Serenity Hospice Care

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 6 (100%) clinical records reviewed, the agency did not ensure that each patient’s individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. The agency’s Plan of Care - Content policy (policy number PC.P45, updated 03/01/2026) stated in part, “The plan of care includes, but is not limited to...measurable outcomes anticipated to meet the needs of the patient.” CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 06/26/2026. The Registered Nurse completed and documented a comprehensive assessment on 06/26/2026. The Plan of Care (POC) dated 06/26/2026-09/23/2026 included, in part, the following goals: “Patient will experience symptom reduction. Patient will maintain optimal cardiac function within constraints of disease. Patient/Caregiver able to verbalize measures to promote comfort related to respiratory system in the terminal patient. Patient’s respiratory status will be stabilized to comfort as possible. Patient/Caregiver(s) will verbalize understanding of care required secondary to bowel incontinence...Patient will receive personal care and hygiene, including other activities of daily living.” An interim order was written on 06/30/2026 for Chaplain orders. The goals on the order stated in part, “Patient will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for funeral/memorial will be completed. An interim order was also written for Medical Social Work on 06/30/2026. The order contained goals: “A medical social worker plan of care will be established that meets the patient’s needs. Patient will transition peacefully through the dying process.” The goals on the POC were not measurable as required by the agency’s policy. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/02/2026. The Registered Nurse completed and documented a comprehensive assessment on 07/02/2026. The Plan of Care (POC) dated 07/02/2026-09/23/2026 included, in part, the following goals: “Patient’s respiratory status will be stabilized to comfort as possible. Patient Caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled instruction. Skin breakdown will be identified and measures to resolve breakdown implemented promptly. Patient/caregivers will verbalize understanding of care required secondary to bowel incontinence. Patient will have safety needs met.” An interim order was written on 07/06/2026 for Chaplain orders. The goals on the order stated in part, “A chaplain plan of care will be established that meets the patient’s needs.” An interim order was also written for Medical Social Work on 07/06/2026. The order contained goals: “ A medical social worker plan of care will be established that meets the patient’s needs. Patient will transition peacefully through the dying process. Patient and caregiver(s) will have decreased fear/anxiety regarding death and dying process.” The goals on the POC were not measurable as required by the agency’s policy. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/16/2026. The Registered Nurse completed and documented a comprehensive assessment on 07/16/2026. The Plan of Care (POC) dated 07/16/2026-09/13/2026 included, in part, the following goals: “ A nursing plan of care will be established that meets the patient’s needs. Caregivers are knowledgeable of care and need to report changes of LOC. Caregivers verbalize understanding of anorexia and/or dehydration in the dying patient and demonstrate comfort with the plan of care. Patient/Caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled instruction. A medical social worker plan of care will be established that meets the patient’s needs. Patient/caregiver will understand how psychosocial/spiritual factors influence pain. Patient will transition peacefully through the dying process. A chaplain plan of care will be established that meets the patient’s needs. Patient will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for funeral/memorial will be completed.” The goals on the POC were not measurable as required by the agency’s policy. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/11/2026. The Registered Nurse completed and documented a comprehensive assessment on 07/11/2026. The Plan of Care (POC) dated 07/11/2026-10/08/2026 included, in part, the following goals: “ A nursing plan of care will be established that meets the patient’s needs. Patient caregiver will express an increased sense of closure and peacefulness at the end of life. Caregivers will experience a sense of accomplishment at having supported the dying person. Patient caregivers will have knowledge of the stages of grief and the grief cycle. A chaplain plan of care will be established that meets the patient’s needs. Patient will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for funeral/memorial will be completed.” The goals on the POC were not measurable as required by the agency’s policy. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 06/28/2026. The Registered Nurse completed and documented a comprehensive assessment on 06/28/2026. The Plan of Care (POC) dated 06/28/2026-09/25/2026 included, in part, the following goals: “A nursing plan of care will be established that meets the patient’s needs. Caregivers are knowledgeable of care and need to report changes of LOC. Patient will be free of signs symptoms of discomfort related to genitourinary system. A medical social worker plan of care will be established that meets the patient’s needs. Patient will transition peacefully through the dying process. Patient/caregiver will express an increased sense of closure and peacefulness at the end of life. Caregivers will experience a sense of accomplishment at having supported the dying person. Patient/caregiver will have knowledge of the stages of grief and the grief cycle. A chaplain plan of care will be established that meets the patient’s needs. Patient will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for funeral/memorial will be completed. The goals on the POC were not measurable as required by the agency’s policy. