Carefirst / Southern Tier Hospice and Palliative

“Based on review of hospice Emergency Preparedness Regulation Set Federal-E-1.04- section 418.113(c)(2), agency emergency preparedness plan and staff interview, the hospice failed to maintain an emergency preparedness communication plan that included contact information for state, regional and local emergency preparedness staff. Failure to maintain emergency contact information has the potential for negative patient outcomes during emergencies. Review of the undated agency “Emergency Preparedness Manual” revealed “A contact list of community partners, including the local health department, local emergency management, emergency medical services and law enforcement will be kept current, via The CareFirst Representative on The Southern Tier Health Care Mutual Aide Plan Steering Committee.” Review of the undated agency “Emergency Preparedness Manual” lacks documentation of telephone numbers for the community partners identified in their manual. During interview on 01/08/2026 at 01:44 PM, the Director of Hospice Services stated additional documentation would be looked for that included the community partners telephone numbers. During interview on 01/09/2026 at 01:17 PM, the Director of Hospice Services stated being unable to locate the identified community partners telephone numbers and would add them to the “Emergency Preparedness Manual” promptly.”

“Based on review of State Operations Manual Appendix A, section 418.113(d)(2)(i and ii), issued on 04/16/2021, agency emergency preparedness plan, and staff interview, the hospice failed to ensure exercises to test the emergency plan are conducted at least annually. Review of the State Operations Manual Appendix A, section 418.113(d)(2)(I and ii) issued on 04/16/2021 revealed “(2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full[1]scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and 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 an emergency plan.” Review of the agency policy and procedure entitled “Administration Emergency Preparedness Plan updated 07/2023 revealed “11. The hospice “participates annually in a state-wide or county-wide drill that includes triaging patient needs in an emergency.” Review of the Public Health Emergency Response Simulation dated 04/03/2023 revealed the agency participated in a county wide drill in 2023. There is a lack of documentation the agency participated in an emergency drill and/or activated their emergency preparedness plan in 2024 and 2025. During interview on 01/08/2026 at 01:45 PM, the Director of Hospice Services acknowledged the hospice failed to participate in an emergency preparedness drill or retained documentation of activating their emergency response plan for 2024, and 2025.”

“Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in one (1) of nineteen (19) clinical records (Patient #6), the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Physician’s Plan of Care from 06/10/2025 to 09/07/2025 revealed an order to discontinue routine maintenance flushing of the implanted mediport in the patient’s right upper chest. Review of the Initial and Comprehensive Assessment dated 06/10/2025 lacks documentation of an assessment of the implanted mediport site to include location, if accessed or deaccessed, and a skin assessment above the implanted mediport. During interview on 01/09/2026 at 11:47 AM, the Registered Nurse (RN) stated patient’s mediport was deaccessed but failed to include an assessment of the port site in the identified assessment. Patient #15 – This 67-year-old patient with a terminal diagnosis of alcoholic cirrhosis of liver with ascites and esophageal varices without bleeding was admitted to the hospice on 12/01/2025.Review of the Physician’s Plan of Care from 12/01/2025 to 03/01/2026 revealed an order for wound care to the coccyx area; cleanse area with soap and warm water and pat dry, apply bag balm and cover with a borded dressing; Frequency: daily and PRN dressing saturated, non-adhered and/or greater than 50% saturated. Wound care to be managed by family/caregiver and/or CareFirstNY staff.Review of the Initial and Comprehensive Assessment dated 12/01/2025 reveals a Wound Assessment of the coccygeal area; Pressure Ulcer Stage 2; wound status is opened; wound measurements documented and patient reported pain of 5/10. Review of the RN Comprehensive Assessment on 12/11/2025 reveals, “Integumentary: Skin Conditions (M1190) – Does the patient have one or more skin conditions?: NO” and “Other Skin S&S: Intact”. There is a lack of documentation that the Registered Nurse (RN) completed a Wound Assessment prior to certifying the patient’s wound closure.During interview on 01/09/2026 at 10:00 AM, the RN stated the patient’s wound had healed/closed and acknowledged a Wound Assessment was not completed prior to completing the RN Comprehensive Assessment.”

