St. Croix Hospice

“Based on record review, policy and procedure review, and staff interview, the agency failed to maintain documentation that the agency provided initial training in emergency preparedness policies and procedures for 11 of 11 (Staff -A, C, D, E, F, G, H, I, J, K, and L) employees when newly employed, and failed to document subsequent emergency preparedness training at least every 2 years with existing staff. The hospice employs 17 staff. Findings are: A. Review of the agency policy and procedure titled Emergency Preparedness and Response Plan, EC.40, last reviewed 10/01/21. revealed:1. The hospice will provide initial training in the agency’s emergency preparedness policies and procedures for all new and existing staff, contracted staff, and volunteers.2. Additional training will be provided at least every two years thereafter.3. Training will also be provided when new or updated policies and/or procedures are issued, and when responsibilities change.4. The hospice is to maintain documentation of the training. B. Review of agency records revealed:1. There was no documentation in the personnel file for Staff -A, C, D, E, F, G, H, I, J, K, and L, that emergency preparedness training was completed in 2023, 2024, 2025, and up to 4/8/2026, as applicable to hire dates of those employees and every two years thereafter.2. There was no documentation included with the emergency preparedness records provided, of initial and/or every two years thereafter training in the agency’s emergency preparedness policies and procedures were provided. C. During an interview on 4/8/26 at 9:30 AM, the Administrator confirmed there was no documentation to demonstrate that Staff -A, C, D, E, F, G, H, I, J, K, and L were trained initially and every two years thereafter in the agency’s emergency preparedness policies and procedures.”

“Based on review of the agency’s records, policy and procedure review and staff interview the agency failed to conduct a community-wide or facility-based exercise and failed to conduct an additional exercise the opposite year from 3/28/24 through 4/8/26. The census was 35. Findings are: A. Review of the agency policy and procedure titled, Emergency Preparedness and Response Plan, EC.40, last reviewed 10/01/21, revealed:1. The hospice will conduct exercises to test the emergency plan at least annually.2. The hospice will participate in a full-scale exercise that is community-based every two years and if not available, a facility-based exercise will be conducted.3. The hospice will conduct an additional exercise every two years, opposite the year the full-scale or functional exercise was conducted. B. Review of the agency emergency preparedness records revealed: 1. A facility-based fire drill was conducted 4/26/23 and another on 3/19/24.2. A facility-based tornado exercise was conducted 3/27/24.3.There was no documentation of any exercises conducted from 3/28/24 through 4/8/26. C. During an interview on 4/8/26 at 9:30 AM, the Administrator confirmed the hospice did not conduct and/or maintain documentation that any exercises were conducted from 3/28/24 through 4/8/26.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to update the medication profile (an up-to-date list of medications and treatments provided to the patient) when medications were changed for 10 of 14 (Patient-1, 2, 5, 7, 8, 9, 11, 12, 13, and 14) records reviewed. The census was 35. Findings are: A. Review of the agency policy and procedure titled Medication List and Monitoring, last reviewed 2/13/25 revealed:1. The hospice will review, monitor, and maintain a current, accurate list of all prescriptions, over-the- counter (OTC), sample, investigational medications, herbal and home remedies taken by the patient, and other alternative treatments that could affect drug therapy.2. The medications will be documented on the medication/drug profile.3. Changes in medications/drug regimen will be documented in the clinical record either on the medication profile, on a verbal order, plan of care, as well as communicate with the patient and/or caregiver.4. The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. B. Review of Patient 1’s clinical record revealed: 1. An untitled form with a date of 12/30/25, included an order for Zithromax (an antibiotic) 250 milligrams (mg), take two tablets today, then 1 tablet for 4 days.2. A Physicians Telephone/Verbal Order form dated 1/29/26 included an order for Mucinex, 1 tablet by mouth twice each day for 5 days and then change to as needed (PRN) for cough.3. An untitled form with a date of 2/3/26, included an order for Furosemide (a diuretic/water pill) 40 mg, take one tablet daily for 7 days, then go back to 20 mg daily.4. The Client Medication Report (medication profile) printed on 3/30/26, did not include the Zithromax, Furosemide 40 mg or 20 mg doses, or the 2 Mucinex orders. C. Review of Patient 2’s clinical record revealed:1. A Skilled Nurse (SN) Visit Note Report dated 3/25/26 revealed that patient reported starting on gabapentin (a prescription anticonvulsant often used to treat nerve pain and restless legs syndrome) that was ordered by his primary care physician (PCP).2. The Client Medication Report printed on 3/31/26 did not include the gabapentin. D. Review of Patient 5 ‘s clinical record revealed:1. A SN Visit Note Report dated 1/9/26 revealed the nurse requested and received an approval for an increase in the patient’s Fentanyl patch (a pain management medication) to 25 micrograms (mcg)/hour.2. A SN Visit Note Report dated 3/20/26, the SN documented that the physician approved an increase in the Fentanyl patch to 50 mcg, as well as orders for morphine and lorazepam concentrates for PRN use (no strength, dosage documented).3. The Client Medication Report printed on 3/30/26 did not include the Fentanyl 25 mcg patch order ordered on 1/9/26, the Fentanyl 50 mcg ordered on 3/20/26, or the morphine and lorazepam concentrate PRN orders. E. Review of Patient 7’s clinical record revealed:1. A SN Visit Note Report dated 3/27/26, the SN documented that the Advanced Practice Registered Nurse (APRN) saw the patient and ordered an antibiotic (not identified). 