Legacy Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the patient’s drug profile included all medications the patient was using. CLINICAL RECORD 3: During the Registered Nurse’s (RN) visit on 09/23/2025, the nurse documented that the patient complained of muscle spasms in his bilateral upper extremities and neck. The RN documentation stated in part, “...Advised them we could order Baclofen for muscle spasms. States they would like to try this...” The RN documented in the Interdisciplinary Group Meeting on 09/26/2025 that due to new muscle spasms in the patient’s bilateral upper extremities and neck, the patient was started on Baclofen. Baclofen was not included on the patient’s medication list and there was no documented physician’s order. CLINICAL RECORD 9: During the Registered Nurse’s (RN) visit on 08/29/2025, the nurse documented that the patient was in pain despite having received scheduled medications: Tramadol, Aspirin, and Acetaminophen. Neither Tramadol nor Aspirin was on the patient’s medication list and there was no documented physician’s order. CLINICAL RECORD 11: On 09/23/2025, the nurse documented in part, “...pt (patient) often has abdominal bloating and can’t tolerate much intake...continues with scheduled Gas-X TID....” Gas-X was not listed on the patient’s medication list and there was no documented physician’s order. A joint clinical record review and interview with the Administrator/RN (Personnel Record 2) on 10/30/2025 confirmed that the medications were not on the patients’ medication lists.”

“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 and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 8 of 19 (42%) clinical records reviewed revealed that the agency did not ensure the patient’ plan of care included at least one of the required elements. CLINICAL RECORD 1: The physician’s certification of terminal illness for the benefit period from 07/30/2025 to 10/27/2025 included that the patient was having difficulty self-propelling his wheelchair further than a few feet due to shortness of breath that limited his speaking. A physician’s order dated 05/01/2025 included oxygen at 2-5 liters per minute via nasal cannula as needed. The plans of care for the benefit periods from 07/30/2025 to 10/27/25 and 05/01/2025 to 07/29/25 were reviewed and found to include the identified problem of “Altered Cardiopulmonary Status,” but the goal for the patient to exhibit a reduction in symptoms was not specific or measurable. Another problem identified was the “Need for Skilled Teaching Regarding Cardiopulmonary Symptom Management” with the associated intervention to instruct measures to manage or relieve cardiac and/or respiratory symptoms. The goal to verbalize an understanding of measures to manage immediate cardiac and/or respiratory symptoms was neither patient-specific nor measurable. CLINICAL RECORD 3: During the nurse’s visit on 08/19/2025, the nurse documented that the patient reported generalized, constant pain and had a stated acceptable level of pain as “no pain.” On 10/14/2025, the Registered Nurse noted that the patient’s pain score was 4 and that his reported pain goal was 2. The patient’s medication list included: Acetaminophen 500mg/5ml: 19.5ml by mouth every 4 hours as needed for pain, Gabapentin 250mg/5ml: 4ml orally three times daily, and Tramadol 50mg by mouth three times a day as needed for pain. The plans of care for the benefit periods from 08/29/2025 to 10/27/2025 and 06/30/2025 to 08/28/2025 were reviewed and found to include the identified problem of pain/altered comfort and the need to assess the effectiveness of the patient’s pain control. The documented goal was to manage the patient’s pain to an acceptable level. This goal was not measurable and not specific to the patient’s stated pain goal. CLINICAL RECORD 5: During the Registered Nurse’s (RN) start of care (SOC) visit on 07/31/2025, the RN noted that the patient was experiencing frequent coughing with food and fluids, recurrent aspirations secondary to dysphagia, leading to a recent hospitalization for aspiration pneumonia. The patient’s medication list included: Buspirone 10mg orally three times a day for anxiety; Gabapentin 100mg by mouth three times daily for anxiety/agitation. The plan of care for the benefit period from 07/31/2025 to 10/28/2025 identified goals for the patient/caregiver to understand the origin/cause of the anxiety/terminal agitation and verbalize/demonstrate appropriate measures to minimize/control anxiety/agitation. However, these goals were not measurable. Additionally, there was no measurable goal documented for the patient’s dysphagia. CLINICAL RECORD 8: During the Registered Nurse’s SOC visit