professional; - Services were to be provided by personnel who had received training and had experience in dealing with grief; - The program was to provide bereavement services to the families and caregivers of hospice patients both before and up to 13 months after the patient’s death in accordance with the plan of care; - On admission, the registered nurse (RN) would complete the “pre-bereavement” section of the assessment; - The social worker did a more extensive grief assessment during his/her visit within five days; - Within two months after the patient’s death, a face-to-face visit would be made in which a bereavement risk assessment of the family and caregiver was completed; - The risk assessment would rate the bereavement risk as low, moderate, and high; - After the risk assessment was completed, a plan would be developed to address bereavement/grief issues and would be implemented as needed; - At six months after the death of a patient, the bereaved would be called and offered a visit; - Persons deemed to have been experiencing moderate or severe grief would be followed with increased services and contact offered as noted in the plan of care; and - If any time during bereavement services grieving was perceived as acute, the bereavement coordinator would attempt to reassess what additional professional services were necessary and appropriate referrals were indicated and documented the referral. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and an adopted daughter (originally identified as a significant other) had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; - The patient and family were in denial of the severity of the diagnosis; - The patient and family were not able to openly discuss the pending death; - There were possible grief process complications due to dependency; and- Bereavement risk factors included children/adolescents in the home. Review of the spiritual care assessment dated 04/22/2025, showed a planned visit schedule of one time per week and as needed.Review of the medical social services assessment dated 07/01/2025, showed a plan for contact once a month. Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the bereavement note dated 07/10/2025, showed in part, an adopted daughter welcomed the chaplain’s invitation to attend the bereavement support group held on Mondays.Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter; - The bereaved was assessed at a moderate risk level; - A spiritual care visit would be offered monthly for the next two months; and - The bereavement POC failed to include the type of interventions/services offered and the frequency of all services being delivered (bereavement support group, social services).Review of the bereavement plan of care updated 09/05/2025, failed to show the following: - Spiritual care visits planned for October and November; - Social services visits once a month; and - The bereaved’s attendance at the bereavement support groups.During an interview on 10/29/2025 at 11:55 AM, registered nurse coordinator (RNC) stated that he/she would expect the bereavement plan of care to be updated. The RNC stated that the program needed to be reorganized.”

“Based on policy review, record review, and interview, the hospice provider failed to forward the discharge summary to the patient’s attending physician, in one of one live discharge records reviewed (Record/Patient #10). This deficient practice has the potential to affect all live discharge patients served by the provider.Findings included:Review of the provider’s policy titled, “Discharge Summary,” reviewed 06/2024, showed in part the following:- The discharge summary and other relevant clinical record documents were to be completed and submitted within 72 hours of discharge of service; and- A copy of the discharge summary was to be provided to the patient’s attending physician. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at home with his/her parents. Review of the discharge summary dated 04/25/2025, showed the provider failed to forward a copy of the patient’s discharge summary to the patient’s receiving care provider. During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that normally, the hospice provider sent the discharge summary to the receiving provider.”

“Based on policy review, record review, and interview, the discharge summary failed to include the plan of care and physician orders, in one of one live discharge record reviewed (Record/Patient #10). This deficient practice has the potential to affect all the live discharge patients served by the provider.Findings included:Review of the provider’s policy titled, “Discharge Summary,” reviewed 06/2024, showed in part that the discharge summary would include the patient’s current plan of care and latest physician orders. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at home with his/her parents. Review of the discharge summary dated 04/25/2025, showed the provider failed to forward a discharge summary that included the plan of care and physician orders to the patient’s receiving care provider. During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that normally, the hospice provider sent the discharge summary to the receiving provider.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure coordination of responsibility for daily wound care between the hospice and the long-term care facility (LTCF) in one of one record reviewed of patients that resided in a LTCF (Record/Patient #2). This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. Findings included:Review of the provider’s policy titled, “ Provision of Care to Residents of Nursing, Intermediate Care, and Mental Retardation Facilities,” last reviewed “06/25”, showed in part:- Purpose: to ensure the coordination of care provided to residents of skilled nursing facilities/nursing facilities (SNF/NF); and- A written plan of care (POC) must be established and maintained in consultation with the SNF/NF. All hospice care provided must be in accordance with this POC. The POC must identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (A condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment. The patient resided in a LTCF.Review of the initial plan of care, dated 10/16/2025 to 01/13/2026, failed to show who was responsible (the hospice provider or the LTCF) for daily care to the buttock/perineal area (peri area - the area of the body between the anus and the genitals). Review of the document titled, “Interdisciplinary Group (IDG) Meeting Review,” dated 10/23/2025, showed under the integumentary (skin) section: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/peri area daily, start effective date: 10/16/2025. The IDG failed to specify when the hospice nurse was to perform wound care and when the LTCF staff would be responsible for wound care.Review of the LTCF’s current physician order sheet dated printed on 10/28/2025, failed to show who was responsible for zinc oxide treatment to the buttock/peri area (the LTCF or the hospice provider). Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed:- He/she provided care to the buttock/peri area; and- The LTCF hospice binder failed to contain any information for this patient.During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that:- “We (the hospice provider) sent that information” (all the required documents for the facility binder). “I know it (all the required documents for the facility binder) was taken there”; and- That was their most difficult facility to get along with.”

“Based on policy review, record review, home visit observation, and interview, the provider failed to provide the long-term care facility (LTCF) with all the required hospice documentation in one of one LTCF patient records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients residing in a LTCF served by the provider. Findings included:Review of the provider’s policy titled, “ Provision of Care to Residents of Nursing, Intermediate Care, and Mental Retardation Facilities”, last reviewed “06/25,” showed in part, the hospice provided the LTCF the following information:- The most recent plan of care (POC);- Hospice election form and advance directives;- Physician certification and recertification of terminal illness;- Names and contact information for hospice personnel involved in hospice care;- Instructions on how to access the hospice’s 24-hour on-call system;- Hospice medication information; and - Hospice physician and attending physician (if any) orders. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (A condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment. The patient resided in a LTCF.Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed the hospice binder at the LTCF failed to include the following documentation:- Physician certification and recertification; - Hospice physician and attending physician orders;- Hospice election form and advance directives; and- The most recent POC. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that:- “We (the hospice provider) sent that information” (all the required documents for the facility binder). “I know it (all the required documents for the facility binder) was taken there”; and- That was their most difficult facility to get along with.”