2. An untitled form with a date of 3/23/26, included an order for Furosemide 40 mg 1 tablet by mouth daily for edema.3. The Client Medication Report printed on 4/7/26 did not include the antibiotic or the Furosemide orders. F. Review of Patient 8’s clinical record revealed:1. A SN Visit Note Report dated 12/24/25, the SN documented that an order was received from the Hospice Medical Director for lorazepam (an antianxiety medication), 0.25mg daily at 5:00 PM.2. A Hospice Physician Order dated 1/20/26, for lorazepam 0.5 mg at 5:00 PM. The order indicated the order was initiated on 1/2/26 but not documented as a physician order until 1/20/26.3. The Client Medication Report printed on 4/6/26 revealed the order for the lorazepam 0.25 MG take at 5:00 PM was not included. The order initiated/ordered on 1/2/26 was not included until 1/20/26 (18 days after ordered). G. Review of Patient 9’s clinical record revealed:1. A SN Visit Note Report dated 3/26/26, the SN documented that the patient’s family member would be picking up the new medication and the patient would be taking the first dose of oxycontin tonight.2. The Client Medication Report printed on 3/30/26 did not include oxycontin. H. Review of Patient 11’s clinical record revealed:1. A SN Visit Note Report dated 9/30/25, the SN documented that the patient was drowsy the first few days of the new nighttime medication (medication not identified in the note).2. A SN Visit Note Report dated 10/2/25, the SN documented that the patient is doing well with the new Seroquel at night.3. A SN Visit Note Report dated 11/4/25, the SN documented that the patient had been started on Seroquel 12.5 mg at bedtime. An additional dose of Seroquel 6.25 mg PRN prior to bathing is being ordered.4. The Client Medication Report printed on 3/31/26 revealed the order for the Seroquel 12.5 mg at bedtime was not included until 10/23/25 (22 days after first recorded notation) and the Seroquel 6.25 MG PRN with bathing dose was not included. I. Review of Patient 12’s clinical record revealed:1. A SN Visit Note Report dated 2/26/26, the SN documented that the APRN ordered diclofenac (a topical gel for arthritis pain) gel 4 grams to apply to right leg 2 to 3 times per day.2. The Client Medication Report printed on 3/31/26 did not include the order for the diclofenac gel. J. Review of Patient 13’s clinical record revealed:1. A SN Visit Note Report dated 4/11/25, the SN documented new orders were received to hold all oral medications except morphine, lorazepam, atropine, and nebulizer. The note also indicated that morphine dose was to be scheduled every 6 hours with nebulizer and lorazepam.2. The Client Medication Report received on 4/6/26 did not include the hold orders for oral medications and did not include the orders for the scheduled doses of morphine, lorazepam and nebulizer treatment. K. Review of Patient 14’s clinical record revealed:1. A SN Visit Note Report dated 7/11/25, the SN documented new orders were received to schedule morphine and lorazepam, and to add PRN atropine.2. The Client Medication Report printed on 4/6/26 did not include the scheduled morphine, lorazepam and PRN atropine. L. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the agency failed to update the medication profile when medication changes occurred for Patient- 1, 2, 5, 7, 8, 9, 11, 12, 13, and 14.”

“Based on record review, policy and procedure review, and staff interview the agency failed to follow the agency’s policies and procedures to document in the clinical record that the patient’s physician was notified of missed visit, the reason for missed visit, that the IDG was notified of missed visit, or if attempts were made to reschedule missed visits for 7 of 14 (Patient 1, 2, 3, 4, 6, 9, and 10) records reviewed. The census was 35. Findings are: A. Review of the agency policy and procedure titled Missed Visits, Policy No. 4-038.1, revised 12/2024, revealed:1. Missed visits will be communicated to the Clinical Care Manager (CCM) and the patient’s physician. 2. Missed visits will be rescheduled for the same week if possible.3. Missed visits will be documented in the clinical record.4. Documentation of the missed visit is to include but not limited to date/time of missed visit, discipline, reason for the missed visit, description of unmet needs and how the needs were met, how the physician was notified. 5. The CCM will track number and reason of missed visits to assess patterns and to assure that the plan of care remains appropriate. B. Review of the agency policy and procedure titled Inter-Disciplinary Group Meeting, effective 3/2022, revealed missed visit reports are to be included in Interdisciplinary Group Meetings (IDG), the IDG is to ensure visit frequencies match the plan of care, and are to document all inconsistencies. C. Review of Patient 1’s clinical record revealed:1. The Hospice Recertification Plan of Care Update for the certification period of 11/13/25 through 1/11/26 included orders for hospice aide (HA) 2 times per week for 1 week, 5 times a week for 8 weeks (which equaled 3 times a week with a second aide assisting 2 times per week).2. The Hospice Recertification Plan of Care Update for the certification period of 1/12/26 through 3/12/26 included orders for hospice aide (HA) 3 times per week.3. The 1/20/26, 2/4/26, 2/19/26 and 3/20/26 Hospice IDG Comprehensive Assessment and Plan of Care Update Report includes orders for HA 2 days per week.4. The 3/5/26 Hospice IDG Comprehensive Assessment and Plan of Care Update Report includes orders for HA 1 day per week.5. 1/11/26 - 1/17/26: 1 HA visit documented (2 missed);1/18/26 - 1/24/26: 2 HA visits documented (1 missed);1/25/26- 1/31/26: 1 HA visit documented (1 missed); 2/8/26 -2/14/26, 2/15/26 - 2/21/26, 2/22/26 - 2/28/26, and 3/22/26 - 3/28/26: 1 HA visit documented (1 missed each week).6. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. D. Review of Patient 2’s clinical record revealed:1. The Hospice Certification and Plan of Care for the certification period of 2/5/26 through 5/5/26 included orders for Skilled Nurse (SN) 2 times a week for 1 week, 1 times a week for 10 weeks, 1 time every 2 weeks for 2 weeks, and 3 as needed visits. 2. 2/5/26-2/7/26; 1 SN visit documented (1 missed).3. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. E. Review of Patient 3’s clinical record revealed:1. The Hospice Recertification and Plan of Care Update for the certification period of 11/26/25 through 1/24/26,1/25/26 through 3/25/26 and 3/26/26 through 5/24/26 included orders for Skilled Nurse (SN) 2 times a week for 8 weeks and 3 as needed visits and HA 2 times per week. 2. 1/11/26 – 1/17/26 and 3/22/26 – 3/28/26: 1 SN visit documented (1 missed each week).3. 2/8/26 – 2/14/26 and 3/22/26 – 3/28/26: 1 HA visit documented (1 missed each week).4. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. F. Review of Patient 4’s clinical record revealed:1. The Hospice Certification and Plan of Care for the certification period of 1/6/26 through 4/5/26 included orders for HA 1 time per week for 1 week, then 3 times per week for 12 weeks. 2. 2/1/26 – 2/7/26, 2/8/26 – 2/14/26, and 3/8/26 – 3/14/26: 2 HA visit documented (1 missed each week).3. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. G. Review of Patient 6’s clinical record revealed:1. The Hospice Certification and Plan of Care for the certification period of 2/5/26 through 5/5/26 included orders for HA 2 times per week for 12 weeks, then 1 time per week for 1 week. 2. 