on 06/27/2025, she documented that the patient stated the pain goal was 0. On 08/13/2025, the patient reported neuropathic pain in her feet. An order was obtained from the Medical Director on the same date for Gabapentin 100mg by mouth three times daily for neuropathy. The plans of care for the benefit periods from September 25, 2025, to December 23, 2025, and June 27, 2025, to September 24, 2025, were reviewed and included an identified problem related to pain/altered comfort, as well as the need for assessing the effectiveness of pain control measures. But the goal documented that the patient’s pain would be managed at an acceptable level, which was not measurable. CLINICAL RECORD 9: During the Registered Nurse’s visit on 08/29/2025, the patient rated his constant, aching back pain with a score of 8. The patient’s stated pain goal was documented as 0. The patient’s plan of care for the benefit period from 06/27/2025 to 09/06/2025 were reviewed. The identified problems included pain/altered comfort, as well as the need to assess the effectiveness of pain control measures. But the goal documented that the patient’s pain would be managed at an acceptable level, which was not measurable. CLINICAL RECORD 12: During the Registered Nurse’s (RN) visit on 10/01/2025, the nurse noted that the patient was “...visibly anxious and demonstrated new symptoms not typical for him, including tremor, shaking, and rapid speech...when asked directly about his anxiety, he gave inconsistent answers, which is not his baseline…the patient referenced friends and military experiences in a way that suggested he was experiencing episodes of both delusion and hallucination…PRN Lorazepam was administered during the visit...anxiety symptoms began to subside, and he appeared calmer afterward...RN will follow up with MD...” On 10/15/2025, the nurse documented that the patient “...continues to exhibit anxiety, sleeplessness, and hallucinations...” The patient’s plans of care for the benefit periods from 07/21/2025 to 10/18/2025 and 10/19/2025 to 12/17/2025 included no interventions and goals related to anxiety and hallucinations. CLINICAL RECORD 13: On 10/25/2025, the Registered Nurse’s note documented “...Pt seen for reported status change of increased lethargy and decreased oral intake...pt has not been able to swallow food or liquids. Pt does not respond to verbal stimuli...Education provided to caregiver regarding end-of-life changes...updated husband on status change.” And on 10/26/2025, the nurse documented that the patient’s neurological status was deteriorating and that the patient remained at a high risk for aspiration. The patient’s plan of care for the benefit period from 10/26/2025 to 12/24/2025 were reviewed and altered nutrition/hydration, and the need for teaching related to nutrition and hydration was identified. However, no interventions or goals were included for the patient’s dysphagia and risk for aspiration. CLINICAL RECORD 14: During the Registered Nurse’s (RN) visit on 08/05/2025, the patient’s pain score was 3, with the worst pain in the last 24 hours a 5. The note included the patient’s pain goal of 0. The noted anxiety score was 1, with a reported goal of 0, with the worst anxiety score in the last 24 hours being 5. The facility staff reported increasing patient confusion and anxiety. On 08/11/2025, the nurse made a visit and noted that the facility staff reported hallucinations in addition to the previously documented confusion. A physician’s order for Tramadol 50mg orally three times a day was documented on 08/25/2025 and reduced to 25mg three times daily on 09/08/2025. On 09/02/2025, a physician’s order was documented for Haldol 0.5mg tablet: 1 tablet by mouth three times daily as needed for hallucinations/agitation. Repeat dose in 30 min if not effective. The plan of care for the benefit period from 07/09/2025 to 10/06/2025 were reviewed and found to include the identified problems of assessing the effectiveness of pain control/comfort measures, the need for skilled teaching regarding pain, and anxiety/agitation. The identified goals for pain management at an acceptable level for the patient included understanding pain management measures and the need to report pain changes to hospice, as well as verbalizing and demonstrating appropriate measures to minimize/control the patient’s anxiety and agitation. However, these goals were not measurable or patient specific. A joint clinical review and interview with the Administrator/RN and the Director of Operations on October 30, 2025, confirmed that the patients’ plans of care did not include interventions and goals that were patient-specific and measurable for identified problems.”

