Lilycare of New Mexico

“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; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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 observation. In 1 of 5 (20%) clinical records reviewed and home visits observed that the agency did not ensure that the comprehensive assessment included a drug profile that contained all of the patient’s current medications. HOME VISIT 1: The patient elected the hospice benefit on 03/05/2025. The patient resided in a skilled nursing facility. A home visit was conducted at a skilled nursing facility with a Registered Nurse (Personnel Record 1) on 08/04/2026. During the visit, the patient’s medication record at the facility was reviewed with the Registered Nurse. The patient’s facility medication record included “Naloxone 4mg/0.1ml nasal spray, give one spray in nostril as needed for signs of opioid overdose, dated 04/18/2026; and Glucagon 1mg injection, give intramuscularly as needed for blood sugar less than 70, dated 12/01/2025”. The agency’s medication profile from the most recent comprehensive assessment dated 07/28/2026 did not include Naloxone or Glucagon. During a joint record review and interview on 08/04/2026, the Administrator confirmed that the patient’s medication profile did not include Naloxone or Glucagon.”

“It is required that Hospice Aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a Hospice Aide are prepared by a RN who is responsible for the supervision of the Hospice Aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure that all written patient care instructions were included in the Hospice Aide care plan. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/06/2026. The plan of care dated 07/06/2026 through 10/03/2026 included orders that read in part “Oxygen 3 liters via nasal cannula as needed for shortness of breath...Seizure precautions”. The plan of care also ordered “hospice aide one time a week time one week, two times a week for 12 weeks (1wk1 and 2wk12)”. The hospice aide care plan dated 07/09/2026 did not include oxygen safety precautions or seizure precautions. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/21/2026. The plan of care dated 07/21/2026 through 10/18/2026 included orders that read in part “Oxygen 2-4 liters via nasal cannula as needed for shortness of breath...Seizure precautions”. The plan of care also ordered “hospice aide one time a week time one week, two times a week for 12 weeks (1wk1 and 2wk12)”. The hospice aide care plan dated 07/22/2026 did not include oxygen safety precautions or seizure precautions. During joint record reviews and interview on 08/03/2026, the Administrator confirmed that oxygen and seizure precautions were not included in the patient’s aide care plans.”

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by document review and interviews which revealed the agency: Failed to demonstrate that its Emergency Preparedness (EP) plan was reviewed and updated on a routine, ongoing basis. [HSEP.2. D/E4/418.113(a)]; Failed to ensure to demonstrate implementation of a comprehensive emergency preparedness testing program, including required exercises to evaluate and validate the effectiveness of the Emergency Preparedness (EP) plan {HSEP.5. D/E37/418.113(d)(1)}; and Failed to ensure that exercises were conducted to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years {HSEP.6.I/E39/ 418.113(d)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation, CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews which revealed issues with the organization’s QAPI program in the following areas: Failed to ensure the data collected monitored the effectiveness and safety of services and quality of care{HQPI.5.I/L564/ 418.58(b)(2)(i)};Failed to ensure that the Governing Body defined, approve or direct the frequency or detail for ongoing QAPI data collection{HQPI.1.D/L565/418.58(b)(3)}; Failed to ensure to track select occurrence data such as falls, infections, medication errors, and incidents, there was no evidence that this information was analyzed, trended, benchmarked, or used to drive targeted performance improvement projects{HQPI.7.I/L569/ 418.58(c)(2)}; and Failed to ensure to demonstrate that the Governing Body maintained ongoing and effective oversight of the hospice’s Quality Assessment and Performance Improvement (QAPI) and patient safety program, limiting accountability for the quality and safety of care provided {HQPI.1. D/L574/ 418.58(e)(1)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.58: Quality assessment and performance improvement. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met, as shown by reviews of documents, personnel records, clinical records, and interviews, which revealed problems with the governing body’s oversight regarding the organization, management, and administration of resources necessary to provide hospice care and services in the following areas: Failed to ensure that the Governing Body assumed responsibility for the agency’s management and ongoing operations including meeting documentation{HSLG.4.I/L650/418.100(a)}; Failed to ensure that the documentation included administrative leadership changes, including the promotion of the Administrator to Regional Director of Clinical Operations in March 2025, there was no formal record documenting Governing Body approval or appointment to this role at the time of the change {HSLG.3.I/L651/418.100(b)}; and Failed to ensure that the skills and competencies of all individuals providing care were assessed including volunteers {HSRM.14. I/L663/ 418.100(g)(3)}; The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice develop and maintain an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview that revealed the hospice did not ensure to demonstrate that its Emergency Preparedness (EP) plan was reviewed and updated on a routine, ongoing basis. A review of the agency’s EP program documentation, in conjunction with an interviews conducted on 06/25/2026 with the Regional Director of Clinical Operations (RDCO)/ Administrator (Personnel Record 2) and 06/26/2026 with the (RDCO)/ Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO) revealed no evidence of documentation that the EP plan had been reviewed, evaluated, or updated for 2024 and 2025. Evidence was provided of a single documented review of the EP plan for 2026. Based on document review and staff interviews, the hospice did not demonstrate that its Emergency Preparedness (EP) plan was reviewed and updated on a routine, ongoing basis. A review of the agency’s EP program documentation, in conjunction with an interviews conducted on 06/25/2026 with the Regional Director of Clinical Operations (RDCO)/ Administrator (Personnel Record 2) and 06/26/2026 with the (RDCO)/ Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO) identified that the hospice was only able to provide evidence of a single documented review of the Emergency Preparedness plan within a three (3) year period, occurring on 06/23/2026, immediately prior to the survey. No additional documentation was available to demonstrate that the EP plan had been reviewed, evaluated, or updated at least every two (2) years, or more frequently as needed based on changes in operations, risks, or identified gaps. The Administrator confirmed that routine, scheduled reviews of the EP plan had not been consistently implemented.”