2/8/26 – 2/14/26: 1 HA visit documented (1 missed).3. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. H. Review of Patient 9’s clinical record revealed:1. The Hospice Recertification and Plan of Care Update for the certification period of 1/4/26 through 4/3/26 included orders for SN 2 times per week and 3 as needed, and HA 3 times per week for 1 week, then 3 times per week. 2. 3/15/26 – 3/21/26: 1 SN visit documented (1 missed).3. 1/4/26-3/28/26: 2 HA visits documented (1 missed visit each week for 12 weeks).4. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. I. Review of Patient 10’s clinical record revealed:1. The Hospice Recertification and Plan of Care Update for the certification period of 12/12/25 through 3/11/26 included orders for HA 1 time per week for 1 week, then 2 times per week for 12 weeks. 2. The Hospice Recertification and Plan of Care Update for the certification period of 3/12/26 through 5/10/26 included orders for SN 2 times per week and 3 as needed.3. 1/4/26 – 1/10/26, 1/18/26 – 1/24/26, 1/25/26 – 1/31/26, and 3/1/26 – 3/7/26: 1 HA visit documented (1 missed each week).4. 3/15/26 – 3/21/26: 1 SN visit documented (1 missed visit).5. There was no documentation in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit. J. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the agency failed to follow the agency’s policies and procedures to document in the clinical record that the patient’s physician was notified of the missed visit, the reason for the missed visit, that the IDG was notified of the missed visit, or if attempts were made to reschedule the missed visit for Patient 1, 2, 3, 4, 6, 9, and 10.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to follow their policy and procedure to ensure clinical record reviews were conducted and included in the agency’s quality assurance and performance improvement (QAPI) program to identify opportunities for improvement, and to monitor for effectiveness of the quality of the services the hospice provided for 2024, 2025, and 2026 (as of end of survey on 4/8/26). The census was 35. Findings are: A. Review of the agency policy and procedure titled Hospice QAPI Process- Standard Operating Procedure, effective 4/1/24, revealed:1. The purpose is to meet the quality standards of patient care based on federal and state regulations and continuous reviewing of documentation to prevent and decrease errors by identifying areas of opportunity to resolve underlying causes of persistent/systemic problems. 2. The QAPI (quality assurance performance improvement) program was to include audits of 4 active patient charts and 4 closed patient charts monthly.3. The Administrator/designee will enter cumulative quarterly audit data. 4. Items falling below target percentage will be reviewed with Administrator, Regional Clinical Specialist.5. Performance Improvement Projects (PIP) will be developed. 6. Monthly data collection findings will be reported to the QAPI Committee quarterly. B. Review of the QAPI Program meeting minutes revealed: 1. 2024 meeting minutes provided by the agency include 6/20/24, 9/24/24, and 12/20/24. a. 6/20/24 and 9/24/24 did not include any information regarding chart audit summarization. b. 12/20/24 noted one opportunity for improvement.2. 2025 meeting minutes provided by the agency included 7/29/25 and 10/16/25. Neither date included information on the results of any chart audit summarizations. 3. No Data provided for 2026. C. During an interview on 4/8/26 at 9:30 AM, the Administrator confirmed that chart audits (patient clinical record reviews) are not conducted for QAPI processes. The agency failed to follow their policy and procedure to complete patient clinical record audits to identify opportunities for improvement, and to monitor for effectiveness of the quality of the services the hospice provided for 2024, 2025, and 2026.”

“Based record review, policy and procedure review, and staff interview the hospice failed to implement changes and/or document changes to the Volunteer Services Performance Improvement Project (PIP) once it was determined that the PIP actions failed to meet the identified goals to attain improvements in the care and services provided to the agency patients. The agency census was 35. Findings are: A. Review of the agency policy and procedure titled Hospice QAPI Process- Standard Operating Procedure, effective 4/1/24, revealed:1. The purpose is to meet the quality standards of patient care based on federal and state regulations and continuous reviewing of documentation to prevent and decrease errors by identifying areas of opportunity to resolve underlying causes of persistent/systemic problems2. Performance Improvement Projects (PIP) will be developed. 3. Monthly data collection findings will be reported to the QAPI Committee quarterly. 4. The policy does not include processes on how to develop a PIP or what steps to take when a PIP identified does not meet desired goals or outcomes. B. Review of the QAPI Program meeting minutes revealed:1. 2024 meeting minutes provided by the agency include 6/20/24, 9/24/24, and 12/20/24. a. A PIP for Volunteer Services is listed on each of the three - 2024 quarterly QAPI meeting minutes.b. No documentation was provided indicating what interventions have been put in place to achieve the stated goal.c. No changes were documented in the 2024 meeting minutes of any adjustments made to the Volunteer Services PIP.2. 2025 meeting minutes provided by the agency included 7/29/25 and 10/16/25. Volunteer Services PIP remains in place.a. The 7/29/25 meeting minutes indicated a new volunteer coordinator was hired.b. The 7/29/25 meeting minutes trend and analysis section indicated the benchmark was not met on the current PIP and a new/expanded PIP was created to reset the target date. New intervention listed: a new volunteer coordinator was hired. There was no documentation about what the new/adjusted goals were, timelines that were revised, or other PIP specifics the agency identified to attain improvements. 3. All five quarterly meeting minutes provided for 2024 and 2025 indicate results for Volunteer Services PIP remain below benchmark and that PIP remains ongoing.4. No Data provided for 2026. C. Review of the Hospice Volunteer Requirement Report (a cost-savings/ volunteer usage report) for 3/2023 through 3/2026 revealed:1. Less than 5% volunteer usage from 3/2023 through 4/2024.2. 0% volunteer usage from 5/2024 through 3/2026. D. During an interview on 4/8/26 at 9:30 AM, the Administrator confirmed the agency failed to develop a PIP that achieved measurable progress and when progress was not achieved, the agency failed to reassess and revise the PIP to attain improvements in the care and services provided to the agency patients for 2024, 2025, and 2026.”

