Alternative Hospice of Western Missouri, LLC

“Based on policy review, contract review, record review, observation, and interview, the hospice provider failed to ensure:- An individualized plan of care (POC) was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments (L0545);- The patient’s POC contained measurable goals and outcomes (L0548);- The interdisciplinary group (IDG) documented an assessment of the patient’s and family’s continuing care needs at the time of discharge (L0551);- The IDG maintained responsibility for directing, coordinating, and supervising the care and services provided (L0554);- Care and services were provided in accordance with the POC (L0555); and- Coordination of care and the ongoing sharing of information between all disciplines providing care and services in all settings so that patient and family needs were met (L0557).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.”

“Based on policy review, job description review, record review, observation, and interview, the hospice provider failed to:- Ensure nursing care and services were provided to meet the nursing needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessment (L0591);- Develop a bereavement plan of care that reflected the needs of the bereaved (L0596); and - Provide spiritual counseling services to meet the spiritual needs of the patient (L0598). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.”

“Based on policy review, record review, observation, and interview, the hospice failed to ensure the patient’s right to receive effective symptom management, in one of five full patient records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Bill of Rights,” revised June 2019, showed in part, that the hospice will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient and during the initial assessment visit. Review of the provider’s document titled, “Patient Bill of Rights/Responsibilities,” revised February 2021, showed in part, that patients have the right to receive effective pain management and symptom control for conditions related to terminal illness. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Review of the registered nurse (RN) visit note dated 06/24/2026, showed in part:- The facility staff needed a refill on the patient’s Remeron (An antidepressant medication used to treat major depressive disorder, anxiety, and insomnia);- It was ordered from the pharmacy; and- The medication would be picked up and delivered at the next (skilled nurse) visit. Review of the RN visit note dated 06/26/2026, showed, in part:- A call was received from the patient’s daughter;- The daughter was upset that the patient ran out of medications (the specific medications were not documented) once around Memorial Day;- The RN apologized to the daughter and explained that the time the patient ran out of medications was because there was a death that prevented the nurse from getting to the pharmacy to pick the medications up before the pharmacy closed for the holiday: and- The medications were picked up and delivered on the Tuesday after Memorial Day.Review of the RN visit note dated 07/06/2026, showed, in part:- The facility staff requested a refill on the patient’s pantoprazole (treats conditions caused by excessive stomach acid); and- There was no further documentation regarding the refill request. Observation on 07/08/2026, beginning at 9:00 AM, showed:- The patient was out of pantoprazole;- The patient’s last dose of pantoprazole was on 07/06/2026;- The ALF staff reported that the hospice nurse was going to bring the medication at the next skilled nurse visit on 07/09/2026; and- The ALF staff reported that the patient often ran out of medications, including the patient’s tramadol (used to treat pain), and had to wait until the next nursing visit for the medications to be delivered. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she spoke with the RN case manager (CM) regarding the medications running out;- The RN CM was unaware of the option to obtain refills from the 24-hour pharmacy;- It was his/her expectation that staff contact him/her if patients were out of medications and unsure of how to obtain refills;- He/she was never contacted by the RN CM; and- He/she educated the RN CM on the 24-hour pharmacy and the expectations regarding the patients medication refills.”

“Based on policy review, record review, and interview, the hospice failed to ensure the patient’s right to be involved in the plan of care (POC), in two of eleven patient records reviewed (Records/Patients #2 and #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, “Patient Bill of Rights,” revised June 2019, showed in part, that the hospice will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient and during the initial assessment visit. Review of the provider’s document titled, “Patient Bill of Rights/Responsibilities,” revised February 2021, showed in part, that patients have the right to be advised in advance of the right to participate in developing the hospice care plan and in planning changes in care before the change is made.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. The patient was admitted back to hospice services on 07/06/2026. Review of the plan of care, dated 07/06/2026, (provided to the state agent after the observation visit on 07/07/2026), showed:- A start of care date of 07/06/2026;- The POC orders were completed and electronically signed (box 23) on 07/06/2026 (one day prior to the initial assessment visit); and- The POC was created prior to the initial assessment of the patient on 07/07/2026 without the involvement of the patient and family. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of emphysema (a progressive, incurable lung disease that destroys the tiny air sacs in the lungs) and resided at home alone. Review of the POC, showed:- A start of care date of 02/27/2026 (prior to the date of the initial assessment); and- Orders (box 23 of the POC) were completed and electronically signed by the registered nurse (RN) coordinator on 02/27/2026. Review of the RN initial assessment, dated 03/01/2026, showed:- The initial assessment was completed on 03/01/2026 by the RN coordinator; and- The initial POC was developed two days before the initial assessment of the patient, without the involvement of the patient and/or family. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she completed the initial assessment within 48 hours of the patient’s election of hospice;- A licensed practical nurse (LPN) completed a “tuck in” visit on 02/27/2026 to assess the patient’s immediate care needs, ordered medications, and ordered durable medical equipment;- Box 23 of the POC was the date the POC was developed; and- He/she was unsure why the POC was developed prior to the initial assessment.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that a registered nurse completed the initial comprehensive assessment of the patient prior to visits and/or assessments being completed by other disciplines and/or staff members, in two of eleven records reviewed (Record/Patient #2 and #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, “Initial Assessment/Comprehensive Assessment,” revised May 2023, showed in part:- Each patient admitted by the hospice provider will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patient’s well-being, comfort and dignity throughout the dying process;- The registered nurse (RN) must complete an initial assessment within 48 hours after the election of hospice;- The initial assessment includes the patient’s immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions; and- The initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. Observation on 07/07/2026, beginning at 11:00 AM, showed:- The patient’s spouse reported that the hospice chaplain made a visit the day prior (07/06/2026);- The chaplain visit was the first time a chaplain made a visit;- Review of the patient’s admission folder showed hospice consents and required paperwork were signed by the patient’s spouse and the hospice marketing coordinator on 07/06/2026;- The observation visit was with the RN case manager (CM); and- During the observation visit, the RN CM was completing the initial assessment of the patient since revoking hospice services on 06/27/2026 (the initial assessment was a day after the chaplain assessment visit). RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of emphysema (a progressive, incurable lung disease that destroys the tiny air sacs in the lungs) and resided at home alone. Review of the RN initial assessment, completed by the RN coordinator on 03/01/2026, showed:- The date the patient was first asked about spiritual concerns was on 02/27/2026;- The date the patient was first asked about cardiopulmonary resuscitation (CPR) was on 02/27/2026;- The date the patient was first asked about life sustaining treatment was on 02/27/2026;- The date the patient was first asked about preference regarding hospitalization was on 02/27/2026;- The date of first screening for pain was on 02/27/2026;- The date of comprehensive pain assessment was 02/27/2026;- The date of the first screening for shortness of breath treatment was 02/27/2026;- The date of symptom impact screening was 02/27/2026;- The date opioid (pain medication) was continued or initiated was 02/27/2026; and- The date bowel regimen was initiated or continued was 02/27/2026. The clinical record failed to show documentation of an initial assessment until 03/01/2026. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she completed the initial assessment within 48 hours of the patient’s election of hospice;- A licensed practical nurse (LPN) completed a “tuck in” visit on 02/27/2026 to assess the patient’s immediate care needs, ordered medications, and ordered durable medical equipment;- The initial assessment documentation that showed dates of 02/27/2026 was everything that was completed during the tuck in visit by the LPN on 02/27/2026; and- The LPN did not document his/her visit that was made on 02/27/2026 (two days prior to the initial assessment by the RN coordinator).”