“It is required that the hospice providing care in the patient’s home conduct annual exercises to test the emergency preparedness plan, including participation in a community-based full-scale exercise every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. An additional exercise must be conducted every two (2) years, except in the year a full-scale or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise; a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview which revealed the hospice did not ensure to demonstrate implementation of a comprehensive emergency preparedness testing program, including required exercises to evaluate and validate the effectiveness of the Emergency Preparedness (EP) plan. A review of the agency’s EP program documentation, in conjunction with interviews conducted on 06/25/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO), identified that the hospice conducted one documented table-top exercise during the review period, which occurred on 06/23/2026 and addressed a community mass shooting scenario. There was no additional documentation demonstrating that the hospice activated its EP plan in response to an actual emergency event, participated in a community-based, multi-agency exercise, or conducted a second required exercise (table-top or full-scale) for the years 2024 and 2025.”

“It is required that the hospice providing care in the patient’s home conduct annual exercises to test the emergency preparedness plan, including participation in a community-based full-scale exercise every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. An additional exercise must be conducted every two (2) years, except in the year a full-scale or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise; a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview which revealed the hospice did not ensure exercises were conducted to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. A review of the agency’s EP program documentation, in conjunction with interviews conducted on 06/25/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO), identified that the hospice conducted only one documented table-top exercise during the review period, which occurred on 06/23/2026 and addressed a community mass shooting scenario. There was no additional documentation demonstrating that the hospice activated its EP plan in response to an actual emergency event, participated in a community-based, multi-agency exercise, or conducted a second required exercise (table-top or full-scale) within the review period from the previous comprehensive (initial) site visit (05/25/2023) through the week of the current first renewal survey (06/24/2026–06/26/2026) until the single exercise completed immediately prior to survey activity. Based on document review and staff interviews, the hospice did not demonstrate implementation of a comprehensive emergency preparedness testing program, including required exercises to evaluate and validate the effectiveness of the Emergency Preparedness (EP) plan. A review of the agency’s EP program documentation, in conjunction with interviews conducted on 06/25/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO), identified that the hospice conducted only one documented table-top exercise during the review period, which occurred on 06/23/2026 and addressed a community mass shooting scenario. There was no additional documentation demonstrating that the hospice activated its EP plan in response to an actual emergency event, participated in a community-based, multi-agency exercise, or conducted a second required exercise (table-top or full-scale) within the review period from the previous comprehensive (initial) site visit (05/25/2023) through the week of the current first renewal survey (06/24/2026–06/26/2026) until the single exercise completed immediately prior to survey activity. The absence of a consistent and comprehensive testing program limits the hospice’s ability to evaluate the effectiveness of its emergency plan, identify gaps in response processes, and ensure staff competency in emergency roles and responsibilities. Without regular participation in exercises, the agency may not be adequately prepared to respond to disasters or emergencies that impact patient care.”

“It is required that the written Patient Bill of Rights must include the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal. This standard was not met as evidenced by document review and interview which revealed the review of the hospice’s admission material did not identify the Community Health Accreditation Partner (CHAP) as the agency’s accrediting organization. Additionally, no information was provided to patients or families on how to contact CHAP or file a grievance or complaint directly with the accrediting body. During an interview conducted on 06/26/2026, the Chief Operating Officer/Chief Compliance Officer confirmed that the admission materials did not include CHAP-specific contact information or instructions for reporting external complaints. A review of the hospice’s admission materials revealed that while the Patient Bill of Rights was included in the admission book, the document did not identify the Community Health Accreditation Partner (CHAP) as the agency’s accrediting organization. Additionally, no information was provided to patients or families on how to contact CHAP or file a grievance or complaint directly with the accrediting body. During an interview conducted on 06/26/2026, the Chief Operating Officer/Chief Compliance Officer confirmed that the admission materials did not include CHAP-specific contact information or instructions for reporting external complaints. The absence of this information limits patients’ and families’ awareness of all available avenues for expressing concerns, seeking resolution, or reporting grievances outside the agency.”