“Based on policy and procedure review, the observation of the provision of cares, and staff interview, 1 of 4 (Staff- C) agency staff observed during the provision of care to 1 of 4 (Patient-1) patients, failed to utilize proper hand hygiene and proper bag technique according to the agency policies to prevent the potential spread of infection. The total sample size was 14. The census was 35. Findings are:A. Review of the agency policy and procedure titled Hand Hygiene-IC15, effective 4/2022, revealed:1. The purpose of the policy was to ensure patient care staff practice proper hand hygiene techniques to prevent the spread of infection.2. Staff are to perform hand hygiene and may use soap and water, antiseptic agent, or alcohol-based hand rub when hands are visibly soiled, prior to entry into the supply bag, before direct patient contact between clean and dirty sites, and after removing gloves. B. Review of the agency policy and procedure titled Bag Technique IC.60, last reviewed 09/01/24, revealed:1. Staff are to always consider and treat the selected bag as a clean area. 2. The bag is to be placed on a clean, safe surface in the home. If that was not possible, a barrier was to be placed under the bag. The bag should never to be placed on the floor. 3. After cleansing hands, supplies needed for the visit are to be removed from the bags. If additional supplies are needed after the hands are contaminated during the visit, hands are to be decontaminated again before re-entering the bag.4. Reusable equipment was to be cleaned using approved cleanser, and equipment returned to the bag.5. Hands are to be cleansed prior to returning clean equipment to the bag. C. During the observation of the provision of cares to Patient-1 on 3/31/26 at 8:30 AM, Staff-C failed to:1. Place a barrier between the supply bag and the floor.2. Sanitize hands after obtaining reusable patient equipment (stethoscope, blood pressure cuff, oximeter). Each item was removed from the bag, used, and the next item removed from the bag without sanitizing hands prior to re-entry into bag.3. Sanitize re-useable equipment after use- used equipment was placed into a plastic ziploc baggie, and baggie was placed into the bag with Staff-C stating “this is the dirty side’ (of the bag). 4. Sanitize hands after using equipment and prior to returning equipment to the bag. D. During an interview on 4/6/26 at 3:00 PM, the Regional Director of Clinical Operations confirmed Staff- C failed to follow the agency’s policies and procedures for hand hygiene and bag technique when providing services to Patient-1.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to coordinate with the patient’s chosen attending physician for the patient’s medical needs for 5 of 7 (Patient 1, 5, 7, 8, and 12) patients who elected to choose a specific attending physician. The total sample size was 14. The census was 35. Findings are: A. Review of the agency policy and procedure titled Physician Services- Role of the Attending Physician (Hospice), Policy No. 4-048.1, revised 12/2024, revealed:1. The medical care of each patient admitted to the agency will be the responsibility of the patient’s attending physician.2. When the attending physician is absent, an alternate physician should be designated by the attending physician group.3. The plan of care is developed by the hospice registered nurse, the patient and family/caregiver, attending physician, and the Hospice Medical Director (HMD).4. Once a comprehensive assessment is completed the interdisciplinary group, in collaboration with the attending physician, will update the plan of care as often as needed, but at least every 15 days.5. Hospice employees will communicate with the attending physician about any changes in the patient’s status, changes in the care or services, changes in physical or psychosocial condition, response to care or services, the patient’s outcome related to care or services, and changes in diagnosis, treatment, or equipment. B. Review of the agency policy and procedure titled Physician Services- Role of the Medical Director (Hospice), Policy No. 4/047.1, revised 12/2024, revealed the Medical Director:1. Has overall responsibility for the medical component of the hospice program.2. Provides certification, recertification, and required regulatory visits.3. Consults with attending physician regarding pain and symptom management for hospice patients.4. Acts as the primary physician when the patient’s attending physician desires to relinquish that care or if the attending physician is not available for further contact. C. Review of Patient 1’s clinical record revealed:1. The start of care date was 3/18/25.2. Nebraska EOB & Consents form (a form the patient/caregiver sign upon admission which includes but is not limited to explanation of hospice, benefits, services available, allows the patient to select an attending physician of choice, confirmation of advanced directives, and more) signed by the patient’s caregiver on 3/18/25. The form indicated the patient/caregiver chose an attending physician (named on the form). 