“Based on policy review, record review, and interview, the hospice failed to ensure the chaplain completed a comprehensive assessment within five (5) calendar days after the election of hospice, in one of five full patient records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Initial Assessment/Comprehensive Assessment,” revised May 2023, showed in part:- Each patient admitted by the hospice provider will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patient’s well-being, comfort and dignity throughout the dying process;- The registered nurse (RN) must complete an initial assessment within 48 hours after the election of hospice;- The initial assessment includes the patient’s immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions; and- The initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services. RECORD/PATIENT #3:Review of the clinical record showed:- The patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories);- The patient resided in an assisted living facility;- The patient’s initial assessment was completed on 02/21/2026; and- The clinical record failed to show an assessment completed by a chaplain. During interview on 07/08/2026, beginning at 11:10 AM, the patient’s daughter stated that:- He/she requested a chaplain when the patient was signed up for hospice;- The patient had never received chaplain services; and- He/she was informed by hospice that a new chaplain was hired and that the patient would be receiving chaplain services once the chaplain was trained. During interview on 07/14/2026, at 2:55 PM, the alternate administrator reported that the patient would be receiving a visit by the chaplain on 07/15/2026 at 10:00 AM (145 days after the election date).”

“Based on policy review, record review, observation, and interview, the hospice failed to ensure an accurate medication review and/or update of the patient medications was completed, in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” revised June 2019, showed in part:- The hospice will reconcile patient’s medications at time of admission and on an ongoing basis;- At the time of the initial assessment, the registered nurse (RN) will create and document a complete list of medications that the patient is taking, including dose, route, and frequency;- Any discrepancies will be reconciled by a RN with the patients physician;- Discrepancies include duplications, omissions, changes, contradictions and or unclear information;- Medications ordered while the patient is receiving care will be compared to the medication list/profile; and- The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Observation on 07/07/2026, beginning at 9:00 AM, showed that the hospice plan of care, provided to the state agent for a home visit observation, had “no prescribed medications,” documented in the medication section. The plan of care failed to show any orders/interventions and had a date of 06/11/2026 in the orders completed box (box 23) but there was no electronic signature of who completed it. Review of a second plan of care copy, provided to the state agent after the observation visit, showed:- A list of medications that the patient was taking since 06/11/2026 (these were not on the POC that was previously provided to the state agent);- The POC had orders/interventions for skilled nursing, medical social worker, hospice aide, and chaplain (these were not on the POC that was previously provided to the state agent);- There was an electronic signature of an RN (RN-B) next to the 06/11/2026 (the electronic signature was not on the previous POC and RN-B was not listed on the employee roster); and- The clinician attestation box was electronically signed by RN-B on 07/07/2026 at 2:01 PM (after the observation visit was conducted). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. Observation on 07/07/2026, beginning at 11:00 AM, showed:- The plan of care provided to the state agent for the observation visit was the POC from the previous hospice admission;- The spouse reported that the patient was not taking any medications (comfort medications were listed on the POC but never delivered to the patient);- The spouse reported that the only thing the patient took was a THC (tetrahydrocannabinol- the main chemical compound found in marijuana that induces the feeling of being “high”) gummy at night before bed;- The spouse gave the patient a fourth of a gummy each night;- Review of the bag of gummies showed that each gummy was 20 milligrams (MG); and- The POC provided to the survey failed to show orders/interventions for THC gummies to be administered to the patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an ALF. Observation on 07/08/2026, beginning at 9:00 AM, showed:- The ALF medication profile had buspirone (used to treat generalized anxiety disorder) 5mg one tablet by mouth three times daily (this was not on the hospice medication profile); and- The ALF medication profile had losartan (used to treat high blood pressure) 50 MG one tablet by mouth daily (the hospice medication profile showed losartan 25 MG daily). During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- The RN CM received the orders for the medications but did not put the order into the electronic medical record (EMR);- The orders have to be entered into the EMR in order for them to show up on the medication profile; and- The medication profiles were updated after the orders were entered.”