“It is required that each patient’s individualized written plan of care reflect the patient and family goals and include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure that the patient’s plan of care reflected patient and family goals and included measurable outcome. CLINICAL RECORD 1: The patient, who resided in a nursing facility, elected the hospice benefit on 03/05/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and a comorbid condition of Alzheimer’s. The physician’s certification of terminal illness for the benefit period 04/29/2026 to 06/27/2026 documented progressive respiratory compromise requiring continuous oxygen up to six (6) LPM (liters per minute) via nasal cannula to maintain oxygen saturation above 90%, dyspnea at rest and with minimal exertion, and functional decline including increased assistance with feeding due to aspiration risk. Cognitive status was noted as oriented to self only, with ongoing hallucinations attributed to dementia-related delirium that intensified at night. Nursing documentation dated 06/15/2026 corroborated significant oxygenation instability, noting oxygen saturation of 93% on 3 LPM with a decline to 80% within five (5) minutes on room air, accompanied by shortness of breath at rest, during minimal activity, and even while speaking. For the identified problem of shortness of breath, the POC included the following goals: medication compliance, caregiver understanding of oxygen therapy and safety, and participation in activities as tolerated. The POC include patient-specific, measurable outcomes to objectively evaluate symptom control. CLINICAL RECORD 2: The patient who resided at home, elected the hospice benefit on 07/08/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and a comorbid condition of heart disease. A review of the patient’s plan of care (POC) for the benefit period 04/29/2026 to 06/27/2026 identified an altered respiratory status. The POC included the following goals: caregiver education on oxygen therapy, including safe use, setup, and indications for administration. The POC did not include individualized, patient-centered, and measurable goals to address the patient’s documented dyspnea. CLINICAL RECORD 6: The patient, who resided in a nursing facility, elected the hospice benefit on 05/22/2026 with a terminal diagnosis of alcoholic cirrhosis of the liver with ascites and secondary conditions including esophageal varices (without bleeding) and hepatic encephalopathy. During the admission nursing visit on 05/22/2026, the patient demonstrated significant clinical compromise, including an oxygen saturation of 90% while receiving six (6) liters per minute (LPM) of oxygen via nasal cannula continuously. The patient exhibited dyspnea with minimal exertion, assigning a dyspnea severity score of 6/10 and identifying a personal goal of 4/10. The patient reported persistent pain described as aching, dull, and tender in the neck and back, which interfered with sleep, appetite, mobility, concentration, and participation in activities. Clinical documentation during the Interdisciplinary Group (IDG) meeting on 05/26/2026 reflected progressive decline, with increasing weakness, continuous oxygen requirements at 6 LPM, and worsening pain. Nursing documentation on 06/23/2026 further identified escalation in symptom burden, with pain rated at 6/10 at the time of assessment and reaching as high as 9/10 within the previous 24 hours. The patient described ongoing constant, throbbing back pain and expressed a revised pain goal of 5/10. A review of the patient’s POC for the benefit period 05/22/2026 to 07/20/2026 identified problems including pain management, altered respiratory status, and overall decline. The POC included the following goals: included generalized goals such as improvement of objective signs and symptoms of pain, caregiver understanding of oxygen therapy, and a peaceful transition with symptoms managed. These goals did not incorporate the patient’s documented, self-identified targets for symptom relief, including a dyspnea goal of 4/10 and a pain goal of 5/10. During a joint clinical record review and interview conducted on 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Clinical Director (CD) (Personnel Record 3), both individuals acknowledged that the goals documented within the patient records reflected standardized selections generated by the electronic medical record (EMR) system. They confirmed that these goals lacked individualized, patient-specific detail, measurable criteria, and clearly defined treatment objectives. CLINICAL RECORD 14: The patient elected hospice services on 06/25/2025 with primary and secondary diagnoses including unspecified sequelae of cerebral infarction, hemiplegia status post cerebrovascular accident (CVA), chronic respiratory failure with hypoxia, COPD, dysphagia, seizures, ataxia, and malnutrition. Review of the clinical record identified significant and progressive clinical decline during the benefit period 09/23/2025 to 11/01/2025, including a decrease in Palliative Performance Scale (PPS) from 40% on 10/22/2025 to 20% on 10/28/2025, escalating oxygen requirements, worsening respiratory distress, aspiration risk, and increased symptom burden including pain, anxiety, restlessness, and neurologic changes. Nursing documentation on 10/21/2025 described acute respiratory changes. Oxygen requirements increased to 3 LPM (liters per minute), and pharmacologic interventions were initiated. The plan of care (POC) was not revised to reflect updated goals of care, measurable symptom-management targets, or defined comfort-focused outcomes related to the patient’s acute respiratory compromise. Documentation on 10/28/2025 and 10/29/2025 demonstrated continued deterioration, including tachypnea, abnormal respiratory rhythm, agitation, worsening anxiety (reported at 8/10 with a goal of 2/10), neurologic changes such as slurred speech and confusion, and increased pain (up to 7/10). Orders were updated to include escalation of comfort medications, including Morphine and Lorazepam; however, the POC did not incorporate these changes with corresponding measurable goals or revised interventions to guide symptom management. Interdisciplinary Group Meeting (IDG) documentation on 10/29/2025 acknowledged progressive decline, dysphagia with frequent choking, aspiration pneumonia with only partial improvement, and ongoing respiratory distress, with nursing goals limited to general monitoring of symptoms. There was no evidence of POC revisions to address the patient’s worsening respiratory failure, increased aspiration risk, or escalating symptom intensity.”

“It is required that the hospice must use the data collected to monitor the effectiveness and safety of services and quality of care. This standard was not met as evidenced by document review and interview that revealed the hospice did not ensure the data collected monitored the effectiveness and safety of services and quality of care. The documentation dated 04/03/2024 reported 39 falls and 7 infections, with interventions limited to continued education on fall prevention. QAPI reports throughout 2024 and 2025 reflected continued tracking of incidents without correlation to patient assessment findings. A review of the hospice’s QAPI program documentation, including quarterly reports, performance data, and Performance Improvement Projects (PIPs), in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified that the agency collected occurrence-based data—such as infections, medication errors, falls/incidents, and complaints. There was no documented evidence that the data collected was used to monitor the effectiveness and safety of services and quality of care. Based on document review and staff interviews, the hospice did not demonstrate that information from patient assessments was consistently used to identify, prioritize, and implement performance improvement activities, thereby limiting the effectiveness of the Quality Assessment and Performance Improvement (QAPI) program in addressing patient care needs. A review of the hospice’s QAPI program documentation, including quarterly reports, performance data, and Performance Improvement Projects (PIPs), in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified that while the agency collected occurrence-based data—such as infections, medication errors, falls/incidents, and complaints—there was no consistent evidence that patient-specific assessment data or interdisciplinary findings were analyzed or incorporated into performance improvement efforts. For example, documentation dated 04/03/2024 reported 39 falls and 7 infections, with interventions limited to continued education on fall prevention despite increasing fall rates; however, there was no evidence that underlying patient-level factors (e.g., fall risk assessments, functional status, medication profiles, or care plan effectiveness) were evaluated to inform targeted or individualized interventions. Similarly, subsequent QAPI reports throughout 2024 and 2025 reflected continued tracking of incidents without correlation to patient assessment findings or demonstration of care process modifications based on identified clinical trends. Although select PIPs were initiated—such as the project dated 02/22/2024 addressing continuity of care during live discharge and additional projects in 2025 related to medication errors and personnel practices—these activities were primarily reactive and event-driven. Documentation did not demonstrate that broader patient assessment data, including symptom burden, functional decline, or psychosocial needs, were systematically analyzed to proactively identify opportunities for improvement. Additionally, references to “100% patient chart audits” and “top 10” audit elements lacked supporting data analysis, defined metrics, or linkage to patient outcomes. QAPI meeting documentation did not reflect interdisciplinary integration of patient assessment data or evidence of trend analysis used to drive performance priorities. The absence of a structured process to incorporate patient assessment data into QAPI activities limits the hospice’s ability to identify clinically relevant trends, tailor interventions, and evaluate the effectiveness of care delivery.”