3. An untitled form, with a date of 12/30/25, included an order for Zithromax (an antibiotic) 250 milligrams (mg), take two tablets today, then 1 tablet for 4 days. This was signed by the HMD.4. A Physicians Telephone/Verbal Order form dated 1/29/26 included an order for Mucinex, 1 tablet by mouth twice each day for 5 days and then change to as needed (PRN) for cough. This was signed by the HMD.5. A Skilled Nurse (SN) Visit Note Report dated 2/3/26. The SN documented symptoms of swelling in feet and hands, shortness of breath with ambulation. The patient’s caregiver requested an increase in the patient’s diuretic. The SN documented that Dr. [HMD] would be contacted.6. An untitled form, with a date of 2/3/26, included an order for Furosemide (a diuretic/water pill) 40 mg, take one tablet daily for 7 days, then go back to 20 mg daily. This was signed by the HMD. D. Review of Patient 5 ‘s clinical record revealed:1. The start of care date was 1/3/26.2. Nebraska EOB & Consents form signed by the patient on 1/3/26. The form indicated the patient/caregiver chose an attending physician (named on the form). 3. A SN Visit Note Report dated 3/20/26, the SN documented that Dr. [alternate HMD] approved an increase in the Fentanyl patch to 50 mcg, as well as orders for morphine and lorazepam concentrates for PRN use (no strength, dosage documented).4. A Hospice Physician Order form dated 3/30/26, with orders from the HMD to increase nurse and hospice aide visits, was sent to the HMD. E. Review of Patient 7’s clinical record revealed:1. The start of care date was 8/12/25.2. Nebraska EOB & Consents form signed by the patient on 8/12/25. The form indicated the patient/caregiver chose an attending physician (named on the form). 3. A SN Visit Note Report dated 3/23/26. The SN documented [gender] would contact the HMD regarding wound care and edema.4. An untitled form, with a date of 3/23/26, included an order for Furosemide 40 mg 1 tablet by mouth daily for edema. This was signed by the HMD.5. A Pharmacist’s Recommendation to Prescriber form, with pharmacy recommended changes to metronidazole for wound care, was sent to the HMD 2/20/26 and signed by the HMD 3/20/26.6. A Pharmacist’s Recommendation to Prescriber form, with pharmacy recommended changes to hydrocodone and morphine, was sent to the HMD 1/6/26 and signed by the HMD 3/20/26. F. Review of Patient 8’s clinical record revealed:1. The start of care date was 12/2/25.2. Nebraska EOB & Consents form signed by the patient’s caregiver on 12/2/25. The form indicated the patient/caregiver chose an attending physician (named on the form). 3. A SN Visit Note Report dated 12/24/25, the SN documented that an order was received from the HMD for lorazepam (an antianxiety medication), 0.25mg daily at 5:00 PM.4. A Hospice Physician Order dated 1/20/26, for lorazepam 0.5 mg at 5:00 PM. This was signed by the HMD.5. A Physicians Telephone/Verbal Order form dated 1/27/26, 2/5/26, 2/13/26, 3/11/26 and 3/13/26 all include treatment orders for the patient. All orders were sent to and signed by the HMD. G. Review of Patient 12’s clinical record revealed:1. The start of care date was 12/31/25.2. Nebraska EOB & Consents form signed by the patient on 12/31/25. The form indicated the patient/caregiver chose an attending physician (named on the form).3. Hospice Physician Order forms dated 1/5/26, 2/5/26 and 3/12/26 were all sent to and signed by the HMD. H. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the agency failed to coordinate with the patient’s chosen attending physician for the patient’s medical needs for Patient 1, 5, 7, 8, and 12 who elected to choose a specific attending physician.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to maintain documentation that a written competency evaluation was completed for 1 of 4 hospice aide (HA-H) files reviewed, prior to the HA providing cares independently to the agency patients. The agency employs 4 HAs. Findings are: A. Review of the agency policy and procedure titled Orientation, Policy No. 7-025.1, revealed:1. All employees will demonstrate knowledge and proficiency in skills appropriate to their assigned responsibilities during the orientation period.2. The policy does not include the type or manner in which knowledge and proficiency would be verified.3. Does not list evaluation topics as required at Neb. Rev. Stat. § 71-6608.01.4. There were no additional policies provided related to HA requirements. B. Review of HA-H’s personnel file revealed:1. Date of Hire was 10/23/23.2. There was no documentation that a written evaluation to verify competency was completed. C. During an interview on 4/8/26 at 11:00 AM, the Administrator confirmed there was no documentation that HA-H had received a written evaluation to verify competency prior to HA-H independently providing care for the agency patients.”