“Based on policy review, record review, observation, and interview, the hospice failed to ensure that each patient received an individualized initial or revised plan of care (POC), in four of eleven patient records reviewed (Records/Patients #1, #2, #3, and #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, “IDG (Interdisciplinary Group) Care Planning Process,” revised February 2022, showed in part:- The hospice provider has designated an IDG which, in consultation with the patients attending physician, prepares a written plan of care for each patient;- The group consists of a physician, registered nurse, social worker, and pastoral or another counselor;- The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions;- All care and services furnished to patients and their families follows an individualized written plan of care;- Each patient and primary caregiver(s) receives education and training appropriate to their responsibilities for the care and services identified in the plan of care;- The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments;- A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs;- Measurable outcomes anticipated from implementing and coordinating the plan of care; and- Drugs and treatments necessary to meet the needs of the patient. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Review of the registered nurse (RN) visit note, dated 06/15/2026, showed in part:- The patient had a wound to his/her right posterior heel;- The RN cleansed the wound with betadine, applied xeroform (a medicated sterile dressing infused with petrolatum), wrapped with kerlix (a loosely woven cotton rolled gauze) and secured with tape; and- The plan of care failed to show wound care orders. Observation on 07/07/2026, beginning at 9:00 AM, showed that the hospice plan of care, provided to the state agent for the home visit, had “no prescribed medications,” documented in the medication section. The plan of care failed to show any orders/interventions. The POC failed to show disciplines ordered and/or discipline visit frequencies. There was a date of 06/11/2026, in the orders completed box (box 23) of the POC but there was no electronic signature of who completed it. Review of a second plan of care copy, provided to the state agent after the observation visit, showed:- A list of medications that the patient was taking since 06/11/2026 (these were not on the POC that was previously provided to the state agent);- The POC had orders/interventions for skilled nursing, medical social worker, hospice aide, and chaplain (these were not on the POC that was previously provided to the state agent);- There was an electronic signature of an RN (RN-B) next to the 06/11/2026 (the electronic signature was not on the previous POC and RN-B was not listed on the employee roster); and- The clinician attestation box was electronically signed by RN-B on 07/07/2026 at 2:01 PM (after the observation visit was conducted). During interview on 07/15/2026, beginning at 4:05 PM, the RN coordinator stated that there were no wound care orders for the patient RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. Observation on 07/07/2026, beginning at 11:00 AM, showed:- The plan of care provided to the state agent for the observation visit was the POC from the previous hospice admission;- The spouse reported that the patient was not taking any medications (comfort medications were listed on the POC but never delivered to the patient);- The spouse reported that the only thing the patient took was a THC (tetrahydrocannabinol- the main chemical compound found in marijuana that induces the feeling of being “high”) gummy at night before bed;- The spouse gave the patient a fourth of a gummy each night;- Review of the bag of gummies showed that each gummy was 20 milligrams (mg); and- The POC provided to the state agent failed to show orders/interventions for THC gummies to be administered to the patient. Review of a second plan of care copy, provided to the state agent after the observation visit, showed:- A start of care date of 07/06/2026;- The POC orders were completed and electronically signed (box 23) on 07/06/2026 (one day prior to the initial assessment visit);- A multivitamin and a stool softener were listed in the medication section(the spouse reported that the patient only took a gummy at bedtime); and- The THC gummy failed to be included in the POC. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided in an ALF. Observation on 07/08/2026, beginning at 9:00 AM, showed:- The ALF medication profile had buspirone (used to treat generalized anxiety disorder) 5mg one tablet by mouth three times daily (this was not on the hospice plan of care); and- The ALF medication profile had losartan (used to treat high blood pressure) 50 mg one tablet by mouth daily (the hospice plan of care showed losartan 25 mg daily). During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- The RN CM received the orders for the medications but did not put the order into the electronic medical record (EMR);- The orders had to be entered into the EMR in order for them to show up on the medication profile; and- The medication profiles were updated after the orders were entered. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of emphysema (a progressive, incurable lung disease that destroys the tiny air sacs in the lungs) and resided at home alone. Review of the POC, showed:- A start of care date of 02/27/2026 (prior to the date of the initial assessment); and- Orders (box 23 of the POC) were completed and electronically signed by the RN coordinator on 02/27/2026. Review of the RN initial assessment, dated 03/01/2026, showed:- The initial assessment was completed on 03/01/2026 by the RN coordinator; and- The initial POC was developed two days before the initial assessment of the patient, preventing the patient from being involved in the development of the initial plan of care. The POC failed to be updated to be updated to include patient-specific orders/interventions to meet the patient’s needs following the initial assessment of the patient. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she completed the initial assessment within 48 hours of the patient’s election of hospice;- A licensed practical nurse (LPN) completed a “tuck in” visit on 02/27/2026 to assess the patient’s immediate care needs, ordered medications, and ordered durable medical equipment;- Box 23 of the POC was the date the POC was developed; and - He/she was unsure why the POC was developed prior to the initial assessment”

“Based on policy review, record review, observation, and interview, the hospice failed to ensure the plan of care (POC) included measurable outcomes in four of eleven patient records reviewed (Records/Patients #1, #2, #3, and #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, “IDG (Interdisciplinary Group) Care Planning Process,” revised February 2022, showed in part:- The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments; and- (The POC includes) measurable outcomes anticipated from implementing and coordinating the plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Review of the registered nurse (RN) visit note, dated 06/15/2026, showed in part:- The patient had a wound to his/her right posterior heel;- The RN cleansed the wound with betadine, applied xeroform (a medicated sterile dressing infused with petrolatum), wrapped with kerlix (a loosely woven cotton rolled gauze) and secured with tape; and- The plan of care failed to show wound care orders. Observation on 07/07/2026, beginning at 9:00 AM, showed that the hospice POC that was provided to the state agent prior to the observation visit, failed to show any measurable goals and/or outcomes. Review of a second plan of care copy, provided to the state agent after the observation visit, showed that the patient would remain “comfortable”. The goal failed to identify measurable components that would indicate when “comfortable” was achieved . The POC failed to include measurable goals for the patient’s pain and symptoms. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. The patient was admitted back to hospice services on 07/06/2026. Review of the plan of care, dated 07/06/2026, (provided to the state agent after the observation visit on 07/07/2026), showed:- A start of care date of 07/06/2026;- The POC orders were completed and electronically signed (box 23) on 07/06/2026 (one day prior to the initial assessment visit); and- The POC was created prior to the initial assessment of the patient on 07/07/2026 without the involvement of the patient and family; and- The POC failed to include measurable goals. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided in an ALF. Review of the POC failed to show measurable goals for pain. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of emphysema (a progressive, incurable lung disease that destroys the tiny air sacs in the lungs) and resided at home alone. Review of the POC, showed:- A start of care date of 02/27/2026 (prior to the date of the initial assessment); and- Orders (box 23 of the POC) were completed and electronically signed by the RN coordinator on 02/27/2026; and- The POC failed to include measurable goals for pain and symptoms. During interview on 07/15/2026, beginning at 4:05 PM, the RN coordinator stated that staff have received in-services on how to develop a proper plan of care to include measurable goals.”

“Based on policy review, record review, and interview, the hospice provider failed to document an assessment of the patient’s and family’s continuing care needs at the time of discharge, in two of three discharge records reviewed (Records/Patients #6 and #8). This deficient practice has the potential to affect the ongoing care of all patients discharged by the provider. Findings included: Review of the provider’s policy titled, “Discharge Summary,” revised 02/2022, showed in part, the discharge summary will include a brief description of services provided and ongoing needs that cannot be met and any other documentation that will assist in post-discharge continuity of care. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 04/11/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Review of the clinical record showed:- The physician signed a decertification of terminal illness (the patient no longer had a terminal prognosis of six months or less) on 03/06/2026; and- The record failed to include interdisciplinary group (IDG) involvement in the assessment or plan for treatment of the continuing care needs of the patient/family prior to discharge, failed to include any discharge education that was provided to the patient/family and failed to include documentation that showed coordination with the LTCF regarding the patient’s post-discharge care. Review of the discharge summary, dated 05/01/2026 showed:- The last day of service was 03/06/2026;- The discharge date was 03/18/2026;- A narrative entry that the patient, daughter (the patient’s power of attorney, POA), the IDG, and the LTCF were “notified prior to discharge”;- A narrative entry that the patient’s daughter did not agree with the patient being discharged and was educated on the appeal process;- The summary failed to include documentation to show the IDG was involved in discharge planning or education for post discharge care; and- The discharge summary was completed by the registered nurse coordinator on 05/01/2026 (44 days after the discharge date). During an interview on 07/14/2026, the registered nurse coordinator stated that he/she could not find any documented discharge planning with the patient or the POA in the clinical record visit notes. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice care on 05/27/2026 with a terminal diagnosis of unspecified severe protein calorie malnutrition (inadequate intake of protein and calories). The patient lived at home with his/her spouse and revoked hospice care on 06/27/2026. Review of the clinical record showed:- An IDG team review note that was completed and electronically signed by the registered nurse on 07/07/2026 (10 days after the patient revoked hospice); and - The record failed to include documentation that showed the IDG was aware of, or involved with, the patient’s revocation. During an interview on 07/14/2026, the alternate administrator stated that evidence of IDG involvement was in an email.”