“The hospice governing body is responsible for ensuring and approving that the QAPI program includes defined data details and frequency of collection. This standard was not met as evidenced by document review and interview which revealed the Governing Body did not define, approve, or direct the frequency or detail for ongoing QAPI data collection. The agency policy “Governing Body (LD.15)” (09/01/2024) stated in relevant parts that the Governing Body is responsible for approving the frequency and detail of QAPI data collection. A review of the agency’s QAPI program documentation and Governing Body records, along with interviews conducted on 06/24/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified evidence of Governing Body involvement in QAPI activities was limited to meeting minutes dated 06/23/2026, which referenced a retrospective review of all quarters of 2025. The documentation noted that “no changes” were identified and that administration would continue to monitor and report issues; however, there was no indication that the Governing Body defined, approved, or directed the frequency or detail for ongoing QAPI data collection. The agency was unable to provide Governing Body records, including meeting minutes or formal reports for 2024. A review of the agency’s QAPI program documentation and Governing Body records, along with interviews conducted on 06/24/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified that the only evidence of Governing Body involvement in QAPI activities was limited to meeting minutes dated 06/23/2026, which referenced a retrospective review of all quarters of 2025. The documentation noted that “no changes” were identified and that administration would continue to monitor and report issues; however, there was no indication that the Governing Body defined, approved, or directed the frequency or level of detail for ongoing QAPI data collection. Further review of agency policy “Governing Body (LD.15)” (09/01/2024) established that the Governing Body is responsible for approving the frequency and detail of QAPI data collection. Despite this requirement, there was no documented evidence of any Governing Body meeting minutes or records that such approval occurred or that expectations for data collection were formally established during the period reviewed 05/24/2023 (after the last comprehensive survey) through 06/23/2026 (the meeting minutes provided). The absence of Governing Body approval and direction regarding the frequency and detail of QAPI data collection limits the hospice’s ability to ensure consistent, meaningful evaluation of performance indicators. Without clearly defined expectations, data collection may be inconsistent, incomplete, or not aligned with organizational priorities, reducing the effectiveness of the QAPI program.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. A review of the hospice’s Quality Assessment and Performance Improvement (QAPI) program documentation, including meeting minutes and performance data, in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer, revealed the agency did not ensure to track select occurrence data such as falls, infections, medication errors, and incidents, there was no evidence that this information was analyzed, trended, benchmarked, or used to drive targeted performance improvement projects. There was no evidence that QAPI data were used to inform and guide ongoing staff education and development. A review of the hospice’s Quality Assessment and Performance Improvement (QAPI) program documentation, including meeting minutes and performance data, in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer, identified that the agency did not demonstrate a QAPI program that appropriately prioritized and focused on indicators related to improved palliative care outcomes and hospice services. The data collected and presented through QAPI activities did not reflect a comprehensive approach to potential problem-prone areas of patient care. While the agency tracked select occurrence data such as falls, infections, medication errors, and incidents, there was no evidence that this information was analyzed, trended, benchmarked, or used to drive targeted performance improvement projects. Repeated references to ongoing issues, including falls and adverse events, did not result in meaningful changes to interventions or demonstrate changes in care approaches related to concerns, despite documented worsening or persistent trends. Further, the QAPI program did not demonstrate a focus on palliative outcomes, including pain and symptom management, effectiveness of interventions, patient and family satisfaction, or timeliness and coordination of care. There was also no evidence that the agency analyzed on-call service trends, evaluated after-hours care needs, evaluated complaints, or assessed the impact of these on patient outcomes and continuity of care. Additionally, documentation did not reflect consistent interdisciplinary participation to ensure a comprehensive evaluation of patient care from multiple clinical perspectives. The agency also did not demonstrate that QAPI data were used to inform and guide ongoing staff education and development. Education efforts were referenced; however, these appeared generalized and not clearly linked to identified trends, measured outcomes, or demonstrated improvement in care practices.”