“Based on record review, policy and procedure review, and staff interview the agency failed to maintain documentation that 3 of 4 hospice aide (HA- H, I, and J) records reviewed received 12 hours of in-service training annually. The agency employs 4 HAs. Findings are: A. Review of the agency policy and procedure titled Training/Inservice Education, Policy No. 7-032.1, revised 12/2024, revealed:1. Attendance at education programs will be required relative to job classification and in accordance with state-specific guidelines.2. A HA must receive at least 12 clock hours of in-service training per calendar year.3. The agency is to maintain a record for each training, including the program objective, content outline, speaker, and list of attendees.4. An in-service log will be kept, tracking the number of in-service hours completed by the HA on a cumulative basis. B. Review of the agency policy and procedure titled Employee Record Contents, Policy No. 7-023.1, revised 1/2025, revealed the personnel file was to include evidence of continuing education documentation, and training/award certificates. C. Review of HA- H’s personnel file revealed:1. HA- H was employed as a hospice aide from 10/23/23-8/29/24.2. There was no documentation in the personnel file that any in-service hours had been completed. D. Review of HA- I’s personnel file revealed: 1. HA- I’s date of hire was 9/30/24.2. There was no documentation in the personnel file that any in-service hours had been completed. E. Review of HA- J’s personnel files revealed:1. HA- J’s date of hire was 6/23/25.2. There was no documentation in the personnel file that any in-service hours had been completed. F. During an interview on 4/7/26 at 10:00 AM, the Director of Human Resources Operations confirmed the personnel file for HA- H, I, and J did not include documentation of in-service training completed.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the Hospice Volunteer Coordinator had training in the role to ensure the agency volunteer services are provided according to federal and state regulatory requirements and are able to meet the needs of the hospice patients. This had the potential to affect all current and future hospice patients of the agency who may require volunteer services. The census was 35. Findings are: A. Review of the agency policy and procedure titled Volunteer Program Standard Operating Procedure, effective 7/2022, revealed:1. The management and supervision of the volunteer program will be completed at the branch level with daily involvement from the branch director and the volunteer coordinator (VC). 2.The volunteer coordinator must recruit volunteers to the agency for the purpose of administrative tasks and/or patient services. B. Review of the agency policy and procedure titled Orientation Policy No. 7-025.1, revised 2/2026, revealed orientation was to include, but not limited to, job related responsibilities, job description, and documentation requirements. C. Review of the job description, Hospice Volunteer Coordinator, revealed the VC: 1. Has overall responsibility for the agency’s volunteer program.2. Maintains documentation of viable and ongoing efforts to recruit and retain volunteers. 3. Ensures volunteers provide day-to-day administrative and/or direct patient care services in an amount that at minimum, equals 5% of the total patient care hours of all paid employees. D. Review of personnel files revealed:1. VC date of hire was 2/17/25.2. There was no signed job description verifying knowledge/acceptance of job responsibilities and requirements.3. There was no documentation the VC was oriented to job responsibilities and requirements. E. During an interview on 4/1/25 at 4:25 PM, the VC confirmed:1. Date of hire was 2/17/25.2. Did not have training in the role of VC, including training for recruitment of volunteers.3. Had not done any recruitment of volunteers since beginning the VC position. F. During review of personnel files on 4/7/26 at 10:00 AM, the Director of Human Resources Operations confirmed the VC file did not contain a signed job description verifying knowledge/acceptance of job responsibilities and requirements and no evidence the VC received orientation and training for the position.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to document efforts to recruit and/or retain volunteers to ensure the agency maintained a volunteer roster to meet the volunteer service needs of the hospice’s patients for 2024, 2025, through 3/2026. The census was 35. Findings are: A. Review of the agency policy and procedure titled Volunteers, HR.95, last reviewed 9/01/24, revealed the hospice will document and demonstrate viable and ongoing efforts to recruit and retain volunteers. B. Review of the agency policy and procedure titled Volunteer Program, Standard Operating Procedure, effective 7/2022, revealed:1. The management and supervision of the volunteer programs will include daily involvement from the branch director and the volunteer coordinator.2. The volunteer coordinator must recruit volunteers to the agency for the purpose of administrative tasks and/or patient services using electronic methods, referral sources, colleges, universities, and community resources. C. Review of hospice records revealed:1.There was no usage from 5/2024 through 4/8/26. 2. There was no available documentation on recruitment efforts. D. During an interview on 4/1/25 at 4:25 PM, the Volunteer Coordinator (VC) confirmed the agency has not conducted any volunteer recruitment efforts since 2/17/25 (VC date of hire) and the VC did not have any documentation of volunteer recruitment efforts made from 2024 through 2/16/25.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to provide day-to-day administrative or direct patient care by volunteers to equal at least 5% of the total direct patient care hours provided by the hospice employees for 3/2023 through 3/2026. The census was 35. Findings are:A. Review of the agency policy and procedure titled Volunteers, HR.95, last reviewed 09/01/2024, revealed the hospice was to provide volunteers for day-to-day administrative and/or direct patient care services, at a minimum, equal to five percent of the total patient care hours of all paid hospice employees and contracted staff. B. Review of the Hospice Volunteer Requirement Report (a cost-savings volunteer usage report) for 3/2023 through 3/2026 revealed:1. Less than 5% volunteer usage from 3/2023 through 4/2024.2. 0% volunteer usage from 5/2024 through 3/2026. C. During an interview on 4/1/26 at 4:45 PM, the Regional Director of Clinical Operations confirmed the hospice failed to utilize volunteers to equal at least 5% of the total direct patient care hours provided by the hospice employees from 3/2023 through 3/2026.”

“Based on hospice and clinical record review, personnel file review, and staff interview, Administrator job description, Quality Assurance and Performance Improvement (QAPI) Review, Emergency Preparedness Program Review, and staff interview the Hospice Administrator failed to maintain responsibility for the day-to-day operations of the hospice program to ensure the regulatory and statutory requirements and agency policy and procedures were followed by the agency. The census was 35. The hospice had 17 employees. Findings are: A. Review of the agency’s Administrator job description, revised 6/1/2020, revealed the Administrator duties included, but are not limited to:1. The primary function of the Administrator is to assume overall responsibility and authority for administrative and leadership functions, supervision of the organizational plan, and ongoing communication with the Governing Body and Interdisciplinary Group, and agency staff. 2. Manages the daily operations of the agency.3. Organizes and directs the agency’s ongoing functions.4. Administratively supervises the provision of quality care.5. Ensures the agency is in compliance with all applicable federal, state, and local laws and regulatory agencies related to the health and safety of the patients. 6. Ensures the development of personnel qualifications and policies.7. Ensures adequate staff education and evaluation.8. Supervises to ensure implementation of agency policy and procedures. B. Review of clinical records revealed deficient practice cited at:L549L554L590L672L678 C. Review of agency personnel files revealed deficient practice cited at:L615L620L643L662 D. Review of the agency’s Quality Assurance and Performance Improvement (QAPI) Program revealed deficient practice cited at:L564L570 E. Review of the agency’s Emergency Preparedness Program revealed deficient practice cited at:E0037E0039 F. Review of the agency’s volunteer records revealed deficient practice cited at:L643L645L647 G. Observation of Hospice staff, providing patient care, revealed deficient practice cited at: L580 H. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the Hospice Administrator failed to maintain responsibility for the day-to-day operations of the hospice program to ensure the regulatory and statutory requirements and agency policies and procedures were followed by the agency staff.”