“Based on review of clinical records and interview with staff, for two (2) of nineteen (19) patients (Patient #’s: 3 and 18), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group to act on inaccurate information. Home visitPatient #3 - This 95 -year-old patient with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 11/25/2025.On 12/03/2025 the hospice nurse (case manager) conducted a comprehensive home visit. The nurse had documented new medications ordered by the physician that included:Lorazepam 0.5mg every 2 hours as needed for dyspnea and restlessness;Senna 8.6mg 2x a day as needed for bowel regime; andMorphine concentrate 5ml every 2 hours as needed for pain, dyspnea, anxiety, and restlessness.Review of the hospice nursing visit dated 12/03/2025 revealed the RN documented the following:Problem – plan of care collaboration requirementGoal- coordinate care with patient, caregiver, attending physician.Intervention- reviewed patient prescription and over the counter drug profile for effectiveness, duplication, drug interactions and actual potential drug side effects.On 01/05/2026 the surveyor conducted an observational home visit with the social worker and patient caregiver present. The surveyor asked the caregiver about the patient’s current medication use. The caregiver stated the medications are in a pill box and filled by a family member. The surveyor asked about the medication MiraLAX that was on the kitchen counter. The caregiver stated that is used for the patient if needed and is not a new medication.On 01/07/2026 the agency provided the surveyor with a policy titled “Standard Operating Procedure for Medication Reconciliation” dated 10/25/2025. That included over the counter medications or treatments taken must be listed on medication list.The hospice nurse failed to complete an accurate comprehensive drug review to identify over the counter medications and frequency of use.Review of the clinical record from 11/25/2025 through 01/05/2026 lacks documented evidence the Hospice Nurse completed a complete medication review and verified all medications including over the counter medications.During interview on 01/09/2026 at 12:20 PM, the Hospice Registered Nurse (case manager ) for the patient and the Registered Nurse that had conducted the 12/03/2025 visit stated the MiraLAX medication should have been included on the medication list. Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the facility summary of care (referral) dated 12/19/2025 revealed the patient was taking the following medication taper: prednisone 50 milligrams (mg) one (1) tablet (50 mg total) daily for five (5) days, then prednisone 20 mg tablet, take two (2) tablets (40 mg total) by mouth daily for five (5) days, then take 1.5 tablets (30 mg total) daily for five (5) days, then one (1) tablet (20 mg total) daily. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following medication taper:- prednisone 50 mg by mouth daily from 12/21/2025 through 12/22/2025;- prednisone 40 mg by mouth daily from 12/23/2025 through 12/27/2025;- prednisone 30 mg by mouth once time weekly from 12/28/2025 to through 01/01/2026; and- prednisone 20 mg by mouth daily beginning 01/02/2026. Review of the clinical record lacks documentation the RN communicated with the physician regarding the prednisone taper discrepancy. During interview on 01/09/2026 at 11:13 AM, the RN stated an error was made on the plan of care orders and the prednisone 30 mg was to be given daily for five (5) days, not weekly.”

“Based on review of clinical records and interview with staff for one (1) of nineteen (19) patients (Patient #5), the hospice failed to ensure an initial bereavement assessment of the needs of the patient’s family and caregivers was conducted. Failure to perform a risk assessment for bereavement places the family and other individuals at risk for not receiving appropriate counseling and supportive services. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung was admitted to the hospice on 10/03/2025. The patient resides in a skilled nursing facility (SNF). Review of the Initial and Comprehensive Assessment dated 10/03/2025 lacks documentation the Registered Nurse (RN) completed an initial bereavement assessment. Review of the Social Worker (SW)- Spiritual Care Counselor (SCC) Initial and Comprehensive Assessment dated 10/06/2025 revealed the SW documented the following bereavement assessment: the bereaved is the patient’s daughter in law who is not present for the visit. Phone call to daughter in law, no answer message left. Review of the clinical record lacks documentation of the SW speaking to the patient’s daughter-in-law to conduct an initial bereavement assessment. During interview on 01/09/2026 at 09:48 AM, the SW stated that they had been unable to contact the daughter-in-law to conduct a required bereavement assessment.”