“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 and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 8 of 19 (42%) clinical records reviewed revealed that the agency did not ensure the patient’ plan of care included at least one of the required elements. CLINICAL RECORD 1: The physician’s certification of terminal illness for the benefit period from 07/30/2025 to 10/27/2025 included that the patient was having difficulty self-propelling his wheelchair further than a few feet due to shortness of breath that limited his speaking. A physician’s order dated 05/01/2025 included oxygen at 2-5 liters per minute via nasal cannula as needed. The plans of care for the benefit periods from 07/30/2025 to 10/27/25 and 05/01/2025 to 07/29/25 were reviewed and found to include the identified problem of “Altered Cardiopulmonary Status,” but the goal for the patient to exhibit a reduction in symptoms was not specific or measurable. Another problem identified was the “Need for Skilled Teaching Regarding Cardiopulmonary Symptom Management” with the associated intervention to instruct measures to manage or relieve cardiac and/or respiratory symptoms. The goal to verbalize an understanding of measures to manage immediate cardiac and/or respiratory symptoms was neither patient-specific nor measurable. CLINICAL RECORD 3: During the nurse’s visit on 08/19/2025, the nurse documented that the patient reported generalized, constant pain and had a stated acceptable level of pain as “no pain.” On 10/14/2025, the Registered Nurse noted that the patient’s pain score was 4 and that his reported pain goal was 2. The patient’s medication list included: Acetaminophen 500mg/5ml: 19.5ml by mouth every 4 hours as needed for pain, Gabapentin 250mg/5ml: 4ml orally three times daily, and Tramadol 50mg by mouth three times a day as needed for pain. The plans of care for the benefit periods from 08/29/2025 to 10/27/2025 and 06/30/2025 to 08/28/2025 were reviewed and found to include the identified problem of pain/altered comfort and the need to assess the effectiveness of the patient’s pain control. The documented goal was to manage the patient’s pain to an acceptable level. This goal was not measurable and not specific to the patient’s stated pain goal. CLINICAL RECORD 5: During the Registered Nurse’s (RN) start of care (SOC) visit on 07/31/2025, the RN noted that the patient was experiencing frequent coughing with food and fluids, recurrent aspirations secondary to dysphagia, leading to a recent hospitalization for aspiration pneumonia. The patient’s medication list included: Buspirone 10mg orally three times a day for anxiety; Gabapentin 100mg by mouth three times daily for anxiety/agitation. The plan of care for the benefit period from 07/31/2025 to 10/28/2025 identified goals for the patient/caregiver to understand the origin/cause of the anxiety/terminal agitation and verbalize/demonstrate appropriate measures to minimize/control anxiety/agitation. However, these goals were not measurable. Additionally, there was no measurable goal documented for the patient’s dysphagia. CLINICAL RECORD 8: During the Registered Nurse’s SOC visit on 06/27/2025, she documented that the patient stated the pain goal was 0. On 08/13/2025, the patient reported neuropathic pain in her feet. An order was obtained from the Medical Director on the same date for Gabapentin 100mg by mouth three times daily for neuropathy. The plans of care for the benefit periods from September 25, 2025, to December 23, 2025, and June 27, 2025, to September 24, 2025, were reviewed and included an identified problem related to pain/altered comfort, as well as the need for assessing the effectiveness of pain control measures. But the goal documented that the patient’s pain would be managed at an acceptable level, which was not measurable. CLINICAL RECORD 9: During the Registered Nurse’s visit on 08/29/2025, the patient rated his constant, aching back pain with a score of 8. The patient’s stated pain goal was documented as 0. The patient’s plan of care for the benefit period from 06/27/2025 to 09/06/2025 were reviewed. The identified problems included pain/altered comfort, as well as the need to assess the effectiveness of pain control measures. But the goal documented that the patient’s pain would be managed at an acceptable level, which was not measurable. CLINICAL RECORD 12: During the Registered Nurse’s (RN) visit on 10/01/2025, the nurse noted that the patient was “...visibly anxious and demonstrated new symptoms not typical for him, including tremor, shaking, and rapid speech...when asked directly about his anxiety, he gave inconsistent answers, which is not his baseline…the patient referenced friends and military experiences in a way that suggested he was experiencing episodes of both delusion and hallucination…PRN Lorazepam was administered during the visit...anxiety symptoms began to subside, and he appeared calmer afterward...RN will follow up with MD...” On 10/15/2025, the nurse documented that the patient “...continues to exhibit anxiety, sleeplessness, and hallucinations...” The patient’s plans of care for the benefit periods from 07/21/2025 to 10/18/2025 and 10/19/2025 to 12/17/2025 included no interventions and goals related to anxiety and hallucinations. CLINICAL RECORD 13: On 10/25/2025, the Registered Nurse’s note documented “...Pt seen for reported status change of increased lethargy and decreased oral intake...pt has not been able to swallow food or liquids. Pt does not respond to verbal stimuli...Education provided to caregiver regarding end-of-life changes...updated husband on status change.” And on 10/26/2025, the nurse documented that the patient’s neurological status was deteriorating and that the patient remained at a high risk for aspiration. The patient’s plan of care for the benefit period from 10/26/2025 to 12/24/2025 were reviewed and altered nutrition/hydration, and the need for teaching related to nutrition and hydration was identified. However, no interventions or goals were included for the patient’s dysphagia and risk for aspiration. CLINICAL RECORD 14: During the Registered Nurse’s (RN) visit on 08/05/2025, the patient’s pain score was 3, with the worst pain in the last 24 hours a 5. The note included the patient’s pain goal of 0. The noted anxiety score was 