“It is required that the hospice’s governing body assume full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview that revealed the hospice did not ensure to demonstrate that the Governing Body maintained ongoing and effective oversight of the hospice’s Quality Assessment and Performance Improvement (QAPI) and patient safety program, limiting accountability for the quality and safety of care provided. A review of Governing Body documentation, in conjunction with interviews conducted on 06/24/2026 with the Regional Director of Clinical Operations (RDCO)Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified that evidence of Governing Body oversight related to QAPI and patient safety activities was limited to the meeting minutes dated 06/23/2026. These minutes reflected a retrospective annual review of QAPI activities for 2025, noting “no changes” and indicating that administration would continue to monitor and report issues to leadership. While multiple operational areas were discussed (e.g., contracts, staffing, policies, and program review), there was no documented evidence of active, ongoing oversight of QAPI data, patient safety indicators, or performance improvement outcomes over time. The agency was unable to provide Governing Body records, including meeting minutes or formal reports for 2024. Based on document review and staff interviews, the hospice did not demonstrate that the Governing Body maintained ongoing and effective oversight of the hospice’s Quality Assessment and Performance Improvement (QAPI) and patient safety program, limiting accountability for the quality and safety of care provided. A review of Governing Body documentation, in conjunction with interviews conducted on 06/24/2026 with the Regional Director of Clinical Operations (RDCO)Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified that evidence of Governing Body oversight related to QAPI and patient safety activities was limited to a single set of meeting minutes dated 06/23/2026, immediately preceding the current survey. These minutes reflected a retrospective annual review of QAPI activities for 2025, noting “no changes” and indicating that administration would continue to monitor and report issues to leadership. While multiple operational areas were discussed (e.g., contracts, staffing, policies, and program review), there was no documented evidence of active, ongoing oversight of QAPI data, patient safety indicators, or performance improvement outcomes over time. Additionally, the agency was unable to provide Governing Body records, including meeting minutes or formal reports, from the conclusion of the previous comprehensive survey (05/25/2023) through 06/23/2026, demonstrating sustained engagement in overseeing quality and safety processes. The absence of consistent Governing Body oversight of QAPI and patient safety activities limits the organization’s ability to ensure that quality concerns are identified, monitored, and addressed in a timely and systematic manner.”

“It is required that the hospice follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation revealed during a tour and inspection of the agency’s supply room on 06/25/2026, the medication refrigerator contained an open vial of Tuberculin Purified Protein Derivative (PPD), Diluted, labeled with a handwritten date of 02/24/2026. There was no indication whether this date represented the date opened or an expiration date. According to manufacturer guidance (FDA DailyMed labeling), once opened, tuberculin PPD must be discarded after thirty (30) days to ensure potency and sterility. A review of the temperature monitoring logs maintained in a binder located on top of the refrigerator revealed that the last documented temperature check occurred on 09/06/2024, with no subsequent entries. The Administrator confirmed that the vial had been opened and verified the date 02/24/2026. The vial was discarded at the time of the survey. A joint review of the temperature logs with the Administrator further confirmed the absence of ongoing documentation after 09/06/2024 and acknowledged that no clearly designated individual was responsible for routine temperature monitoring and oversight. During a tour and inspection of the agency’s supply room on 06/25/2026, the medication refrigerator contained an open vial of Tuberculin Purified Protein Derivative (PPD), Diluted, labeled with a handwritten date of 02/24/2026. There was no indication whether this date represented the date opened or an expiration date. According to manufacturer guidance (FDA DailyMed labeling), once opened, tuberculin PPD must be discarded after thirty (30) days to ensure potency and sterility. The presence of this vial beyond the allowable use period indicated that proper dating, monitoring, and disposal practices were not consistently followed. Additionally, a review of the temperature monitoring logs maintained in a binder located on top of the refrigerator revealed that the last documented temperature check occurred on 09/06/2024, with no subsequent entries. This gap of more than 1 year without documented monitoring indicates that the refrigerator temperature was not routinely assessed to ensure medications were stored within the required parameters. These findings were immediately brought to the Administrator’s attention, who confirmed that the vial had been opened and verified the date 02/24/2026. The vial was discarded at the time of the survey. A joint review of the temperature logs with the Administrator further confirmed the absence of ongoing documentation after 09/06/2024, and acknowledged that no clearly designated individual was responsible for routine temperature monitoring and oversight. The lack of consistent medication dating, timely disposal of opened multidose vials, and routine temperature monitoring compromises medication safety and effectiveness.”