“Based on a review of clinical records and staff interview for five (5) of nineteen (19) clinical records (Patient #’s: 2, 4, 5, 6, and 18), the hospice failed to ensure the patient’s comprehensive assessments include changes that have occurred since the initial assessment, are updated every fifteen (15) days, and that the hospice nurses are communicating changes in the patient’s condition or treatment to the Interdisciplinary Group (IDG). Failure to ensure that comprehensive assessments are updated and reflect the patient’s status has the potential for unmet patient needs. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. A.) Review of the Registered Nurse (RN) Comprehensive Assessment dated 10/23/2025 revealed the RN documented the patient reported a recent fall and sustained a skin tear to the left elbow that is pink with no drainage. Review of the RN Comprehensive Assessment dated 10/30/2025 revealed the RN documented the patient has a skin tear but fails to specify the location and status of the skin tear. During interview on 01/09/2025 at 10:48 AM, the RN stated the skin tear was on the left elbow and was dry but failed to document this in the identified assessment. B.) Review of the Physician’s Plan of Care from 10/03/2025 to 12/31/2025 revealed an order for oxygen one (1) liter per minute by nasal cannula continuous as directed, may titrate from one (1) to three (3) liters per minute via nasal cannula. Review of RN Comprehensive Assessment dated 12/01/2025 revealed the RN documented the patient’s room air oxygen saturation is 93 percent and has diminished breath sounds in all lung fields bilaterally. Review of the assessment lacks documentation of the ordered oxygen use. Review of the IDG Report dated 12/03/2025 revealed the RN Case Manager documented the patient’s current problems are with pain that is managed with MS Contin and Roxanol and gas exchange that is managed with Roxanol and oxygen. Oxygen is ordered at one (1) liter per minute by nasal cannula continuous as directed and may titrate from one (1) to three (3) liters per minute. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient’s room air oxygen saturation is 96% and has diminished breath sounds in all lung fields bilaterally. Review of the assessment lacks documentation of the ordered oxygen use. During interview on 01/09/2026 at 10:22 AM, the RN stated the patient was not wearing oxygen as ordered during the identified assessments and failed to document this and report the change to the IDG. C.) Review of the IDG Report dated 12/03/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) every twelve (12) hours for pain;- Acetaminophen 650 mg every six (6) hours as needed for pain;- Morphine Concentrate take 5 mg (100 mg per 5 milliliters) (ml) (20 mg/ml) solution by mouth every two (2) hours as needed for pain; and- Oxycodone-Acetaminophen (5 mg-325 mg tablet) by mouth every six (6) hours as needed for pain. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient is experiencing ten (10) out of ten (10) severe pain to the abdomen. Additionally, the RN documented collaborating with the skilled nursing facility (SNF) nurse to medicate the patient for abdominal pain. The assessment lacks a patient response to the pain medication requested to be administered by the SNF nurse. During interview on 01/09/2026 at 10:34 AM, the RN stated the patient was not assessed after the request for the SNF nurse to administer the pain medication was made to determine if effective pain control was obtained. The RN stated the patient visit ended when requesting the SNF staff administer pain medication, and no follow-up was made to determine if the patient received effective pain control. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the Spiritual Care Counselor (SCC) documented visualizing a gun resting in the corner of the patient’s bedroom during the visit and no gun safe was noted. Review of the Patient Related Collaboration Note dated 06/18/2025 revealed the Social Worker (SW) documented the following “Discussion with SCC, shown a gun out in open in upstairs, patient stated she could shoot spouse, did not appear to SCC to have intent to harm, more of a frustration statement. SW to follow up on friday.” Review of the Focused and Comprehensive Assessment dated 06/20/2025 revealed the SW made a home visit to the patient but lacks documentation of follow-up regarding the presence of a gun being in the home on 06/18/2025 and an assessment of home, hospice staff and patient safety. During interview on 01/09/2026 at 09:06 AM, the SW stated the gun that was visualized in the home was a pellet gun, determined the gun was not a safety risk and failed to document regarding this. The SW stated the IDG failed to be notified regarding gun and potential safety risk it posed. Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following wound care orders:- wound area one (1): right elbow- cleanse area with normal saline and pat dry, apply bag balm, cover with non adherent pad, secure with gauze wrap every three (3) days and as needed for dressing saturated, non-adhered and/or greater than fifty (50) percent saturated.- wound area two (2): coccyx- cleanse area with soap and water and pat dry, apply bag balm, leave open to air daily and as needed if greater than fifty (50) percent saturated. Review of the RN Comprehensive Assessment dated 12/29/2025 revealed the RN documented the following:- Skin condition: Yes;- Types of skin conditions: Pressure Ulcer(s)/ injuries;- Skin and ulcer/injury treatments: Application of nonsurgical dressings (with or without topical medications) other than to feet (patient refused assessment at this visit).The documentation fails to specify which wound, right elbow and/or coccyx the RN is writing about. During interview on 01/09/2026 at 10:54 AM, the RN stated the patient refused an assessment of both the right elbow and coccyx wounds but failed to specify this in the identified visit documentation. Home visit1. Patient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility. On 01/06/2026 the agency provided there wound policy titled “Standard Operating Procedure” dated 02/17/2023 that included:The Registered Nurse (RN) will complete in its entirety a wound assessment including measurement’s of width, length, and depth and description in the record. The plan of care to include problems, goals and interventions. Multiple wounds should have a specific order. The 10/28/2025 initial nursing assessment included wound care to the following sites:Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.Back right lower calf, description deep tissue injury- wound length 11.5cm, width 8.5cm, depth 0.5cm and wound color beefy red.Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.Right forearm – description skin tear, see photo in document library. However, there were no measurements with the photo in the record.The 10/28/2025 Hospice plan of care included wound care orders only for right calf site, clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every 3 days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff.On 10/29/2025 the hospice nurse documented pressure ulcer dressing performed by facility staff. On 11/03/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff every 3 days.On 11/10/2025 the hospice nurse failed to document location of wounds and who performed wound care.11/17/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.11/24/2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/01/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.12/08/2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/15/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.12/22/2025 2025 the hospice nurse failed to document locations of wounds and who performed wound care.12/29/2025 the hospice nurse documented pressure ulcer wound care performed by facility staff.The Hospice nurse failed to perform a comprehensive assessment to address all four wound sites and assess areas to determine if the plan of care needed to be updated and monitor for resolution.During interview on 01/09/2026 at 9:30 AM, the hospice nurse that performed the initial assessment stated they did not measure all the wounds and did not obtain wound care orders for the left elbow, right elbow and back of lower calf. The hospice case manager stated they did not obtain measurements of any wounds since patient was admitted to the hospice and had not changed the dressing to any wounds. The Director of Hospice Services stated the wounds should have been measured and assessed. Home VisitPatient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of lip, oral cavity, and pharynx was admitted to the hospice on 12/01/2025.Review of the RN Comprehensive Assessment dated 12/11/2025 revealed the RN Case Manager documented the patient received wound care to the coccyx area, Pressure Ulcer Stage 1: cleanse with warm soapy water and pat dry, apply bag balm, cover with island dressing; care completed by patient’s daughter prior to RN’s scheduled visit.Review of the Wound Assessment dated 12/29/2025 revealed the RN Case Manager documented the coccygeal area wound status is closed with wound measurements documented and patient reported pain of 0/10.During a scheduled observational home visit on 01/06/2026 at 08:15 AM, the Licensed Practical Nurse (LPN) and the patient’s daughter assisted the patient with showering/dressing. When questioned, the LPN stated the patient is no longer receiving wound management to the coccyx area; bag balm is applied as a preventative measure daily and PRN.Review of the current LPN Personal Care/Plan of Care reveals wound management including a borded dressing remain as a tasked Intervention by the LPN at each patient visit and/or managed by family caregivers.Review of the IDT meeting on 01/07/2026 at 08:30 AM revealed no changes in the patient’s Plan of Care.During interview on 01/09/2026 at 11:21 AM, the RN acknowledged the Plan of Care should have been updated to reflect wound closure. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. A.) Review of the Registered Nurse (RN) Comprehensive Assessment dated 10/23/2025 revealed the RN documented the patient reported a recent fall and sustained a skin tear to the left elbow that is pink with no drainage. Review of the RN Comprehensive Assessment dated 10/30/2025 revealed the RN documented the patient has a skin tear but fails to specify the location and status of the skin tear. During interview on 01/09/2025 at 10:48 AM, the RN stated the skin tear was on the left elbow and was dry but failed to document this in the assessment. B.) Review of the Physician’s Plan of Care from 10/03/2025 to 12/31/2025 revealed an order for oxygen one (1) liter per minute by nasal cannula continuous as directed, may titrate from one (1) to three (3) liters per minute via nasal cannula. Review of RN Comprehensive Assessment dated 12/01/2025 revealed the RN documented the patient’s room air oxygen saturation is 93 percent and has diminished breath sounds in all lung fields bilaterally. The assessment lacks documentation of the ordered oxygen use. Review of the IDG Report dated 12/03/2025 revealed the RN Case Manager documented the patient’s current problems are with pain that is managed with MS Contin and Roxanol and gas exchange that is managed with Roxanol and oxygen. Oxygen is ordered at one (1) liter per minute by nasal cannula continuous as directed and may titrate from one (1) to three (3) liters per minute. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient’s room air oxygen saturation is 96% and has diminished breath sounds in all lung fields bilaterally. The assessment lacks documentation of the ordered oxygen use. During interview on 01/09/2026 at 10:22 AM, the RN stated the patient was not wearing oxygen as ordered during the identified assessments and failed to document this and report the change to the IDG. C.) Review of the IDG Report dated 12/03/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) every twelve (12) hours for pain;- Acetaminophen 650 mg every six (6) hours as needed for pain;- Morphine Concentrate take 5 mg (100 mg per 5 milliliters) (ml) (20 mg/ml) solution by mouth every two (2) hours as needed for pain; and- Oxycodone-Acetaminophen (5 mg-325 mg tablet) by mouth every six (6) hours as needed for pain. Review of the RN Comprehensive Assessment dated 12/08/2025 revealed the RN documented the patient is experiencing ten (10) out of ten (10) severe pain to the abdomen. Additionally, the RN documented collaborating with the skilled nursing facility (SNF) nurse to medicate the patient for abdominal pain. The assessment lacks a patient response to the pain medication requested to be administered by the SNF nurse. During interview on 01/09/2026 at 10:34 AM, the RN stated the patient was not assessed after the request for the SNF nurse to administer the pain medication was made to determine if effective pain control was obtained. The RN stated the patient visit ended when requesting the SNF staff administer pain medication, and no follow-up was made to determine if the patient received effective pain control. Home VisitPatient #2 – This 71-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of lip, oral cavity, and pharynx was admitted to the hospice on 12/01/2025. Review of the RN Comprehensive Assessment dated 12/11/2025 revealed the RN Case Manager documented the patient received wound care to the coccyx area, Pressure Ulcer Stage 1: cleanse with warm soapy water and pat dry, apply bag balm, cover with island dressing; care completed by patient’s daughter prior to RN’s scheduled visit. Review of the Wound Assessment dated 12/29/2025 revealed the RN Case Manager documented the