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/10/2026. The Registered Nurse completed and documented a comprehensive assessment on 07/10/2026. The Plan of Care (POC) dated 07/10/2026-09/07/2026 included, in part, the following goals: “A nursing plan of care will be established that meets the patient’s needs. A medical social worker plan of care will be established that meets the patient’s needs. A chaplain plan of care will be established that meets the patient’s needs. Patient will receive personal care and hygiene including other activities of daily living. Patient/caregiver will express an increased sense of closure and peacefulness at the end of life. Caregivers will experience a sense of accomplishment at having supported the dying person. Patient/caregivers will have knowledge of the stages of grief and the grief cycle. Patient will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for a funeral memorial will be completed.” The goals on the POC were not measurable as required by the agency’s policy. The Clinical Director (Personnel Record 2) reviewed the plan of care and the agency’s policy and was interviewed on 07/28/2026. The Clinical Director agreed that the goals written in the plans of care were not measurable.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 6 (83%) clinical records reviewed, the agency did not ensure that services were provided as ordered on the plan of care. The agency’s “Plan of Care - Content” policy (policy number: PC.P45, Updated March, 2026) stated in part, “The patient’s plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. The plan of care includes, but is not limited to... A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.” CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 06/26/2026. The Plan of Care (POC) dated 06/26/2026-09/23/2026 included orders for Skilled Nursing (SN) services with a visit frequency of 2 visits weekly for 13 weeks, then 1 visit for 1 week. There was only one documented SN visit each week from 06/26/2026 through 07/14/2026 (1 missed visit each week). There was no documentation in the record of missed visits, documentation of communication to the ordering physician regarding missed visits, or interim orders changing the SN visit frequency. SN services were not provided as ordered in the POC. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/02/2026. The Plan of Care (POC) dated 07/02/2026-09/29/2026 included orders for Skilled Nursing (SN) services with a visit frequency of 3 visits for the 1st week, 2 visits each week for 12 weeks, then 1 visit for 1 week. There was only one documented SN visit each week from 07/02/2026 through 07/20/2026 (2 missed visits the first week, then 1 missed visit each following week). There was no documentation in the record of missed visits, documentation of communication to the ordering physician regarding missed visits, or interim orders changing the SN visit frequency. SN services were not provided as ordered in the POC. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/16/2026. The Plan of Care (POC) dated 07/16/2026-09/13/2026 included orders for Skilled Nursing (SN) services with a visit frequency of 3 visits for the first week, then 2 visits weekly for 8 weeks. There was 1 documented SN visit for the first 2 weeks of services (2 missed visits the first week, 1 missed visit the subsequent week). There was no documentation in the record of missed visits, documentation of communication to the ordering physician regarding missed visits, or interim orders changing the SN visit frequency. SN services were not provided as ordered in the POC. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 06/28/2-26. The Plan of Care (POC) dated 06/28/2026-09/25/2026 included orders for Skilled Nursing (SN) services with a visit frequency of 3 visits the first week, 2 weekly visits for 11 weeks, then 1 visit for 1 week. There were 2 documented SN visits the first week, then 1 weekly visit for the next 2 weeks (1 missed visit the first week of care, 1 missed visit each week for the next 2 weeks). There was no documentation in the record of missed visits, documentation of communication to the ordering physician regarding missed visits, or interim orders changing the SN visit frequency. SN services were not provided as ordered in the POC. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 07/10/2026. The Plan of Care (POC) dated 07/10/2026-09/07/2026 included orders for Skilled Nursing (SN) services with a visit frequency of 2 visits each week for 9 weeks, then 1 visit for 1 week. There were documented weekly SN visits from 07/10/2026 through 07/27/2026 (1 missed visit each week during the first 4 weeks of service). There was no documentation in the record of missed visits, documentation of communication to the ordering physician regarding missed visits, or interim orders changing the SN visit frequency. SN services were not provided as ordered in the POC. The Clinical Manager (Personnel Record 2) was interviewed on 07/28/2026 and stated, “When the clinician plots the visits on the calendar, [the electronic medical record] adds all of the visits to the frequency string on the care plan. The clinicians add extra visits in the orders in case PRN [as needed] visits need to be made. The extra visits are not really missed because they were never assigned. They are just available if needed. This happens for social work and chaplain, too.” The Clinical Manager also stated that the staff can use the PRN visits anytime for any reason (specific parameters are not in place for the use of PRN visit).”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed where the patient received aide services, the agency did not ensure that aide supervision was performed no less frequently than every 14 days. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 06/28/2026. The Registered Nurse performed and documented a comprehensive assessment on 06/28/2026. The Plan of Care (POC) dated 06/28/2026-09/25/2026 contained orders for a Hospice Aide (HA) with a visit frequency of 5 visits weekly for 13 weeks. HA services were provided as ordered in the POC. There was a documented HA supervision in the nursing note dated 06/29/2026. Subsequent nursing visits were documented on 07/07/2026 and 07/15/2026. There was no documentation of HA supervision in the nursing notes. The Skilled Nurse did not perform and document Hospice Aide supervision at least every 14 days as required. The Clinical Director (Personnel Record 2) reviewed the clinical record and was interviewed on 07/28/2026. The Clinical Director stated, “The supervision should have been done during the nursing visit made during the week of the 13th. The nurse moved the visit, and the aide supervision was not done.””

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review and interview, which revealed the agency failed to ensure that: 1. each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. (HCPC.21.I/L550); 2. each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatments necessary to meet the needs of the patient.(HCPC.21.I/L549); and 3. each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments (HCPC.21.I/L545). The cumulative effect of these deficiencies indicates a lack of effective oversight and could result in the hospice agency’s inability to ensure the provision of quality hospice care in a safe environment for the Condition of Participation CFR 418.56 Interdisciplinary group, care planning, and coordination of services. The deficient practice demonstrates systemic process failures that have the potential to affect all patients cared for by the hospice agency.”

“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 6 of 27 (22%) clinical records from the community program, the agency did not ensure that the plans of care documented interventions for all problems identified in the nursing assessments. CLINICAL RECORD 8: The Hospice Benefit election date was 04/14/2026 with a primary diagnosis of cerebral infarction. The initial comprehensive nursing assessment, completed on 04/14/29026, documented that the patient was receiving a tube feeding via a gastric tube of Glucerna 1.2 cal (calories) at 70 milliliters per hour to a total volume of 1500 milliliters. Also the patient was using oxygen at 2 liters per nasal cannula and a duo nebulizer. The initial plan of care and plans that were updated every two weeks did not document any interventions for oxygen, or the tube feeding. CLINICAL RECORD 10: The Hospice Benefit election date was 04/14/2025 with a primary diagnosis of cerebral infarction. The updated nursing assessment, completed on 05/13/2026, documented a sacral pressure ulcer with wound care, and the assessment on 05/22/2026 documented a patient fall and that the patient was using oxygen per nasal cannula. The plans of care updated every two weeks did not document interventions for oxygen, falls, or skin integrity for the patient. CLINICAL RECORD 11: The Hospice Benefit election date was 05/05/2026 with a primary diagnosis of chronic obstructive pulmonary disease. The nursing assessment, completed on 05/06/2026, documented a stage 2 wound with wound care ordered. The plan of care that was updated every two weeks did not document any interventions for skin integrity as of the date of review, 06/17/2026. CLINICAL RECORD 12: The Hospice Benefit election date was 12/09/2026 with a primary diagnosis of breast cancer. The nursing assessment, completed on 01/08/2026, documented a sacral wound to be cleaned with normal saline, pat dry, apply wound get and a foam dressing. The plan of care that was updated every two weeks did not document any interventions for skin integrity as of the date of review, 06/17/2026. CLINICAL RECORD 16: The Hospice Benefit election date was 05/28/2026 with a primary diagnosis of cerebral infarction. The initial nursing comprehensive assessment, completed on 05/28/2026, documented that the patient had a Foley catheter and a J-tube for feedings. The initial plan of care and the plans that were updated every two weeks did not document any interventions for the Foley catheter and the J-tube. CLINICAL RECORD 25: The Hospice Benefit election date was 01/01/2026 with a primary diagnosis of Alzheimer’s Disease. The initial nursing comprehensive assessment, completed on 01/07/2026, documented that the patient had a Foley catheter to dependent drainage, a stage 4 wound and a PEG (Percutaneous Endoscopic Gastrostomy) tube for “pleasure feeding”. The initial plan of care and plans updated every two weeks did not document any interventions for the Foley catheter or the PEG tube. The patient did revoke the Hospice Benefit on 01/07/2026. The Clinical Director, during interview on 06/18/2026, stated that there was a current PIP (performance improvement project) in place for interventions as they realized it was a problem.