1, with a reported goal of 0, with the worst anxiety score in the last 24 hours being 5. The facility staff reported increasing patient confusion and anxiety. On 08/11/2025, the nurse made a visit and noted that the facility staff reported hallucinations in addition to the previously documented confusion. A physician’s order for Tramadol 50mg orally three times a day was documented on 08/25/2025 and reduced to 25mg three times daily on 09/08/2025. On 09/02/2025, a physician’s order was documented for Haldol 0.5mg tablet: 1 tablet by mouth three times daily as needed for hallucinations/agitation. Repeat dose in 30 min if not effective. The plan of care for the benefit period from 07/09/2025 to 10/06/2025 were reviewed and found to include the identified problems of assessing the effectiveness of pain control/comfort measures, the need for skilled teaching regarding pain, and anxiety/agitation. The identified goals for pain management at an acceptable level for the patient included understanding pain management measures and the need to report pain changes to hospice, as well as verbalizing and demonstrating appropriate measures to minimize/control the patient’s anxiety and agitation. However, these goals were not measurable or patient specific. A joint clinical review and interview with the Administrator/RN and the Director of Operations on October 30, 2025, confirmed that the patients’ plans of care did not include interventions and goals that were patient-specific and measurable for identified problems.”

“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. 2 of 3 (67%) applicable clinical records reviewed revealed that the agency did not ensure a bereavement plan of care was documented for the bereaved upon the patient’s death. CLINICAL RECORD 17: The patient elected the hospice benefit on 01/24/2025 and died on hospice services on 07/06/2025. The Registered Nurse assessed the post-death risk level as low during the pronouncement visit on 07/06/2025. No bereavement plan of care was documented in the clnical record or in paper documentation. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/25/2025 and died on hospice services on 03/25/2025. The Registered Nurse assessed the post-death risk level as low during the pronouncement visit on 03/25/2025. No bereavement plan of care was documented in the clnical record or in paper documentation. During a review of the bereavement program documentation and an interview with the Bereavement Coordinator (BC - Personnel Record 6) on 10/30/2025, it was revealed that the BC kept the bereavement documentation on paper. While bereavement activities were documented on paper for the bereaved in Clinical Records 17 and 19, no bereavement plans of care were developed.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed a competency evaluation program. The competency evaluation addresses each of the following subject areas by observation of an aide’s performance with a patient or pseudo-patient, including appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) hospice aide personnel files reviewed revealed the agency did not document utilization of a patient or pseudo-patient when evaluating the aide’s performance on all of the required subject areas. Agency policy, Competency Evaluation of Home Care Staff (D-220), stated in part, “All new employees will be assessed for competency based on the expected requirements for the position...Annual performance reviews will address competencies in areas of essential function...Home Health Aide Competency...Skills competency is evaluated by observing the aide with client or “pseudo” client (not a manikin). A Home Health Aide will not be permitted to provide Home Health Aide Services until evidence of adequate training and/or competency has been determined by the designated professional in the agency. The Home Health Aide must demonstrate evidence of...Successful completion of a competency evaluation program...The required topics are...Appropriate and safe techniques in personal hygiene and grooming, including (following all with asterisk) bed bath, sponge, tub or shower bath; shampoo in sink, tub, or bed; nail and skin care; oral hygiene; toileting and ambulation; safe transfer techniques and ambulation; normal range of motion and positioning...areas with an asterisk must be evaluated after observation of the Home Health Aide’s performance of the tasks with a client...” PERSONNEL RECORD 7: A review of the personnel record for the Hospice Aide hired on 03/25/2024 included the documents titled “Competency Evaluation Home Health Aide/Home Health Aide Skills Checklist” dated 3/25/2024. The following skills were marked as completed satisfactorily, however, there was no documentation that these skills were performed with a patient or pseudo-patient: bathing (shower with bench, tub bath, tub bath with bench, shower with bench), identify pressure points, positioning (side lying, prone, supine, use of trochanter rolls), mouth care (brush teeth, brush dentures, mouth care for unconscious client), hair care (comb/brush, shampoo, shampoo tray), shaving (electric razor, safety razor), nail care (clean/trim/file fingernails, soak, trim file toenails), Hoyer lift, or positioning to relieve pressure areas. The record also included forms titled “Competency Evaluation Home Health Aide/Home Health Aide Skills Checklist”, dated 03/18/2025. The following skills were marked as completed satisfactorily, however, there was no documentation that these skills were performed with a patient or pseudo-patient: identify pressure points, positioning (side lying, prone, supine, use of trochanter rolls), mouth care (brush dentures, mouth care for unconscious client), shaving (electric razor, safety razor), nail care (soak, trim file toenails), Hoyer lift, or positioning to relieve pressure areas. A joint personnel record review and interview with the Owner/RN and the Director of Operations on 10/28/2025 verified that not all required skills were documented as observed with a patient or pseudo-patient. A review of the regulations pertaining to the requirement for skills observation with a patient or pseudo-patient (L 615) was conducted jointly. No documentation was provided to support that the skills in question had been observed and recorded with a patient or pseudo-patient.”