“It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This standard was not met as evidenced by document review and interview which revealed, the hospice did not demonstrate implementation of a comprehensive infection control surveillance process that included tracking, analysis, and correlation of employee infections with patient infections. A review of the Quality Assessment and Performance Improvement (QAPI) Program and Infection Tracking documentation, in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer, revealed no documented tracking of work-related employee infections. Leadership acknowledged that this component of infection surveillance had not been incorporated into the agency’s infection control surveillance. Based on document review and staff interview, the hospice did not demonstrate implementation of a comprehensive infection control surveillance process that included tracking, analysis, and correlation of employee infections with patient infections, limiting the agency’s ability to identify trends and mitigate transmission risks. A review of the Quality Assessment and Performance Improvement (QAPI) Program and Infection Tracking documentation, in conjunction with interviews conducted on 06/24/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer, revealed no documented tracking of work-related employee infections. Additionally, there was no evidence of analysis evaluating potential relationships between employee infections and patient infections. Leadership acknowledged that this component of infection surveillance had not been incorporated into the agency’s current QAPI activities. The absence of a structured process to monitor and analyze employee infections in relation to patient infections limits the organization’s ability to identify potential sources of transmission, detect patterns or outbreaks, and implement timely infection prevention interventions.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed a competency evaluations that addresses each of the following subject areas by observation of an aide’s performance with a patient or pseudo-patient, including communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including bed bath, sponge, tub and shower bath, hair shampoo (skin, tub, and bed), nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) hospice aide’s personnel records reviewed revealed that the agency did not ensure that there was a documented observed competence of the hospice aide by the Registered Nurse (RN) upon hire and annually. HOSPICE POLICY: The hospice policy “Hospice Aide/Homemaker Competency Evaluation (HR.45)” dated 09/01/2024 read in part that “The hospice will ensure that each hospice aide successfully completes a hospice aide skills and competency evaluation...prior to the aide performing care independently. The competency evaluation must be performed by a registered nurse (RN)...The competency evaluation and skills checklist will be administered by an RN...and will be scheduled during the orientation period. The RN will document observation of skills as required and will sign and date the completed checklist. The following subject areas must be evaluated by observing an aide’s performance of the task with a patient...communication...reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including: bed bath, sponge, tub, and shower bath; hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; normal range of motion and positioning; and safety transfer techniques and ambulation...any other task that the hospice may choose to have an aide perform as permitted under state law...The hospice will maintain documentation that demonstrates competency requirements are met...a record that indicates which skills the aide was judged to be competent...The completed competency evaluations will be kept in the employee’s personnel file and may be administered annually as a skills...checklist...” HOSPICE POLICY: The agency’s policy entitled “Staff Competency (HR.10)” and dated 11/15/2024 included in part that “...The hospice will establish the competency criteria for each job classification. The criteria will be listed on the competency evaluation checklist...The hospice may be determining initial and ongoing competency in a variety of ways such as...At least annually on site in a patient’s home for all hospice aides...” PERSONNEL RECORD 8: A review of the personnel record for the hospice aide who was hired on 09/05/2024 revealed an incomplete Initial Hospice Aide - Skills Competency Checklist (Determined by Direct Observation of the Aide) dated 09/10/2024 that included the observation of the HA performing the following skills satisfactorily: measuring the patient’s oral temperature, pulse, respirations, and blood pressure; providing a tub bath, tub shampoo, nail/skin care, oral hygiene, toileting/elimination, safe transfer technique/ambulation, and normal ROM/positioning. Bed bath, sponge bath, shower, sink shampoo, and bed bath shampoo were not observed and deemed competent. There was no documented evidence of an annual aide competency for 2025. After a joint personnel record review and interview with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2), the Clinical Director (Personnel Record 3), and the Business Office Manager (BOM) on 06/26/2026, the missing competency was confirmed, and no documentation of the missing competency could be produced prior to the end of the site visit. The RDCO acknowledged that the agency needed to revise its onboarding and ongoing compliance processes for personnel record completion, documentation, and oversight.”

“It is required that the hospice documents and provide hospice volunteer orientation and training that is consistent with hospice industry standards. It includes hospice goals, services, and philosophy; family dynamics and psychological issues surrounding terminal illness, death, and bereavement; and procedures to be followed in an emergency and/or following the death of a patient; This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) volunteer personnel records reviewed revealed that the agency did not ensure that there was documentation of the hospice providing a volunteer orientation upon hire. HOSPICE POLICY: The hospice’s policy “Employee Orientation (HR.40)” dated 05/12/2025 read in part that “...The hospice will provide orientation about the philosophy of hospice to all employees, including volunteers...who have patient and family contact. The hospice will orient each employee...to their respective job responsibilities...prior to performing job duties independently...The hospice orientation will include, but not be limited to... patient and business ethics...Safety/OSHA: Exposure Control Plan and the Infection Control Program, Respiratory Protection Program, Emergency Preparedness and Response, Safety and Workplace Violence Prevention Program, Hazardous Materials/Waste, and the Hazard Communication Program...Patient care policies and procedures, including but not limited to Patient rights and responsibilities, Advance Directives, Abuse, Neglect, and Exploitation, Patient Care issues...” PERSONNEL RECORD 9: A review of the personnel record for the volunteer who was hired on 12/10/2025 revealed there was no documented evidence of volunteer orientation or training upon hire. During a joint personnel record review and interview with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2), the RDCO explained that the volunteer had not been working; however, was listed as an active volunteer on the employee list provided.”

“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 on 06/25/2026 with the Social Worker/Volunteer Coordinator (Personnel Record 5) and the Administrator (Personnel Record 2) identified that the organization did not meet the requirement for hospice volunteers to provide administrative or patient care services in the amount of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The data provided indicated that volunteers contributed an average of 0.77% of total patient care hours among all paid hospice employees and contract staff in 2025. No documentation was available to substantiate volunteer service hours for 2024 or year-to-date for 2026. During the interview, the Social Worker/Volunteer Coordinator confirmed limited prior experience in hospice care and indicated that this role represents her first involvement in a hospice setting, having previously worked in long-term care. Although recruitment and retention activities were documented for 2025 and for 01/2026–02/2026, the Administrator acknowledged a lapse in program oversight associated with the staffing transition. A review of the agency’s Volunteer Program documentation, along with interviews conducted on 06/25/2026 with the Social Worker/Volunteer Coordinator (Personnel Record 5) and the Administrator (Personnel Record 2), identified that the organization did not meet the requirement for hospice volunteers to provide administrative or patient care services in the amount of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The data provided indicated that volunteers contributed an average of 0.77% of total patient care hours among all paid hospice employees and contract staff in 2025. No documentation was available to substantiate volunteer service hours for 2024 or year-to-date for 2026, limiting the agency’s ability to demonstrate or evaluate volunteer utilization requirements over time. Further inquiry revealed that continuity and oversight of the Volunteer Program were disrupted by staffing changes. The previous Volunteer Coordinator, who served in a part-time capacity, separated from the organization abruptly in 02/2026 due to a family matter, prior to transitioning responsibilities or providing program orientation to the current Social Worker/Volunteer Coordinator, who began employment on 02/02/2026. During the interview, the Social Worker/Volunteer Coordinator confirmed limited prior experience in hospice care and indicated that this role represents her first involvement in a hospice setting, having previously worked in long-term care. Although recruitment and retention activities were documented for 2025 and for 01/2026–02/2026, the Administrator acknowledged a lapse in program oversight associated with the staffing transition.”