“Based on policy review, registered nurse (supervising nurse) job description review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) maintained responsibility for coordinating and supervising the care and services of the patient, in two of eleven records reviewed (Records/Patients #6, and #8). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “IDG Care Planning Process,” revised February 2022, showed in part, that the IDG members provide care and services offered by the hospice and the IDG supervises the care and services. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 04/11/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Review of the clinical record showed:- The physician signed a decertification of terminal illness (the patient no longer had a terminal prognosis of six months or less) on 03/06/2026; and- The record failed to include IDG involvement in the assessment or plan for treatment of the continuing care needs of the patient/family prior to discharge, failed to include any discharge education that was provided to the patient/family and failed to include documentation that showed specific coordination with the LTCF regarding the patient’s post-discharge care. Review of the discharge summary, dated 05/01/2026 (44 days after discharge) showed:- The last day of service was 03/06/2026;- The discharge date was 03/18/2026;- A narrative entry that the patient, daughter (the patient’s power of attorney, POA), the IDG, and the LTCF were “notified prior to discharge”;- An entry that showed “POC (plan of care) collaboration: Coordination of care-Hospice medical director, family, caregiver, facility nurse, facility staff, hospice MSW, hospice chaplain, hospice aide, hospice case manager”. The entry failed to specify what type of “coordination” or “collaboration” occurred; and- The summary failed to include documentation to show the IDG was involved in discharge planning or education for post discharge care. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice care on 05/27/2026 with a terminal diagnosis of unspecified severe protein calorie malnutrition (inadequate intake of protein and calories). The patient lived at home with his/her spouse and revoked hospice on 06/27/2026. Review of the clinical record showed:- An IDG team review note that was completed and electronically signed by the registered nurse on 07/07/2026 (10 days after the patient revoked hospice); and - The record failed to include documentation that showed the IDG was aware of, or involved with, the patient’s revocation. During an interview on 07/14/2026, the alternate administrator stated that evidence of IDG involvement was in an email.”

“Based on policy review, record review, observation, and interview, the hospice failed to ensure that the care and services were provided in accordance with the plan of care (POC), in two of five full patient records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “IDG (Interdisciplinary Group) Care Planning Process,” revised February 2022, showed in part, that all care and services furnished to patients and their families follows an individualized written plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF) Review of the registered nurse (RN) visit note, dated 06/15/2026, showed, in part:- The patient had a wound to his/her right posterior heel;- The RN cleansed the wound with betadine, applied xeroform (a medicated sterile dressing infused with petrolatum), wrapped with kerlix (a loosely woven cotton rolled gauze), and secured with tape; and- The plan of care failed to show wound care orders. During interview on 07/15/2026, beginning at 4:05 PM, the RN coordinator stated that there were no wound care orders for the patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided in an assisted living facility. Review of the POC showed the patient was to receive hospice aide services twice weekly. The clinical record failed to show hospice aide visits between 06/30/2026 and 07/06/2026. Observation on 07/08/2026, beginning at 9:00 AM, showed:- The ALF staff reported that the hospice aide visits were missed that entire week due to the hospice aide being on paid time off (PTO) and the hospice not providing a back-up for showers; and- The ALF staff would have made arrangements to assist the patient with a shower during that week if the hospice staff would have informed them that hospice was unable to assist that week. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she was aware that the hospice aide was going to be on vacation at that time;- He/she was unaware that the hospice aide was not able to shower the patient prior to being on vacation;- He/she was not aware that the patient needed a shower; and- He/she would have made arrangements for a back-up aide had he/she known the patient needed one.”

“Based on contract review, record review, and interview, the hospice provider failed to ensure the ongoing sharing of information between the hospital providing general inpatient (GIP) care and the hospice in one of one GIP record reviewed (Record/Patient #7). This deficient practice has the potential to affect the continuity of care for all hospice patients receiving short-term inpatient care. Findings included: Review of the hospice provider’s contract with (named) hospital titled, “Inpatient and/or Respite Care Services Agreement,” dated 11/20/2024, showed in part:- The hospital shall prepare and maintain accurate and complete clinical records concerning each hospice patient receiving services;- The hospital shall include a record of all inpatient services furnished and events regarding care that occurred at the hospital in each hospice patient’s clinical record; and- At the time of discharge, the hospital shall make available to the hospice, a copy of each patient’s clinical record. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services for GIP on 07/23/2025 through 07/28/2025 with a terminal diagnosis of chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient expired at his/her home on 07/30/2025. Further review of the clinical record showed the provider failed to obtain a discharge summary of care from the hospital upon discharge from GIP services. During an interview on 07/14/2026 at 12:00 PM, the alternate administrator stated that the hospice did not receive a copy of the discharge summary from the hospital.”