“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. 4 of 16 (25%) applicable clinical records reviewed revealed that the agency did not ensure complete instructions were provided to the Hospice Aide by the Registered Nurse. CLINICAL RECORD 3: The patient, who resided at home, elected the hospice benefit on 07/11/2023. The plan of care for the benefit period from 08/29/2025 to 10/27/2025 included orders for the Hospice Aide (HA) to visit the patient twice a week. The HA care plan dated 09/29/2025, included interventions to be performed at every visit: bed bath, perineal care, catheter care, shampoo, hair care, oral care, shaving, skin care, and weekly nail care. The previous HA plan of care included shampooing, hair care, and shaving to be performed at each visit. During the Registered Nurse’s (RN) visit on 08/26/2025, she documented two stage 4 pressure wounds: coccyx wound and the left iliac crest wound. An updated physician’s order was documented on 09/02/2025 to cleanse wounds with wound cleanser daily, pack with Mesalt and Alginate, apply skin prep to wound edges, cover with Optilock dressings, and secure edges with hypafix tape. The HA plan of care did not include instructions to the HA about what to do should the patient’s wound dressing(s) become wet, loose, or soiled during delivery of care. CLINICAL RECORD 7: The patient, who resided at home, elected the hospice benefit on 09/15/2025. The plan of care for the benefit period from 09/15/2025 to 12/13/2025 included orders for the Hospice Aide (HA) to visit the patient twice a week. The HA care plan dated 09/15/2025 included interventions to be performed at every visit: bed bath, shampoo, hair care, and nail care. During the RN’s start of care (SOC) visit on 09/15/2025, she noted a stage 4 pressure wound to the patient’s coccyx. The patient was incontinent of bowel and bladder with a Foley catheter. On 09/19/2025, a physician’s order was documented to moisten gauze with Vashe, pack it into the wound, cover it with an Alginate dressing, place a Suprabsorb dressing, and cover it with a sacral foam dressing three times a week. CLINICAL RECORD 8: The patient, who resided at home, elected the hospice benefit on 06/27/2025. The plans of care for the benefit periods from 09/25/2025 to 12/23/2025 and 06/27/2025 to 09/24/2025 included orders for the Hospice Aide (HA) to visit the patient once a week. The HA care plans dated 06/30/2025 and 09/22/2025 included interventions to be performed at each visit: bed bath, perineal care, catheter care, skin care, hair care, and oral care. During the RN’s SOC visit on 06/27/2025, she noted the patient was incontinent of bowel and bladder with a Foley catheter. On 07/07/2025, a right buttock surgical wound with an onset date of 06/26/2025 was documented. A physician’s order dated 07/07/2025, directed wound care three times a week and as needed, to cleanse the right buttock wound with wound cleanser, pack the tunneling areas with a cleanser-soaked Kerlix, and cover with an ABD pad. The HA plan of care did not include instructions to the HA about what to do should the patient’s wound dressing become wet, loose, or soiled during delivery of care. CLINICAL RECORD 13: The patient, who resided in an assisted living facility (ALF), elected the hospice benefit on 01/29/2025 with the diagnosis of senile degeneration of the brain. The plan of care for the benefit period from 08/27/2025 to 10/25/2025 was reviewed and included orders for the Hospice Aide (HA) to visit the patient twice a week. The HA care plan, dated 01/29/2025, and active since admission, included the following interventions to be performed at every visit: standby assistance with ambulation, shower (a bed bath is acceptable if showering is unsafe), shampoo, hair care, skin care, perineal care, and oral care. During the Nurse Practitioner’s face-to-face visit on 08/29/2025, she noted that the patient was alert and oriented to self only but was unable to maintain a coherent conversation or express needs and was incontinent of bowel and bladder. During the Registered Nurse’s (RN) visit on 10/06/2025, a sacral stage 2 pressure wound was documented. A physician’s order for wound care twice a week and as needed was documented on the same day. The order specified cleansing the wound with Dakin’s solution, applying skin prep to the peri-wound area, covering with barrier cream, and using a bordered foam dressing. The HA plan of care did not include instructions to the HA about what to do should the patient’s wound dressing become wet, loose, or soiled during delivery of care. The HA plan of care included a choice of shower or bed bath for a dementia patient who resided in an ALF. The plan of care did not specify instructions to define “unsafe” in order for the HA to determine whether to provide a shower or bed bath. During a joint clinical record review and interview with the Administrator/RN (Personnel Record 2) on 10/30/2025, she confirmed the aide care plans did not provide instructions to the aide on wound/dressing management during care. She confirmed that the choice of a bath for a dementia patient in an ALF was outside the scope of an aide to determine.