“It is required that the management and governing body (or designated persons so functioning) of the hospice is responsible for providing care that optimizes comfort and dignity and is consistent with patient and family needs and goals, with the patient’s needs and goals as priority. This standard was not met as evidenced by document review and interview which revealed, the hospice did not ensure that the Governing Body assumed responsibility for the agency’s management and ongoing operations including meeting documentation. A review of the Governing Body meeting minutes dated 06/23/2026 identified that multiple administrative and operational elements were discussed—including annual program review, QAPI activities, policy review, contracts, staffing, and agency evaluation The documentation did not provide evidence as to how the activities ensured that care optimized patient comfort and dignity or aligned with individualized patient and family needs and goals. There was no documentation of Governing Body minutes for 2024 and 2025. During interviews conducted on 06/24/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO), both acknowledged that Governing Body meeting documentation was not available for the years 2024 and 2025. Based on document review and staff interviews, the hospice did not demonstrate that the Governing Body actively assumed responsibility for the agency’s management and ongoing operations, including meeting documentation, formal appointment of an administrator, and sustained oversight of organizational activities. During interviews conducted on 06/24/2026 and 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Chief Operating Officer (COO)/Chief Compliance Officer (CCO), both acknowledged that Governing Body meeting documentation was not available for review for prior periods, and the only documentation provided was a Governing Body meeting agenda and minutes dated 06/23/2026, immediately preceding the survey, which reflected a retrospective review of operational topics, including QAPI, contracts, staffing, and annual evaluation activities. While the minutes referenced leadership changes, including the promotion of the current Administrator in March 2025, there was no documented evidence that this appointment was formally reviewed or approved by the Governing Body at the time of the transition. A review of the Governing Body meeting minutes dated 06/23/2026 identified that while multiple administrative and operational elements were discussed—including annual program review, QAPI activities, policy review, contracts, staffing, and agency evaluation—the documentation did not clearly demonstrate how these activities translated into ensuring care that optimizes patient comfort and dignity or aligns with individualized patient and family needs and goals. There was inclusion of the plan to develop key performance indicators. Overall, the documentation from 06/23/2026 reflects an administrative and compliance-focused review rather than a patient-centered governance process. There was no clear evidence that the Governing Body evaluated whether hospice services were consistently delivered in a manner that promotes comfort, preserves dignity, and aligns care with the expressed goals and needs of patients and their families. This lack of explicit focus on patient-centered outcomes in governance oversight limits the organization’s ability to ensure that operational and quality initiatives are meaningfully directed toward improving the lived experience and end-of-life care for hospice patients. Furthermore, there was no documentation demonstrating that the Governing Body maintained ongoing oversight or actively assumed responsibility for hospice operations during the period reviewed prior to the 06/23/2026 meeting minutes. The agency also reported that prior records were unavailable due to the potential destruction of documents by a former administrator; therefore, no subsequent/alternate documentation was provided to substantiate Governing Body engagement or oversight. The absence of consistent Governing Body involvement, formal leadership appointment processes, and documented operational oversight limits the organization’s ability to ensure clear accountability, effective management, and continuity of leadership. Without active governance, there is an increased risk of gaps in organizational direction, inconsistent implementation of policies and procedures, and reduced ability to respond to operational and clinical issues. This lack of oversight may negatively affect the coordination, quality, and safety of hospice services for patients and their families.”

“It is required that a qualified administrator be appointed by the governing body, report to it, and be responsible for the day-to-day hospice operations. The hospice administrator informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities. This standard was not met as evidenced by document review and interview. The Governing Body meeting agenda and minutes dated 06/23/2026 include a review of operational activities, including QAPI, contracts, staffing, and annual evaluation. The organization did not ensure that the documentation included administrative leadership changes, including the promotion of the Administrator to Regional Director of Clinical Operations in March 2025, there was no formal record documenting Governing Body approval or appointment to this role at the time of the change. Based on document review and staff interviews, the hospice did not demonstrate that the Governing Body maintained formal meeting documentation or evidence of its appointment and oversight of the hospice administrator, limiting accountability and governance structure necessary to ensure effective leadership of hospice operations. A review of Governing Body records, in conjunction with interviews conducted on 06/24/2026 and 06/26/2026 with the Administrator (Personnel Record 2) and the Chief Operating Officer/Chief Compliance Officer (COO/CCO), identified the absence of Governing Body meeting minutes or formal documentation from 05/25/2023, or for the years 2024 and 2025. As a result, there was no evidence to support that the Governing Body formally appointed or maintained documented oversight of the hospice administrator during this period. The only available documentation was a Governing Body meeting agenda and minutes dated 06/23/2026, immediately prior to the current survey, which reflected review of operational activities, including QAPI, contracts, staffing, and annual evaluation. While this documentation identified administrative leadership changes, including the promotion of the Administrator to Regional Director of Clinical Operations in March 2025, there was no formal record documenting Governing Body approval or appointment to this role at the time of the change. “Surveyor Access to Hospice” documented on 06/18/2026 outlined the Administrator, Alternate Administrator, Clinical Director, and Alternate Clinical Director The Governing Body documentation did not substantiate ongoing governance activities or formal actions prior to the survey period. The agency further reported that the previous administrator destroyed key administrative documents prior to departure. The COO/CCO began employment with the agency in February 2026.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 4 of 7 (57%) personnel records reviewed revealed the agency did not ensure competency was assessed of all individuals providing care, including volunteers. HOSPICE POLICY: The agency’s policy entitled, “Staff Competency (HR.10)” which was dated 11/15/2024, read in part that “...The hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including volunteers (if applicable), contracted staff...The competency evaluation and/or checklist will be completed and retained in the staff’s personnel file...” PERSONNEL RECORD 4: A review of the personnel record for the Registered Nurse (RN) hired on 10/24/2024 revealed an initial Hospice Nursing Competency Checklist completed 10/26/2024. There was no documented evidence of an annual competency for 2025. PERSONNEL RECORD 6: A review of the personnel record for the Chaplain/Bereavement Coordinator (CH/BC) hired on 11/05/2023 revealed that no initial CH or BC competency was documented. Skills Competency Assessments for both roles, CH and BC, were documented on 03/25/2024. There was no documented evidence of an annual competency for 2025. PERSONNEL RECORD 7: A review of the personnel record for the Licensed Practical Nurse (LPN) hired on 01/26/2026 revealed that no initial LPN competency was documented. PERSONNEL RECORD 9: A review of the personnel record for the Volunteer hired on 12/10/2025 revealed that no initial volunteer competency was documented. After a joint personnel record review and interview with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2), the Clinical Director (Personnel Record 3), and the Business Office Manager (BOM) on 06/26/2026, the missing competencies were confirmed, and no documentation of the missing competencies could be produced prior to the end of the site visit. The RDCO acknowledged that the agency needed to revise its onboarding and ongoing compliance processes for personnel record completion, documentation, and oversight.”