coccygeal area wound status is closed with wound measurements documented and patient reported pain of 0/10. During a scheduled observational home visit on 01/06/2026 at 08:15 AM, the Licensed Practical Nurse (LPN) and the patient’s daughter assisted the patient with showering/dressing. When questioned, the LPN stated the patient is no longer receiving wound management to the coccyx area; bag balm is applied as a preventative measure daily and PRN (as needed). Review of the current LPN Personal Care/Plan of Care indicates that wound management, including the application of a bordered dressing, remains a tasked intervention for the LPN at each patient visit, or is managed by family caregivers. Review of the IDG meeting on 01/07/2026 at 08:30 AM revealed no changes in the patient’s Plan of Care. During interview on 01/09/2026 at 11:21 AM, the RN acknowledged the Plan of Care should have been updated to reflect wound closure and that only preventative balm is being applied to the area. Home visitPatient #4- This 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resides in a Skilled Nursing Facility (SNF). The agency policy entitled “Standard Operating Procedure” dated 02/17/2023 revealed: “The RN will complete in its entirety a wound assessment including measurements of width, length, and depth and description in the record. The plan of care to include problems, goals and interventions. Multiple wounds should have a specific order.”Review of the initial nursing assessment dated 10/28/2025 revealed the following wound assessments: -Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.-Back right lower calf, description deep tissue injury- wound length 11.5cm (centimeters), width 8.5cm, depth 0.5cm and wound color beefy red.-Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.-Right forearm – description skin tear, see photo in document library. However, there were no measurements with the photo in the record. Review of the Hospice Plan of Care dated 10/28/2025 revealed wound care orders for right calf site to include clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every three (3) days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff. There were no additional wound care orders for the right lower leg, or bilateral forearms. Review of the RN Comprehensive Assessments dated 10/29/2025, 11/03/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/01/2025, 12/08/2025, 12/15/2025, 12/22/2025, and 12/29/2025 lack assessments of the wounds or information specifying the wound care performed and by whom.During interview on 01/09/2026 at 09:30 AM, the Hospice Nurse that performed the initial assessment stated they did not measure all the wounds and did not obtain wound care orders for the left elbow, right elbow and back of lower calf. The Hospice Case Manager (who completed follow-up assessments) stated they did not assess any of the wounds for worsening or healing and never obtained measurements on any wounds. The Director of Hospice Services stated the wounds should have been measured and assessed and wound care should have been addressed. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the Spiritual Care Counselor (SCC) documented visualizing a gun resting in the corner of the patient’s bedroom during the visit and no gun safe was noted. Review of the Patient Related Collaboration Note dated 06/18/2025 revealed the Social Worker (SW) documented the following “Discussion with SCC, shown a gun out in open in upstairs, patient stated she could shoot spouse, did not appear to SCC to have intent to harm, more of a frustration statement. SW to follow up on Friday.” Review of the Focused and Comprehensive Assessment dated 06/20/2025 revealed the SW made a home visit to the patient but lacks documentation of follow-up regarding the presence of a gun being in the home on 06/18/2025 and an assessment of home, hospice staff and patient safety. During interview on 01/09/2026 at 09:06 AM, the SW stated the gun that was visualized in the home was a pellet gun, determined the gun was not a safety risk and failed to document regarding this. The SW stated the IDG failed to be notified regarding gun and potential safety risk it posed. Patient #15 – This 67-year-old patient with a terminal diagnosis of alcoholic cirrhosis of liver with ascites and esophageal varices without bleeding was admitted to the hospice on 12/01/2025. Review of the Physician’s Plan of Care from 12/01/2025 to 03/01/2026 revealed an order for wound care to the coccyx area; cleanse area with soap and warm water and pat dry, apply bag balm and cover with a bordered dressing; Frequency: daily and PRN dressing saturated, non-adhered and/or greater than 50% saturated. Wound care to be managed by family/caregiver and/or agency staff. Review of the Initial and Comprehensive Assessment dated 12/01/2025 reveals a Wound Assessment of the coccygeal area; Pressure Ulcer Stage 2; wound status is opened; wound measurements documented, and patient reported pain of 5/10. Review of the RN Comprehensive Assessment on 12/11/2025 reveals, “Integumentary: Skin Conditions (M1190) – Does the patient have one or more skin conditions?: NO” and “Other Skin S&S: Intact”. There is a lack of documentation that the RN completed a Wound Assessment prior to certifying the patient’s wound closure. During interview on 01/09/2026 at 10:00 AM, the RN stated the patient’s wound had healed/closed and acknowledged a Wound Assessment was not completed prior to completing the RN Comprehensive Assessment. Patient #18 – This 68-year-old patient with a terminal diagnosis of acute and chronic respiratory failure with hypoxia was admitted to the hospice on 12/21/2025. Review of the Physician’s Plan of Care dated 12/21/2025 revealed the following wound care orders:- wound area one (1): right elbow- cleanse area with normal saline and pat dry, apply bag balm, cover with non-adherent pad, secure with gauze wrap every three (3) days and as needed for dressing saturated, non-adhered and/or greater than fifty (50) percent saturated.- wound area two (2): coccyx- cleanse area with soap and water and pat dry, apply bag balm, leave open to air daily and as needed if greater than fifty (50) percent saturated. Review of the RN Comprehensive Assessment dated 12/29/2025 revealed the RN documented the following:- Skin condition: Yes;- Types of skin conditions: Pressure Ulcer(s)/ injuries;- Skin and ulcer/injury treatments: Application of nonsurgical dressings (with or without topical medications) other than to feet (patient refused assessment at this visit).The documentation fails to specify which wound, right elbow and/or coccyx the RN is writing about. During interview on 01/09/2026 at 10:54 AM, the RN stated the patient refused an assessment of both the right elbow and coccyx wounds but failed to specify this in the identified visit documentation.”