“Based on job description review, policy review, record review, observation, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met as identified in the patient’s initial, comprehensive assessment, and updated assessments, in two of eleven records reviewed (Records/Patients #3 and #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, “Initial Assessment/Comprehensive Assessment,” revised May 2023, showed in part:- Each patient admitted by the hospice provider will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patient’s well-being, comfort and dignity throughout the dying process;- The registered nurse (RN) must complete an initial assessment within 48 hours after the election of hospice;- The initial assessment includes the patient’s immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions; and- The initial assessment gathers essential information necessary to begin the plan of care (POC) and provide the immediate necessary care and services. Review of the provider’s policy titled, “Reassessment/Update to the Comprehensive Assessment,” revised May 2023, showed in part:- Each patient will have appropriate reassessments and updates to the comprehensive assessment performed and documented;- The update of the comprehensive assessment must be accomplished by the hospice and must consider changes that have taken place since the initial assessment;- The update to the comprehensive assessment will include assessments of changes in physical, psychosocial, emotional and spiritual needs; and- Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Review of the RN visit note, dated 06/24/2026, showed in part:- The facility staff needed a refill on the patient’s Remeron (An antidepressant medication used to treat major depressive disorder, anxiety, and insomnia);- The medicine was ordered from the pharmacy; and- The medication would be picked up and delivered at the next (skilled nurse) visit. Review of the RN visit note, dated 06/26/2026, showed in part:- A call was received from the patient’s daughter;- The daughter was upset that the patient had ran out of medications (the specific medications were not documented) once around Memorial Day;- The RN apologized to the daughter and explained that the time the patient ran out of medications was because there was a death that prevented the nurse from getting to the pharmacy to pick the medications up before the pharmacy closed for the holiday; and- The medications were picked up and delivered on the Tuesday after Memorial Day.Review of the RN visit note, dated 07/06/2026, showed in part:- The facility staff requested a refill on the patient’s pantoprazole (treats conditions caused by excessive stomach acid); and- There was no further documentation regarding the refill request. Observation on 07/08/2026, beginning at 9:00 AM, showed:- The patient was out of pantoprazole;- The patient’s last dose of pantoprazole was on 07/06/2026;- The ALF staff reported that the hospice nurse was going to bring the medication at the next skilled nurse visit on 07/09/2026; and- The ALF staff reported that the patient often ran out of medications, including the patient’s tramadol (used to treat pain) and had to wait until the next nursing visit for the medications to be delivered. During interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she spoke with the RN case manager (CM) regarding the medications running out;- The RN CM was unaware of the option to obtain refills from the 24-hour pharmacy;- It was his/her expectation that staff contact him/her if patients were out of medications and unsure of how to obtain refills;- He/she was the back-up nurse on-call;- He/she was never contacted by the RN CM; and- He/she educated the RN CM on the 24-hour pharmacy and the expectations regarding the patients medication refills. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of emphysema (a progressive, incurable lung disease that destroys the tiny air sacs in the lungs) and resided at home alone. Review of the RN initial assessment, completed by the RN coordinator on 03/01/2026, showed:- Prognosis: the patient was on 6 liters of oxygen via nasal cannula (NC) and continued to have severe shortness of breath (SOB);- Respiratory assessment: shortness of breath, wheezing, abnormal breath sounds in bilateral lower lobes (BLL), shortness of breath treatment was initiated on 02/27/2026 (two days prior to the initial assessment), respirations were shallow and the patient fatigued easily. The clinical record failed to show documentation of how the nursing needs of the patient were being met between the start of care date on 02/27/2026 and the initial assessment on 03/01/2026. During an interview on 07/14/2026, beginning at 10:25 AM, the RN coordinator stated that:- He/she completed the initial assessment within 48 hours of the patient’s election of hospice;- A licensed practical nurse (LPN) completed a “tuck in” visit on 02/27/2026 to assess the patient’s immediate care needs, ordered medications, and ordered durable medical equipment;- Box 23 of the POC was the date the POC was developed; and- He/she was unsure why the POC was developed prior to the initial assessment.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the bereavement plan of care reflected the needs of the bereaved in one of one bereavement record reviewed (Record/Patient #11). This deficient practice has the potential to affect the bereaved family and other bereaved individuals of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Bereavement Services,” revised 02/2022, showed in part:- A plan of care (POC) will be developed based on the initial bereavement risk assessment and will include specific counseling to the patient and family members to be provided by the social worker, chaplain, or bereavement counselor;- The POC will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery;- Bereavement services must reflect the needs of the bereaved and are available for up to one year following the death of the patient;- Unless bereavement services have been refused, a bereavement counselor, chaplain, or social worker will call designated bereaved to continue bereavement supportive or counseling services;- A bereavement POC may include telephone support, letters and cards, referral to community resources, memorial services, bereavement camps, telephone contacts, individual/family counseling or bereavement groups; and- Bereavement assessment and clinical notes are documented in the patient’s permanent record. RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 06/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient lived at home and his/her adult children provided around-the-clock care. Review of the initial bereavement assessment dated 06/19/2025, showed the following:- The patient’s main caregiver (the patient’s adult child) stayed in the patient’s home every night;- The caregiver stated that someone in the family relieved him/her so he/she could go to work;- The caregiver described the support system as strong and the family as “very close knit”; and- Interdisciplinary group (IDG) comments showed the social worker (MSW) would continue to visit to offer support and community resources as necessary to the patient and family. MSW would continue to visit to assess stress and anxiety level of the caregivers and offer support as needed. Further review of the clinical record showed the following:- The patient expired on 06/21/2025;- The provider failed to document any contact with the bereaved, which included but was not limited to: * Offer or make home visits * Make telephone contact with the bereaved * Offer or send any printed materials to the bereaved * Offer bereavement support groups; and- The provider failed to develop a bereavement plan of care that reflected the needs of the bereaved. During an interview on 07/14/2026 at 3:19 PM, the registered nurse (RN) coordinator stated that the bereavement plan of care did not reflect the family’s needs. The chaplain was declined so the RN would have had to add those interventions, and he/she did not add them.”

“Based on job description review, policy review, record review, and interview, the hospice provider failed to provide spiritual counseling services to the meet the patient’s and family’s needs, in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “IDG (Interdisciplinary Group) Care Planning Process,” revised February 2022, showed in part, that the IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of the patients and families facing terminal illness and bereavement. RECORD/PATIENT #3:Review of the clinical record showed:- The patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories);- The patient resided in an assisted living facility; and- The clinical record failed to show spiritual counseling services provided to the patient. During interview on 07/08/2026, beginning at 11:10 AM, the patient’s daughter stated that:- He/she requested a chaplain when the patient was signed up for hospice;- The patient never received chaplain services; and- He/she was informed by hospice that a new chaplain was hired and that the patient would receive chaplain services once the chaplain was trained. During interview on 07/14/2026, at 2:55 PM, the alternate administrator reported that the patient would receive a visit by the chaplain on 07/15/2026 at 10:00 AM (145 days after the start of care date).”