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 16 (6%) applicable clinical records reviewed revealed that the agency did not ensure that the Hospice Aide notified the Registered Nurse (RN) when the Hospice Aide’s plan of care was not followed. CLINICAL RECORD 2: The plans of care for 07/28/2025 to 09/25/2025 and 09/26/2025 to 11/24/2025 were reviewed and included orders for the Hospice Aide to provide care to the patient twice a week. The Hospice Aide (HA) care plans dated 05/20/2205 and 09/05/2025 included interventions to be performed every visit: bed bath, shampoo, hair care, skin care, perineal care, oral care, nail care, and catheter care. During the HA visit on 08/27/2025 the aide documented that the patient refused nail care. Then during the HA visit on 10/08/2025 noted the following incomplete interventions: bed bath patient refused; patient son bringing pt lunch; shampoo not completed; oral care not completed; patient about to eat food her son brought her; nail care not done. There was no documentation that the HA notified the RN regarding refused and incomplete hospice aide interventions. A joint clinical record review and interview with the Administrator (Personnel Record 2) on 10/30/2025, confirmed that not all interventions were marked as completed by the HA, and the HA did not document that the nurse was notified.”

“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. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 8) and the Director of Operations on 10/30/2025, it was determined that the average volunteer services percentage rate for 2024 and year-to-date for 2025 was less than 0.5% of the total patient care hours of all paid hospice employees and contract staff. There was no identified or active Volunteer Quality Assurance Performance Improvement Project for the percentage that falls below the required 5%. Documented recruitment activities included local churches, a local university and technical college, and going out with the hospice’s marketers. Retention activities for active volunteers consisted of one-on-one phone calls and text messages to keep them apprised of the agency’s activities and needs. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 8) and the Director of Operations on 10/30/2025, it was determined that the average volunteer percentage rate for 2024 and year to date for 2025 was less than 0.5% of the total patient care hours of all paid hospice employees and contract staff. There was no identified or active Volunteer QAPI Performance Improvement Project for the percentage that falls below the required 5%. Documented recruitment activities included local churches, going out with the hospice’s marketers, and a local university and technical college. With the active volunteers, retention activities consisted of one-on-one phone calls and text messages to keep them apprised of the agency’s activities and needs.”

“The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical records reviewed revealed that the agency did not identify whether the hospice, SNF/NF, or both were responsible for providing the patient’s needed care and services. CLINICAL RECORD 5: During the Registered Nurse’s (RN) Start of Care visit on 07/31/2025, the nurse noted that the patient coughed frequently with food and liquids, had a recent hospitalization for aspiration pneumonia, and had failed a swallow study while in the hospital. It was further noted that if the patient wished to consume food or fluids, he must be supervised and provided with suction. The initial plan of care for the benefit period from July 31, 2025, to October 28, 2025, included thickened liquids and bite-sized food only with supervision. The plan of care did not specify the care and services to be provided by the nursing facility or hospice. A joint clinical record review and interview with the Administrator/RN (Personnel Record 2) confirmed that there was no delineation of duties between the nursing facility and the hospice regarding care and services.”