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 27 (4%) clinical records for the community program, the agency did not ensure that all medications and (complete) treatments were documented on the plans of care. CLINICAL RECORD 7: The hospice benefit was elected on 06/16/2025. The patient resided in a skilled nursing facility (SNF). Physician orders were written 02/17/2026 as follows: “Cleanse site with Dakins, apply calcium alginate and Xeroform to site, cover with dressing, change daily and prn (as needed)”. The order did not include the location of the wound. Another physician order, dated 03/24/2026, was documented as follows: “Cleanse site with small amount of Dakins solution, apply calcium alginate and Xeroform, cover with dressing, change daily and prn”; the order did not include the location of the wound. CLINICAL RECORD 8: The Hospice Benefit date of election was 04/14/2026 with a primary diagnosis of cerebral infarction. The initial comprehensive nursing assessment on 04/14/2026 documented that the patient was using oxygen. The initial plan of care that was updated every two weeks did not document oxygen on the plan of care. CLINICAL RECORD 24: The hospice benefit was elected on 01/08/2026. The patient resided in a SNF and died on 01/26/2026. A physician order was documented on 01/09/2026 stating, “Cleanse left hip with normal saline, apply Medihoney, cover with Optifoam”. There was no frequency documented for the wound care. CLINICAL RECORD 26: The patient elected the hospice benefit on 01/15/2026 and died on 02/23/2026. A physician order was documented on 01/16/2026 stating: “Cleanse with wound spray, apply triple antibiotic ointment and Xeroform to site, apply abdominal pad and gauze roll, secure with paper tape, complete wound care daily and prn if dressing soiled. The order did not include the location of the wound. During interview with the Clinical Director on 06/18/2026 she agreed that oxygen was not documented on the plan of care for Clinical Record 8 and provided the Process Improvement Plan for wound documentation and orders.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: 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 2 of 27 (7%) clinical records reviewed for the community program, the agency did not ensure that all supplies and appliances used by the patient and covered were included on the plans of care. CLINICAL RECORD 8: The Hospice Benefit election date was 04/14/2026 with a primary diagnosis of cerebral infarction. The initial comprehensive nursing assessment on 04/14/2026 documented that the patient was using oxygen and a tube feeding via a gastric tube. The 04/30/2026 nursing assessment documented use of a Duo-neb. The initial plan of care that was updated every two weeks documented supplies on the plan of care as NONE. The Supplies section of the plan of care did not document the oxygen concentrator and supplies, duo neb, and the tube feeding supplies. CLINICAL RECORD 26: The Hospice Benefit election date was 01/15/2026 with a primary diagnosis of congestive heart failure. The date of the patient’s death was 02/23/2026. The initial nursing comprehensive assessment, completed on 01/15/2026, documented that the patient was using oxygen and had a wound with wound care. The plan of care that was updated every two weeks documented supplies on the plan of care as NONE. The oxygen concentrator, tubing, and wound care supplies were not documented in the Supplies section of the plan of care. The Clinical Director, during interview on 06/18/2026, stated that supplies have been a PIP (performance improvement project) and it has improved but they are still working on it.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records of patients who were deceased and accepted bereavement services, the agency did not ensure that bereavement plans were documented with frequency of service delivery. CLINICAL RECORD 23: The hospice benefit election date was 01/09/2026. The patient died on 02/02/2026. The bereavement plan documented: “Initial sympathy card/letter, standard bereavement form letters, information referral to community resource’s, final follow up letter at end of 13 months”; there was no frequency of service delivery documented for the first few directives. NOTE: There was contact made for bereavement on 02/16/2026, 03/17/2026, that documented an initial call and a 1 month call but the plan did not document any frequencies. CLINICAL RECORD 26: The patient elected the hospice benefit on 01/15/2026. The patient died on 02/23/2026. The staff spoke with the daughter who was the identified bereaved. There was no bereavement plan of care documented with identified tasks or frequency of service delivery. There were contacts made on 03/05/2026 and 04/06/2026 that documented an initial call and a follow up call. During interview with the Bereavement Coordinator (who has had the position for a month) and the Clinical Director on 06/18/2026, they reviewed the records and agreed they had a plan but that the plans were not documented.”