“Based on policy review, current survey findings, observation, and interview, the hospice provider failed to ensure the administrator was responsible for the day-to-day operations of the organization. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Administrator: Defined,” revised February 2022, showed in part, that the governing body has appointed the administrator to run the hospice providers day-to-day operations and reports to the governing body. The director is authorized in writing to act in the absence of the administrator. The current survey findings showed the hospice administrator failed to effectively manage the overall day-to-day operations of the provider resulting in noncompliance with the following six Conditions of Participation: - §418.52 Condition of participation: Patient rights;- §418.54 Condition of participation: Initial and comprehensive assessment of the patient; - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records.Observation on 07/06/2025, at 2:15 PM showed, the state agent arrived at the hospice provider’s office. The door was locked and the lights were off. The state agent attempted to contact the hospice provider at the phone number posted on the door and did not receive an answer. The state agent then attempted to contact the phone number listed, for the provider, in the Internet Quality Improvement and Evaluation System (IQIES- a portal that is managed by the Centers for Medicare & Medicaid Services (CMS) to track patient assessments, provider data, and survey and certification results). The phone number connected to an individual who was not affiliated with the hospice provider. At 2:50 PM the state agent, again, attempted to reach hospice staff at the phone number posted on the door. The phone was answered by a staff member at a sister hospice provider. The staff member reported that the phone call must have automatically transferred due to no answer at the hospice provider the state agent was attempting to reach. The state agent was transferred to the alternate administrator. The alternate administrator reported that he/she was currently at the sister office approximately, two hours away, and that he/she would contact the marketing coordinator and have him/her go to the hospice office to unlock the door. The alternate administrator reported that the office manager would normally be at the office but was on vacation. The alternate administrator reported that the marketing coordinator would meet the state agent at the hospice office to get the survey started and that he/she (alternate administrator) would be at the hospice office the following day. The hospice survey entrance was conducted with the marketing coordinator at 3:45 PM. During an interview on 07/15/2025, at 12:54 PM, the alternate administrator stated that:- He/she and the administrator rotated between offices (other offices were under a separate provider number) to ensure the day-to-day operations;- He/she had daily discussions with the administrator regarding any concerns and/or issues; and- The RN coordinator was included in the discussions to address any clinical issues.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that all clinical record entries were clear, complete, and appropriately authenticated in eight of eleven patient records reviewed (Records/Patients #1, #3, #4, #5, #6, #8, #9, and #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, “Timely Submission of Patient Documentation,” revised June 2019, showed in part:- Telephone or verbal physician orders must be submitted to the hospice office for processing within three (3) business days after receipt; and- Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding 3 business days. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Observation on 07/07/2026, beginning at 9:00 AM, showed that the hospice plan of care, provided for the home visit observation, had “no prescribed medications,” documented in the medication section. The plan of care failed to show any orders/interventions. The POC failed to show disciplines ordered and/or discipline visit frequencies. There was a date of 06/11/2026, in the orders completed box (box 23) of the POC but there was no electronic signature of who completed it. Review of a second plan of care copy, provided to the state agent after the observation visit, showed:- A list of medications that the patient was taking since 06/11/2026 (these were not on the POC that was previously provided to the state agent);- The POC had orders/interventions for skilled nursing, medical social worker, hospice aide, and chaplain (these were not on the POC that was previously provided to the state agent);- There was an electronic signature of a registered nurse (RN-B) next to the 06/11/2026 (the electronic signature was not on the previous POC and RN-B was not listed on the employee roster); and- The clinician attestation box was electronically signed by RN-B on 07/07/2026 at 2:01 PM (after the observation visit was conducted). Review of the RN) initial assessment, dated 06/11/2026, showed:- The initial assessment was completed on 06/11/2026 by the RN case manager (CM); and- The initial assessment was electronically signed and dated by the RN CM on 07/06/2026 at 9:07 PM. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided in an ALF. Review of the RN visit note, dated 06/09/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 7:36 PM. Review of the RN visit note, dated 06/12/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 10:50 PM. Review of the RN visit note, dated 06/15/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 9:21 AM. Review of the RN visit note, dated 06/18/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 10:55 AM. Review of the RN visit note, dated 06/24/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 11:22 AM. Review of the RN visit note, dated 06/26/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 12:20 PM. Review of the RN visit note, dated 07/06/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 4:02 PM. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of malignant neoplasm of prostate (prostate cancer) and resided at home. Review of the RN initial assessment, dated 06/12/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 10:43 PM. Review of the RN initial assessment, dated 06/18/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 10:01 AM. Review of the RN initial assessment, dated 06/25/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 11:58 AM. Review of the RN initial assessment, dated 06/29/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 12:52 PM.Review of the RN initial assessment, dated 07/02/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 1:14 PM. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/30/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided at home. Review of the RN initial assessment, dated 06/04/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 6:46 PM. Review of the RN initial assessment, dated 06/11/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 7:55 PM. Review of the RN initial assessment, dated 06/16/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 9:50 AM. Review of the RN initial assessment, dated 07/06/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 8:30 PM. RECORD/PATIENT #6: Review of the document titled, “Notification of Termination of Hospice Benefits” showed the physician signed the decertification of terminal illness (the patient no longer had a terminal prognosis of six months or less) effective 03/06/2026. Review of the provider’s discharge summary showed:- The patient’s last service date was 03/06/2026;- The patient’s discharge date was 03/18/2026 (12 days after last service date); and- The discharge summary was completed and signed by the registered nurse coordinator on 05/01/2026 (44 days after the discharge date). RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026.Review of the two discharge summaries for patient #8, provided to the state agent by the hospice staff, showed the following:- Discharge summary A showed “Electronically signed and dated by:” with a space below for the electronic signature and date of the clinician who completed the discharge summary. The electronic signature line and date were blank;- Discharge summary A also contained a list of the interdisciplinary group (IDG) members by name and discipline. A hand-written signature and date was placed beside the RN’s printed name. The date written beside the RN signature was “6/6/26” (21 days prior to the revocation/discharge); and- Discharge summary B showed “Electronically signed and dated by:” with a space below for the electronic signature and date of the clinician who completed the discharge summary. The electronic signature line contained a hand-written signature with the registered nurse coordinator’s name and a hand-written date of “6/29/26”. Further review of the clinical record showed an IDG review note that was completed and electronically signed by the registered nurse on 07/07/2026 (10 days after the patient revoked hospice). RECORD/PATIENT #9:Review of the clinical record showed the following:- The patient was discharged from hospice services on 03/26/2026; and- The discharge summary was not completed until 04/08/2026 (13 days after discharge). RECORD/PATIENT #10:Review of the clinical record showed the following:- The patient was discharged from hospice services on 03/05/2026; and- The discharge summary was not completed until 04/07/2026 (33 days after discharge). During an interview on 07/09/2026, at 2:00 PM, the alternate administrator and the RN coordinator stated that they were aware of the late documentation issues.”