“Based record review, policy and procedure review, and staff interview, the agency failed to maintain documentation confirming the employee’s awareness of the title of that individual’s job position, qualifications, and description of the duties and functions assigned to that job position and failed to maintain documentation that an orientation program was completed upon hire date for 10 of 11 (Staff- A, C, D, E, F, G, H, I, J, and L) employee files reviewed. The agency employs 17 staff. Findings are: A. Review of the agency policy and procedure titled Employee Record Contents, policy No. 7-023.1, revised 1/2025, revealed the employee record was to include a signed job description. B. Review of the agency policy and procedure titled Orientation, Policy Np. 7-025.1, revised 2/2026, revealed all employees will be required to attend an orientation program upon employment and at time of reassignment to a new position. Orientation topics in the policy included, but are not limited to, job duties and responsibilities, organizational structure, patient rights, patient care policies and procedures, and personnel policies. The policy does not include the requirement to include reporting requirements for abuse, neglect, and exploitation in accordance with state law and with hospice policies and procedures. C. Review of Staff-A’s personnel file revealed:1. Date of hire was 12/1/20.2. A change of position to Administrator on 1/12/26.3. There was no documentation confirming the employee’s awareness/receipt of registered nurse (12/1/20) or Administrator (1/12/26), qualifications, and description of the duties and functions assigned to those positions.4. There was no documentation to verify an orientation program was completed upon hire. D. Review of Staff-C’s personnel file revealed:1. Date of hire was 6/2/25.2. There was no documentation confirming the employee’s awareness/receipt of registered nurse, qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. E. Review of Staff-D’s personnel file revealed:1. Date of hire was 2/13/23.2. There was no documentation confirming the employee’s awareness/receipt of licensed practical nurse qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. F. Review of Staff-E’s personnel file revealed:1. Date of hire was 1/3/23.2. The employee has the dual role of Bereavement Coordinator and Chaplain.3. There was no documentation confirming the employee’s awareness/receipt of Bereavement Coordinator or Chaplain qualifications, and description of the duties and functions assigned to those positions.4. There was no documentation to verify an orientation program was completed upon hire. G. Review of Staff-F’s personnel file revealed:1. Date of hire was 12/2/24.2. There was no documentation confirming the employee’s awareness/receipt of registered nurse case manager qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. H. Review of Staff-G’s personnel file revealed:1. Date of hire was 3/4/24.2. There was no documentation confirming the employee’s awareness/receipt of medical social worker qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. I. Review of Staff- H’s personnel files revealed:1. Date of hire was 10/23/23.2. A change of position date of 8/29/24.3. There was no documentation confirming the employee’s awareness/receipt of hospice aide (10/23/23) and health information manager (8/29/24) qualifications, and description of the duties and functions assigned to that position.4. There was no documentation to verify an orientation program was completed upon hire. J. Review of Staff- I’s personnel file revealed: 1. Date of Hire was 9/30/24.2. There was no documentation confirming the employee’s awareness/receipt of hospice aide qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. K. Review of Staff- J’s personnel files revealed:1. Date of hire was 6/23/25.2. There was no documentation confirming the employee’s awareness/receipt of hospice aide qualifications, and description of the duties and functions assigned to that position.3. There was no documentation to verify an orientation program was completed upon hire. L. Review of Staff- L’s personnel files revealed:1. Date of hire was 2/17/25 with the dual role of Volunteer Coordinator and Medical Records Manager.2. There was no documentation confirming the employee’s awareness/receipt of Volunteer Coordinator or Medical Records Manager qualifications, and description of the duties and functions assigned to those positions.3. There was no documentation to verify an orientation program was completed upon hire. M. During an interview on 4/7/26 at approximately 10:00 AM, the Director of Human Resources Operations confirmed the personnel file for Staff- A, C, D, E, F, G, H, I, J, and L did not include documentation confirming the employee’s awareness/receipt of position qualifications, and description of the duties and functions assigned to those positions and did not include documentation that an orientation program was completed upon hire.”

“Based on record review, policy and procedure review, and staff interview the agency failed to document in the clinical record the on-call follow-up visit note, and coordination and follow-up notes for 4 of 4 (Patient 5, 9, 12, and 13) records reviewed who requested a visit outside the regular office hours. The total sample size was 14. The census was 35. Findings are: A. Review of the agency policy and procedure titled Coordination of Care, last reviewed 9/1/24, revealed all communication and coordination of care is to be documented in the clinical record. B. Review of the agency policy and procedure titled Clinical/Services Data Collection, Policy No. 2-012.1, revised 12/24, revealed:1. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 2. Entries are to be made on the day care/service is provided to the patient. C. Review of Patient 5’s clinical record revealed:1. A Client Episode Coordination Notes Report dated 3/21/26. The note is an on-call triage note. The note indicated the patient was calling to report symptoms of pain and nausea. Patient was agreeable to having the on-call nurse notified for follow-up.2. There was no documentation by the on-call nurse of the follow-up to the phone call. D. Review of Patient 9’s clinical record revealed:1. A Skilled Nurse (SN) Visit Note Report dated 3/24/26. The SN documented they will discuss the patient’s pain and potential constipation with the Hospice Medical Director (HMD) and update the patient with the physician recommendations.2. There was no documentation in the clinical record of MD or patient communication regarding the physician’s recommendations. E. Review of Patient 12’s clinical record revealed:1. A Client Episode Coordination Notes Report dated 1/4/26 at 12:15 PM. The note is an on-call triage note. The patient’s family member was calling to obtain medication for nausea, as well as education on patient prognosis. Triage documents the on-call nurse was notified.2. A Client Episode Coordination Notes Report dated 1/4/26 at 2:31 PM. The note is an on-call triage note. The patient’s family member was calling to obtain authorization for the medication for nausea that was called to the pharmacy. Triage documents the on-call nurse was notified and will follow-up.3. There was no documentation in the clinical record of communication completed with the pharmacy or the family member regarding the triage calls on 1/4/26. F. Review of Patient 13’s clinical record revealed:1. A Client Episode Coordination Notes Report dated 2/2/26 at 3:49 PM. The note is an on-call triage note. The patient’s family member was calling to report the patient received a skin tear that was wrapped due to bleeding. The family member was requesting a nurse visit. Triage documents the on-call nurse was notified, and confirms a follow-up and an as needed visit was added.2. There was no documentation in the clinical record of the as needed visit conducted on 2/2/26 in follow-up to the triage call. G. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the agency failed to document in the clinical record the on-call follow-up visit note, coordination and/or follow-up notes for Patient 5, 9, 12, and 13.”