“Based on a review of clinical records and staff interviews for one (1) of nineteen (19) patients (Patient #12), the hospice failed to ensure care and services provided by the hospice follow an individualized written plan of care. Failure to provide care and services in accordance with the plan of care has the potential for unmet patient needs. Patient #12 – This 91-year-old patient with a terminal diagnosis of malignant neoplasm of left upper lobe of lung was admitted to the hospice on 11/05/2025.Review of the Interdisciplinary Group (IDG) Report dated 12/31/2025 revealed the following order: Chaplain/SCC (Spiritual Care Counselor) start 11/25/2025 one (1) visit every seven (7) to fourteen (14) days and five (5) as needed visits per patient /family request.Review of the clinical record revealed the SCC conducted home visits on: 11/07/2025, 11/14/2025, 11/25/2025, 12/04/2025, and 12/15/2025.Review of the clinical record revealed for the weeks of 12/21/2025 through 12/27/2025 and 12/28/2025 through 01/03/2026 the patient did not receive services from the SCC.Review of the clinical record from 12/21/2025 through 01/03/2026 lacks documentation the patient refused SCC visits and physician notification of not providing visits as ordered.During interview on 01/09/2026 at 11:45 AM, the Admissions Team Manager stated the SCC was unavailable for interview. The Admissions Team Manager acknowledged the SCC failed to meet the visit frequency for the identified time period and failed to notify the physician/IDG.”

“Based on review of clinical records and interviews with staff, for two (2) of nineteen (19) patients (Patient #’s: 4 and 6) the hospice failed to develop an individualized written plan of care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the Physician’s Plan of Care from 06/10/2025 to 09/07/2025 revealed an order for Chaplain Services with visit frequency to be determined after initial visit. Review of the Telephone Contact Note dated 06/12/2025 revealed the Spiritual Care Counselor (SCC) called and spoke with the patient’s spouse who declined the SCC making a visit on 06/12/2025. Review of the Initial and Comprehensive Assessment dated 06/18/2025 revealed the SCC conducted an initial visit and developed interventions and goals for future visits. Review of the clinical record lacks documentation of a SCC order to include the visit frequency to be provided to the patient. During interview on 01/09/2026 at 12:10 PM, the Admissions Team Manager stated the SCC failed to enter an order to include the anticipated visit frequency after conducting the initial visit. Home visitPatient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility. The Plan of Care from 10/28/2025 from 01/26/2026 failed to include a diet order.The surveyor conducted an observational home visit at the Skilled Nursing Facility (SNF) with the hospice nurse present on 01/05/2026 at 3 PM. Observed were 2 cups of thickened liquid drinks on the patient’s bed side table.The nursing comprehensive assessment conducted on 12/29/2025 included nutrition/dietWith honey thickened liquids and puree diet.Review of the clinical record lacks documentation of an assessment for the need of altered diet of puree foods and thickened liquids.During interview on 01/09/2026 at 12:30 PM, the Registered Nurse (case manager) stated the thickened liquids and diet should have been included in the plan of care.”