“Based on policy review, record review, and interview, the hospice provider failed to send a discharge summary to the patient’s attending physician in three of three discharge records reviewed (Records/Patients #6, #9, and #10) and in one of one revocation record reviewed (Record/Patient #8). This deficient practice has the potential to affect the ongoing care of all the provider’s discharge/revocation patients. Findings included: Review of the provider’s policy titled, “Discharge Summary,” revised 02/2022, showed in part, if the patient revokes the election of hospice care, or is discharged, the hospice will forward a copy of the discharge summary to the patient’s attending physician. RECORD/PATIENT #6:Review of the clinical record showed:- The patient was discharged from hospice services on 03/18/2026; and- The record failed to show that a discharge summary was sent to the patient’s attending physician. RECORD/PATIENT #8:Review of the clinical record showed:- The patient revoked hospice services on 06/27/2026; and- The record failed to show that a discharge summary was sent to the patient’s attending physician. RECORD/PATIENT #9:Review of the clinical record showed:- The patient was discharged from hospice services on 03/26/2026; and- The record failed to show that a discharge summary was sent to the patient’s attending physician. RECORD/PATIENT #10:Review of the clinical record showed:- The patient was discharged from hospice services on 03/05/2026; and- The record failed to show that a discharge summary was sent to the patient’s attending physician. During an interview on 07/09/2026 at 11:45 AM, the registered nurse coordinator stated that a discharge summary was not sent to the attending physician for patient #9. During an interview on 07/14/2025 at 10:25 AM, the registered nurse coordinator stated that discharge summaries were only faxed if the attending physician was not a hospice doctor. Discharge summaries were hand delivered when the attending was a hospice physician and documentation of the delivery was not recorded in the records.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that all clinical records were made readily available upon request by the state agent, in five of five full records reviewed (Record/Patient #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Timely Submission of Patient Documentation,” revised June 2019, showed in part:- Telephone or verbal physician orders must be submitted to the hospice office for processing within three (3) business days after receipt; and- Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding 3 business days. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of severe protein-calorie malnutrition (inadequate intake of protein and calories) and resided in an assisted living facility (ALF). Observation on 07/07/2026, beginning at 9:00 AM, showed that the hospice plan of care, provided to the state agent for a home visit observation, had “no prescribed medications,” documented in the medication section. The plan of care failed to include any orders/interventions and had a date of 06/11/2026 in the orders completed box (box 23) but failed to include the electronic signature of the clinician who completed it. Review of a second plan of care copy, provided to the state agent after the observation visit, showed:- A list of medications that the patient was taking since 06/11/2026 (these were not on the POC that was previously provided to the state agent);- The POC had orders/interventions for skilled nursing, medical social worker, hospice aide, and chaplain (these were not on the POC that was previously provided to the state agent);- There was an electronic signature of a registered nurse (RN-B) next to the 06/11/2026 (the electronic signature was not on the previous POC and RN-B was not listed on the employee roster); and- The clinician attestation box was electronically signed by RN-B on 07/07/2026 at 2:01 PM (after the observation visit was conducted).Review of the RN initial assessment, dated 06/11/2026, showed:- The initial assessment was completed on 06/11/2026 by the RN case manager (CM); and- The initial assessment was electronically signed and dated by the RN CM on 07/06/2026 at 9:07 PM (after the survey began). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 05/27/2026 and revoked hospice on 06/27/2026. The patient was readmitted to hospice services on 07/06/2026. Review of the current patient census obtained during survey entrance showed the patient was an active patient with a start of care date of 05/27/2026. The clinical record and the current census failed to reflect the patient’s revocation and readmission to hospice at the time the survey began. Observation on 07/07/2026, beginning at 11:00 AM, showed:- The observation visit was with the RN CM;- The RN CM was completing the initial assessment of the patient following revocation from hospice;- The spouse reported that the chaplain made an initial visit the date prior 07/06/2026; and- The plan of care provided to the state agent for the observation visit was the POC from the previous hospice admission. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/20/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided in an ALF. Review of the RN visit note, dated 06/09/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 7:36 PM. Review of the RN visit note, dated 06/12/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 10:50 PM. Review of the RN visit note, dated 06/15/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 9:21 AM. Review of the RN visit note, dated 06/18/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 10:55 AM. Review of the RN visit note, dated 06/24/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 11:22 AM. Review of the RN visit note, dated 06/26/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 12:20 PM. Review of the RN visit note, dated 07/06/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 4:02 PM. The survey began on 07/06/2026 and the RN visit notes were not readily available at the time of request by the state agent. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/11/2026 with a terminal diagnosis of malignant neoplasm of prostate (prostate cancer) and resided at home. Review of the RN initial assessment, dated 06/12/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 10:43 PM. Review of the RN initial assessment, dated 06/18/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 10:01 AM. Review of the RN initial assessment, dated 06/25/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 11:58 AM. Review of the RN initial assessment, dated 06/29/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 12:52 PM.Review of the RN initial assessment, dated 07/02/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 1:14 PM. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/30/2026 with a terminal diagnosis of severe protein-calorie malnutrition and resided at home. Review of the RN initial assessment, dated 06/04/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 6:46 PM. Review of the RN initial assessment, dated 06/11/2026, showed that the RN CM electronically signed and dated the visit on 07/06/2026 at 7:55 PM. Review of the RN initial assessment, dated 06/16/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 9:50 AM. Review of the RN initial assessment, dated 07/06/2026, showed that the RN CM electronically signed and dated the visit on 07/09/2026 at 8:30 PM. During interview on 07/09/2026, at 2:00 PM, the alternate administrator and the RN coordinator stated that they were aware of the late documentation issues.”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 13 (8%) clinical records that included oxygen orders, the agency did not ensure that the patient and primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. CLINICAL RECORD 2/Home Visit 2: The patient was admitted on 12/20/2024 with a diagnosis of pancreatic cancer and initial orders included oxygen as needed for shortness of breath. During a home visit on 01/09/2024, with the Social Worker (Personnel Record 2), the home smelled of cigarette smoke. The caregiver was observed walking to the sliding glass door of the kitchen to smoke. The patient was not currently using oxygen, but did have it available in the home. There was no documented evidence that the patient or caregiver’s home was assessed for oxygen safety, including smoke alarms, fire extinguishers, or oxygen in-use signs. The Administrator and Clinical Director on 01/09/2025 stated that the patient and caregivers did receive oxygen safety education, but the assessment only allowed them to check a box for oxygen safety. The Social Worker assessment included a home safety assessment, but the oxygen safety items were not addressed.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient was admitted on 10/18/2024 with a diagnosis of Alzheimer’s Disease. The patient’s progress notes from (facility) dated 09/30/2024 noted that the patient had a history of seizures and was admitted to hospice with an order for Keppra 750mg at bedtime. The Plan of Care for the certification period of 12/31/2024 to 03/30/2025 did not include seizure precautions. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 2: The hospital referral dated 12/18/2024 and comprehensive assessment dated 12/24/2024 identified the following allergies: Latex, Naproxen, Meclizine, Quinolones, Statins, yellow dye, ciprofloxacin, lisinopril, prednisone, and latanoprost. The plan of care for the certification period 12/24/2024 to 03/19/2025 included only the latex allergy. The Administrator and Clinical Director stated in an interview on 01/09/2025, after a review of the record, that the allergies did not flow from the comprehensive assessment to the Plan of Care due to a computer glitch. CLINICAL RECORD 3: The patient was admitted on 12/19/2024 with a diagnosis of Cardiac Disease requiring Oxygen (as needed) and a walker due to weakness with fall risk. Eliquis (anticoagulant) 5mg twice daily was included in the Plan of Care (POC). Bleeding precautions were not included in the POC. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 5: The patient was admitted on 11/30/2024 with a diagnosis of Alzheimer’s Disease and Type Two Diabetes Mellitus. The patient was actively being treated for Diabetes with Jardiance 25mg and Januvia 100mg daily. The Plan of Care for the certification period of 11/30/2024 to 02/27/2025 did not include interventions and goals for the Diabetes. The Administrator and Clinical Director stated in an interview on 01/10/2025, after a review of the clinical record, that the interventions and goals should have been included. Still, they agreed they were missing from the POC due to oversight.”

“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 2 of 13 (15%) clinical records reviewed, of patients that accepted aide services, it was revealed that the agency did not ensure the Registered Nurse (RN) provided written patient care instructions for the hospice aide that included precautions to take when providing care. CLINICAL RECORD 1: The patient was admitted on 10/18/2024 with a diagnosis of Alzheimer’s Disease. The patient’s progress notes from (facility) dated 09/30/2024 noted that the patient has a history of seizures and was admitted to hospice with an order for Keppra 750mg at bedtime. The aide care plan dated 01/02/2025 for the certification period 12/31/2024 to 03/30/2025 did not include seizure precautions. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 3: The patient was admitted on 12/19/2025 with a diagnosis of Atrial Fibrillation and was on Eliquis, an anticoagulant. The patient was at high risk for falls and utilized a walker. Bleeding precautions were not included in the aide care plan. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight.”