“It is required that hospice care for the patient/resident be documented in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services needed and specifies which provider is responsible for performing the functions agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed revealed that the agency did not ensure that patient’s plan of care reflected the delineation of responsibilities between the hospice and the facility for the care and services provided to the patient living in a nursing facility. CLINICAL RECORD 1: The patient, who resided in a nursing facility, elected hospice services on 03/05/2025. A review of the plans of care (POC) for the benefit periods 02/28/2026 to 04/28/2026 and 04/29/2026 to 06/27/2026 identified multiple care needs, including advanced chronic obstructive pulmonary disease requiring continuous oxygen therapy, dyspnea at rest, cognitive impairment with orientation to self only, frequent hallucinations, increased risk for aspiration, incontinence, decreased functional status, and the need for maximum assistance with activities of daily living. Nursing documentation on 06/15/2026 and 06/24/2026 further confirmed significant clinical decline, including oxygen dependency (3–5 liters per minute (LPM) with saturation drops to 80% on room air), shortness of breath during conversation, inability to consistently express needs, missed meals due to somnolence, and behavioral symptoms requiring PRN (as needed) medication management. The POC did not specify which interventions or aspects of care were the responsibility of hospice staff versus those to be carried out by nursing facility personnel. This included care elements such as oxygen administration and monitoring, feeding assistance and aspiration precautions, management of incontinence and skin care, and implementation of behavioral interventions for agitation and confusion. CLINICAL RECORD 6: The patient, who resided in a nursing facility, elected hospice services on 05/22/2026 with a primary diagnosis of alcoholic cirrhosis of the liver with ascites and secondary conditions including esophageal varices without bleeding, hepatic encephalopathy, and chronic pancreatitis. A review of the plan of care (POC) for the benefit period 05/22/2026 to 07/20/2026 identified a patient with significant care needs, including continuous oxygen use at 6 liters per minute (LPM) with dyspnea (score 6/10 with a goal of 4/10), persistent and escalating pain (up to 9/10), increasing weakness, incontinence, declining functional status requiring assistance with most activities of daily living, cognitive changes including confusion and forgetfulness, and development of new edema associated with ascites. Clinical documentation dated 06/23/2026 further reflected worsening symptoms, including increased pain (7–9/10), lower extremity edema, and new medical interventions, including the initiation of Spironolactone and an order for paracentesis for comfort. The POC did not clearly define which aspects of care—such as medication administration, oxygen management, incontinence care, skin integrity interventions, monitoring for ascites-related complications, or implementation of safety measures—were the responsibility of hospice staff versus nursing facility staff. Additionally, nursing and IDG documentation emphasized the patient’s increasing need for assistance with medications, mobility, and personal care, yet these responsibilities were not delineated within the POC to reflect coordinated care delivery between disciplines and care settings. During a joint clinical record review and interview conducted on 06/26/2026 with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2) and the Clinical Director (CD) (Personnel Record 3), they were unable to identify within the plan of care (POC) where responsibilities of the hospice and nursing facility staff were delineated. Upon further discussion, the Clinical Director acknowledged that the current electronic medical record (EMR) system lacked functionality to incorporate or assign interventions or goals to facility staff within the POC. The Clinical Director indicated that the agency would need to modify the EMR to allow for inclusion of nursing facility staff roles in order to clearly define and document shared responsibilities for patient care.”

“It is required that the hospice obtain criminal background checks for all employees who have direct patient contact or access to patient records. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 9 (11%) personnel records reviewed revealed that the agency did not ensure that a criminal background check was completed on the volunteer. HOSPICE POLICY: The hospice policy “Personnel Records (HR.55)” dated 05/01/2025 read in part that “...The hospice will maintain a personnel record for each employee and volunteer...Personnel contents for the hospice employees and volunteers may include but not be limited to... criminal background check...” PERSONNEL RECORD 9: A review of the personnel file for the Volunteer hired 12/10/2025 revealed that there was no evidence of a criminal background check documented in her personnel file. During a joint personnel record review and interview with the Regional Director of Clinical Operations (RDCO)/Administrator (Personnel Record 2), she confirmed that the background check was missing and explained that the volunteer was being onboarded during the time that the previous Volunteer Coordinator left employment.”