“Based on review of clinical records and interview with agency staff, for one (1) of nineteen (19) patients (Patient #12) the agency failed to ensure the plan of care was revised when the updated comprehensive assessment identified changes in the patient’s condition. Failure to update the plans of care based on information from the comprehensive assessment, has the potential for unmet patient needs. Patient #12 – This 91-year-old patient with a terminal diagnosis of malignant neoplasm of left upper lobe of lung was admitted to the hospice on 11/05/2025. Review of the Registered Nurse (RN) Comprehensive Assessment dated 12/30/2025 revealed the RN documented the following wound assessment: left buttock pressure ulcer stage 2, wound open, length-2.5 centimeters (cm), width is 0.5 cm, depth is 0 cm. Wound is pink, no exudate and periwound tissue is pink. Review of the Physician Orders dated 12/30/2025 revealed the following wound order: “Wound area: left buttocks, cleanse area with warm soapy water, pat dry, do not rub, apply bag balm, cover with leave open to air, secure with n/a, frequency twice daily and as needed if dressing saturated, non-adhered and greater than fifty (50) percent saturated”. During interview on 01/09/2026 at 11:55AM, the RN stated the wound was not covered with a dressing and failed to update the identified order to reflect the correct dressing procedure.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure in one (1) of nineteen (19) patients (Patient #5) that care and services are provided in accordance with the plan of care. Failure to provide care in accordance with the patient’s established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung was admitted to the hospice on 10/03/2025. The patient resides in a skilled nursing facility (SNF).Review of the Interdisciplinary Group (IDG) Report dated 12/03/2025 revealed the following orders:- Licensed Practical Nurse (LPN): offered and declined; and- Professional Nurse, Registered Nurse (RN): one (1) visit every seven (7) to ten (10) days and five (5) as needed visits per patient and family request.Review of the LPN Observation Note dated 10/04/2025 revealed the LPN made a home visit to perform symptom monitoring of the patient.Review of the clinical record lacks documentation of orders for LPN services.During interview on 01/09/2026 at 10:11 AM, the Admissions Team Manager stated the hospice utilizes LPNs for care in addition to aide services and failed to obtain an order for identified LPN service provided.”

“Based on review of the agency’s Board of Directors Meeting Minutes for 2025 and staff interview, the Governing Authority (GA) failed to ensure involvement in oversight of the Quality Assurance and Performance Improvement (QAPI). Failure to ensure responsibility and oversight of the hospice’s QAPI program has the potential to result in negative patient outcomes and adversely affect organizational operations. Review of the Board of Directors Meeting Minutes provided by the hospice revealed the Board of Directors met the following dates in 2025: 01/30/2025, 04/24/2025, 07/31/2025, and 11/13/2025. Review of the identified 2025 Board of Directors Meeting Minutes lack documentation of involvement and oversight of the hospice’s QAPI program. During interview on 01/08/2026 at 02:53 PM, the Director of Hospice Services stated being present for the identified Board of Directors meetings but fails to see documentation of Board involvement and oversight of QAPI in the identified meeting minutes.”

“Based on review of Quality Assurance Performance Improvement (QAPI) meeting minutes and staff interview, the hospice failed to ensure the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases is part of the QAPI program. Failure to ensure infection control is an integral part of the hospice’s QAPI program has the potential to result in negative patient outcomes. Review of the QAPI/Compliance Meeting Minutes for the year 2025 revealed the committee met in 2025 on the following dates: 03/20/2025 and 10/15/2025. Review of the identified meeting minutes for 2025 lack documentation of infection control monitoring and investigation. During interview on 01/08/2026 at 02:55 pm, the Director of Hospice Services stated there has been much transition in the staff overseeing QAPI in the last year and acknowledged infection control monitoring has not been part of the 2025 QAPI meetings. During interview on 01/08/2026 at 03:00 PM, the QAPI and Compliance Manager stated being new in the role, has led one QAPI meeting in 2025, which occurred 10/15/2025. Additionally, the QAPI and Compliance Manager stated that infection control data is currently being tracked but was unaware infection control monitoring must be included in the QAPI program.”

“Based on review of the hospice’s infection control program, policies and procedures, and staff interviews, the hospice failed to maintain and document a comprehensive infection control program. Failure to maintain and document a comprehensive infection control program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes and adversely affect hospice operations. Review of the hospice’s infection control program policies under the general title “Infection Control”; Policy Numbers: B241, P238, E239, P240, p240.1, R242, I243, I244, O245, R246, S247, P248, E249, C250, B251, B252, H253, S254, C5255, CE256, C1257, CT258; all last reviewed 03/2023, revealed the hospice infection control program lacks the following protocols for prevention of infection from:Infusion therapy;Urinary tract care;Respiratory tract care;Multi-drug-resistant organisms;Additionally, the hospice policy lacks language addressing the transmission of infectious agents in all setting where patients reside.During an interview on 01/08/2026 at 03:41 PM, the Director of Hospice Services acknowledged that the components are not included in current policies, and the policies will be updated.”