“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. This CONDITION of participation was not met as evidenced by personnel record reviews, interviews, and review of the findings with the Administrator which revealed issues with the hospice organizing, managing and administering its resources to provide the hospice care and services to patients, families, and caregivers in the following area: Failed to ensure that the hospice assessed the skills and competencies of all individuals providing care, including volunteers providing services {HSRM.14.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 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 4 of 15 (27%) clinical records reviewed it was revealed that the agency did not ensure that each individualized plan of care reflected the planned interventions and family goals. Clinical Record 4: The patient was admitted to hospice on 07/25/2024 with a primary diagnosis of heart failure and a secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Oxygen was ordered on admission for 2L/min per NC PRN (2 liters per minute, per nasal cannula, as needed). The plan of care dated 07/25/2024 -10/22/2024 did not include any interventions or goals related to oxygen use or respiratory status. Oxygen safety was identified in the plan of care. Clinical Record 5: The patient was admitted on 09/22/2024 with a diagnosis of Multiple Myeloma. Skilled Nurse (SN) assessment on 09/22/2024 revealed that the patient was experiencing some shortness of breath and oxygen was ordered at 2 L/min PRN. The plan of care dated 09/22/2024 to 12/20/2024 did not include any interventions or goals related to the respiratory status or the use of oxygen. Oxygen safety was identified on the plan of care. Clinical Record 6: The patient was admitted on 05/09/2024 with a diagnosis of acute and chronic congestive heart failure. The SN assessment on 05/09/2024 described the need the patient to utilize continuous oxygen. Oxygen was ordered and placed on medication profile but the care plan dated 05/09/2024 -08/06/2024 did not include any interventions or goals related to the patient respiratory status or the use of oxygen. Oxygen safety was noted on the plan of care under safety measures. Clinical Record 12: The patient was admitted on 05/14/2024 with a diagnosis of breast cancer. Oxygen 2 L/min per NC PRN was ordered and oxygen safety was included on the plan of care. There were no respiratory goals or interventions on the plan of care. On 12/04/2024 after a joint review of the clinical record, the administrator stated, “OK” and confirmed the finding.”

“It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, in which medical supplies were required for the patient’s care reviewed revealed that the agency did not ensure that all medical supplies were included on the plan of care. Clinical Record 15: The patient was admitted on 11/04/2024 with a diagnosis of multiple sclerosis with a suprapubic catheter in place. Catheter supplies were not included on the plan of care. In an interview on 12/06/2024 the administrator stated, “I understand. I am creating an in-service as we speak,” and confirmed the finding.”

“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 5 of 13 (38%) clinical records reviewed, with a hospice aide ordered, it was revealed that the agency did not ensure that a Registered Nurse (RN) created a plan of care with specific instructions for the aide to follow. Clinical Record 4: The patient was admitted on 07/25/2024 with a diagnosis of heart failure and Chronic Obstructive Pulmonary Disease (COPD). Oxygen 2 L per NC PRN (2 liters per minute, per nasal cannula, as needed) was ordered for the patient on 07/25/2025. The hospice aide care plan, initiated by the RN on 07/25/2024, did not include instructions to the aide related to oxygen safety or patient oxygen use. Clinical Record 5: The patient was admitted on 09/22/2024 with a diagnosis of multiple myeloma. Oxygen was ordered for the patient on 09/22/2024. The hospice aide care plan, initiated by the RN on 09/22/2024 did not include instructions to the aide related to oxygen safety or patient oxygen use. Clinical Record 6: The patient was admitted on 05/09/2024 with a diagnosis of chronic heart failure. The Skilled Nurse assessment on 05/09/2024 described the need the patient to utilize continuous oxygen. An aide care plan was developed on 05/09/2024 for aide services 1 time per week. The aide care plan did not identify oxygen precautions or the patient use of oxygen. Clinical Record 10: The patient was admitted 03/11/2024 with a diagnosis of unspecified protein malnutrition. Upon admission oxygen was ordered as well as aide visits. The aide plan of care, developed on 03/11/2024, did not include any information to the aide related to the use of oxygen. Clinical Record 15: The patient was admitted on 11/04/2024 with a diagnosis of multiple sclerosis and a suprapubic catheter in place. The aide plan of care developed 11/04/2024 did not include any information to the aide related to the suprapubic catheter. After joint clinical record review, Administrator confirmed finding on 12/04/2024 and stated, “ I have sent a note to the EMR company for enhancements to the aide care plan.””

“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. This standard was not met as evidenced by interview and personnel record review. In 8 of 8 (100%) personnel files reviewed revealed that the agency did not ensure that all individuals providing care were assessed for competency of skills. Personnel Record 1: The Director of Clinical Services/ Registered Nurse (RN) was hired on 11/07/2023. The personnel file did not include evidence of a competency assessment, or skills check for any role including RN or Director of Clinical Services. Personnel Record 2: The Volunteer was hired on 07/15/2024. The personnel file did not include evidence of a competency assessment, or skills check for the volunteer role. Personnel Record 3: The Social Worker was hired on 11/27/2024. The personnel file did not include evidence of a competency assessment, or skills check for the social work role. Personnel Record 4: The Medical Director was contracted on 12/05/2024. The personnel file did not include evidence of a competency assessment, or skills check. Personnel Record 5: The Massage Therapist was hired on 11/14/2024. The personnel file did not include evidence of a competency assessment, or skills check. Personnel Record 6: The Chaplain/ Bereavement Coordinator was hired on 12/13/2023. The personnel file did not include evidence of a competency assessment, or skills check for a Chaplain or Bereavement Coordinator role. Personnel Record 7: The Hospice Aide/ intake coordinator was hired on 10/09/2023. The personnel file did not include any evidence of a competency assessment, or skills check for the aide role or the intake coordinator role. Personnel Record 8: The Administrator/ Volunteer Coordinator was hired on 09/20/2023. The personnel file did not include evidence of a competency assessment, or skills check. In an interview on 12/05/2024, the administrator stated, “No, you won’t find competency checklists in any of the personnel files. We have not done them and that’s on me.””

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 15 (20%) clinical records reviewed revealed that the agency did not ensure that documentation was completed consistent with agency policy. Agency policy titled, “Timely submission of patient documentation” No. 11.6.1( revised June 2019), read in part, “Procedure.2. Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days.” Clinical Record 3: A massage therapy visit was conducted on 11/5/2024, however, the documentation for the massage therapy visit was completed and signed on 11/18/2024 (9 business days). Clinical Record 7: A hospice aide visit was conducted on 07/02/2024. Documentation for the hospice aide visit was not completed and placed in the clinical record until 07/12/2024 (7 business days). Clinical Record 15: The chaplain assessment was conducted on 11/05/2024. The documentation for the chaplain encounter was not completed until 11/12/2024 (5 business days). A massage therapy visit was conducted on 11/05/2024 but the documentation for the encounter was not completed until 11/18/2024 (9 business days). The administrator stated in an interview on 12/05/2024, “Oh, that is too long and not acceptable. I will be speaking to all staff about timeliness.”