“Based on record review, policy and procedure review, and staff interview, the agency failed to ensure a physician order was written when new orders were received for 8 of 14 (Patient 5, 7, 8, 9, 11, 12, 13, and 14) records reviewed and failed to have a written policy and procedure specific to staff obtaining and writing physician orders/verbal ordes. The census was 35. Findings are: A. Review of the agency policy and procedure titled Medical Record Content, last reviewed 9/1/24, revealed the medical record was to contain physician orders. B. Review of the agency policy and procedure titled Medication List and Monitoring, reviewed 2/13/25, revealed:1. The hospice will review, monitor, and maintain a current, accurate list of all prescriptions, over-the-counter (OTC), sample, investigational medications, herbal and home remedies taken by the patient, and other alternative treatments that could affect drug therapy.2. Changes in medications/drug regimen will be documented in the clinical record either on the medication profile, on a verbal order, plan of care, as well as communicate with the patient and/or caregiver. C. The agency did not provide a policy and procedure specific to obtaining and writing physician orders/verbal orders. D. Review of Patient 5 ‘s clinical record revealed:1. A Skilled Nurse (SN) Visit Note Report, dated 1/9/26, the nurse requested and received an approval for an increase in the patient’s Fentanyl patch (a pain management medication) to 25 micrograms (mcg)/hour.2. A SN Visit Note Report, dated 3/20/26, the SN documented that the physician approved an increase in the Fentanyl patch to 50 mcg, as well as orders for morphine and lorazepam concentrates for PRN (as needed) use (no strength, dosage documented).3. There was no documentation that a physician order/verbal order form was completed for the Fentanyl 25 mcg patch ordered on 1/9/26, or the Fentanyl 50 mcg, ordered on 3/20/26, or for the morphine and lorazepam concentrate PRN ordered on 3/20/26. E. Review of Patient 7’s clinical record revealed:1. A SN Visit Note Report, dated 3/27/26, the SN documented that the Advanced Practice Registered Nurse (APRN) saw the patient and ordered an antibiotic (not identified). 2. There was no documentation that a physician order/verbal order form was completed for the antibiotic ordered on 3/27/26. F. Review of Patient 8’s clinical record revealed1. A SN Visit Note Report, dated 12/24/25, the SN documented that an order was received from the Hospice Medical Director (HMD) for lorazepam (an antianxiety medication), 0.25 mg (milligrams) daily at 5:00 PM.2. A Hospice Physician Order, dated 1/20/26, for lorazepam 0.5 mg at 5:00 PM. The order indicated the medication was initiated on 1/2/26 but not documented as a physician order until 1/20/26.3. There was no documentation that a physician order/verbal order form was completed for the lorazepam ordered on 12/24/25. G. Review of Patient 9’s clinical record revealed:1. A SN Visit Note Report, dated 3/26/26, the SN documented that the patient’s family member would be picking up the new medication and the patient would be taking the first dose of oxycontin tonight.2. There was no documentation that a physician order/verbal order form was completed for the oxycontin ordered on 3/26/26. H. Review of Patient 11’s clinical record revealed:1. A SN Visit Note Report, dated 9/30/25, the SN documented that the patient was drowsy the first few days of the new nighttime medication (medication not identified in the note).2. A SN Visit Note Report, dated 10/2/25, the SN documented that the patient is doing well with the new Seroquel at night.3. A SN Visit Note Report, dated 11/4/25, the SN documented that the patient had been started on Seroquel 12.5 mg at bedtime. An additional dose of Seroquel 6.25 mg PRN prior to bathing is being ordered.4. There was no documentation that a physician order/verbal order form was completed for the Seroquel ordered on 9/30/25 and 11/4/25. I. Review of Patient 12’s clinical record revealed:1. A SN Visit Note Report, dated 2/26/26, the SN documented that the APRN ordered diclofenac (a topical gel for arthritis pain) gel 4 grams to apply to right leg 2 to 3 times per day.2. There was no documentation that a physician order/verbal order form was completed for the diclofenac ordered on 2/26/26. J. Review of Patient 13’s clinical record revealed:1. A SN Visit Note Report, dated 4/11/25, the SN documented new orders were received to hold all oral medications except morphine, lorazepam, atropine, and nebulizer. The note also indicated that morphine dose to be scheduled every 6 hours with nebulizer and lorazepam.2. There was no documentation that a physician order/verbal order form was completed for the medications ordered on 4/11/25. K. Review of Patient 14’s clinical record revealed:1. A SN Visit Note Report, dated 7/11/25, the SN documented new orders were received to schedule morphine and lorazepam, and to add PRN atropine.2. There was no documentation that a physician order/verbal order form was completed for the medications ordered on 7/11/25. L. During an interview on 4/8/26 at 9:00 AM, the Regional Director of Clinical Operations confirmed the agency failed to ensure a physician order was written when new orders were received for Patient 5, 7, 8, 9, 11, 12, 13, and 14.”