“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 28 (18%) clinical records reviewed, in which a hospice aide services were provided, it was revealed that the agency did not ensure that the RN(s) prepared hospice aide plans of care that included clear and specific instructions for the patients’ required care. CLINICAL RECORD 1: The Hospice Benefit election date was 07/26/2025 with a primary diagnosis of senile degeneration. The hospice aide plan of care, last updated 03/24/2026 with assigned tasks of tub bath every visit, shampoo as requested, and nail/foot care as requested did not document an identified decision-maker for a confused patient. CLINICAL RECORD 3: The Hospice Benefit election date was 07/11/2025 with a primary diagnosis of unspecified protein malnutrition and a secondary diagnosis of senile degeneration. The hospice aide plan of care, last updated 12/22/2025, with an assigned task of shampoo as requested did not document an identified decision-maker. CLINICAL RECORD 8: The Hospice Benefit election date was 04/14/2026 with a primary diagnosis of cerebral infarction. The hospice aide plan of care, documented on 04/14/2026, did not document that the patient had a G(gastric)-tube feeding and a G-tube in place. The assigned task for bathing was a bed bath each visit but the G-tube was not identified on the plan of care. CLINICAL RECORD 10: The Hospice Benefit election date was 05/12/2026 with a primary diagnosis of Malignant Neoplasm of Kidney. The hospice aide plan of care, documented on 05/13/2026, did not identify that the patient had a sacral wound and a dressing that was in place. The patient was documented as confused. The assigned task for shampoo was written “as requested” daily; there was no identified decision-maker. CLINICAL RECORD 16: The Hospice Benefit election date was 05/28/2026 with a primary diagnosis of cerebral infarction. The initial nursing comprehensive assessment, documented on 05 28/2026, documented that the patient had a Foley catheter to dependent drainage and a J-tube with feedings as requested. The hospice aide plan of care, documented on 06/12/2026, did not document any assigned tasks for Foley catheter care or that the patient had a J-tube (jejunostomy-tube) in place. The Clinical Director and Administrator, on interview, stated that the aide plans of care would be a work in progress as they transition this to their electronic medical record.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 25 (8%) clinical records in which a hospice aide was accepted, the agency did not ensure hospice aide supervision was documented every 14 days. CLINICAL RECORD 8: The Hospice Benefit election date was 04/14/2026 with a primary diagnosis of cerebral infarction. The ordered hospice aide visit frequency was 5 times a week. The first aide supervisory visit was documented on 04/15/2026 and a second aide supervisory visit documented on 05/28/2026; no further aide supervisory visits were documented as of the date of review, 06/17/2026 (20 days). CLINICAL RECORD 10: The Hospice Benefit election date was 04/14/2025 with a primary diagnosis of cerebral infarction. The ordered hospice aide visit frequency was 7 times a week with the first aide visit documented 05/18/2026. There were no aide supervisory visits documented until 06/12/2026 (25 days from the first aide visit). The Clinical Director, during interview on 06/18/2026, stated that paper documentation and clinical record documentation were reviewed and these aide supervisory visits were late.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the agency’s volunteer cost report revealed that the agency did not ensure that volunteer administrative and direct patient care services equaled five percent of the total patient care hours. The volunteer cost report supplied on 06/18/2026 reported the Total Percentage of Volunteer Hours, with an average for 2025 of 4.22%; a low of 1.32% in February 2025 and a high of 7.31% in June 2025. The average, from January 1, 2026 to the date of review, 06/18/2026, was 3.45%, with a low of 2.29% in January 2026 and a high of 4.82% so far in June 2026. During an interview on 06/17/2026 with the Volunteer Manager (Personnel Record 8), he confirmed that the volunteer hours are not adding up to the required 5% of total patient care hours, and have not since the end of the volunteer hours waiver established due to COVID. A review of the agency’s volunteer cost report revealed that the agency did not ensure that volunteer administrative and direct patient care services equaled five percent of the total patient care hours.”