“Based on clinical record review and staff interview for one (1) of two (2) patients discharged to the community (Patient #6), the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. Patient #6 – This 65-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified site of the breast was admitted to the hospice on 06/10/2025 and revoked hospice services on 07/02/2025. Review of the agency policy entitled “Discharge For Reasons Other Than Death” dated 06/2018 revealed “5. The discharge summary is filed in the clinical record and includes: a. the reason for the discharge;b. a summary of the patient’s stay including treatments, symptoms, and pain management;c. a copy of the patient’s current plan of care;d. The patient’s latest physician orders;e. any other documentation that will assist in post-discharge continuity of care.” Review of the Revocation of Hospice Benefits form dated 07/01/2025 revealed the patient was revoking hospice services in order to receive hospitalization, intravenous hydration and explore additional treatment for their cancer. Review of the Discharge Summary and Checklist dated 07/02/2025 lacks the following required components: the patient’s current plan of care, and the latest physician orders. During interview on 01/09/2026 at 12:15 PM, the Director of Hospice Services stated that the current plan of care and physician orders are often attached to the Discharge Summary but acknowledged the identified Discharge Summary failed to include the required components.”

“Based on review of clinical records and interviews with staff for two (2) of two (2) patients receiving care in a Skilled Nursing Facility (SNF) (Patient #’s 4 and 5), the hospice failed to coordinate and implement a plan of care with interventions that reflect the needs of the patient and that are consistent with the SNF plan of care (POC). Failure to communicate, coordinate and provide professional management of hospice patients that reside in a SNF has the potential for the provision of inadequate patient care and unmet patient needs. Patient #5 – This 68-year-old patient with a terminal diagnosis of malignant neoplasm of the left lower lobe of lung, residing in a skilled nursing facility, was admitted to the hospice on 10/03/2025. Review of the Interdisciplinary Group (IDG) Report dated 12/31/2025 revealed the patient is ordered the following medications for pain:- MS Contin 30 milligrams (mg) by mouth every twelve (12) hours for pain; and- Oxycodone-Acetaminophen (5 mg-325 mg) one tablet by mouth every six (6) hours as needed for pain. Review of the Assessment Visit dated 01/05/2026 revealed the Registered Nurse (RN) documented the patient is reporting abdominal pain rated an eight (8) out to ten (10) pain that is affecting the patient’s ability to perform activities of daily living. Additionally, the RN documented no collaboration occurred with SNF staff as Nurse Manager was not available. Review of the clinical record lacks documentation of follow-up with the SNF Staff and the patient regarding the 01/05/2026 poor pain control. During interview on 01/09/2026 at 10:40 AM, the RN stated the patient refused for the RN to locate the SNF staff to administer pain medication and no collaboration was conducted with the SNF staff and IDG regarding the patient’s poor pain control during the identified visit. Home visitPatient #4 this 94-year-old patient with terminal diagnosis of senile degeneration of the brain with secondary diagnoses of dysphagia and chronic right leg ulcer was admitted to the hospice on 10/28/2025. The patient resided in a Skilled Nursing Facility. The 10/28/2025 initial nursing assessment included wound care to the following sites:Back right lower leg, description of deep tissue injury – unable to measure facility staff performed care.Back right lower calf, description deep tissue injury- wound length 11.5cm, width 8.5cm, wound color beefy red.Left forearm – description skin tear- wound status open length 0.5cm, width 0.25cm peri wound pink.Right forearm – see photo, however there were no measurements of wound with photo.The surveyor conducted an observational home visit at the Skilled Nursing Facility (SNF) with the hospice nurse present on 01/05/2026 at 3 PM. Prior to the hospice nursing visit the Skilled facility staff provided a printed medication review report that included wound care orders and medications. The wound care orders included:-Left forearm skin tear- clean with saline soaked gauze, cover with ABD pad and wrap with rolled gauze. Do not remove steri strips, change daily and as needed if soiled.-right calf wound (only change on Wednesday - unless non-adherent) clean the contact layer with normal saline soaked gauze, apply puracol ag (a collagen dressing) to wound bed, cover with ABD pad and wrap with rolled gauze. As needed daily if soiled. The patient was observed to have dressings to the left forearm, right forearm, and right leg calf. The patient had a bed cradle in place to keep bedding off lower legs and there was thickened liquid drinks on the bed side table. The hospice nurse stated the left and right forearm dressing were not there on 12/22/2025 form their last nursing visit. The hospice nurse stated the facility staff provide wound care and dressing changes.After the visit the hospice nurse could not find facility staff to report off to and stated they would send a communication note later that day. However, the communication documented in the recoded dated 01/05/2026 did not include any request for clarification on wound care orders to all 3 sites, an updated status on the wounds, how they developed, or on thickened liquids and the bed cradle in place.The 01/05/2026 hospice wound care orders included:Right calf – clean with saline, apply xeroform dressing, cover with abdominal padding secure in place with gauze. Change dressing every 3 days and as needed for saturation, non-adhered and/or greater than 50% saturated. Wound care managed by family, caregiver, and or hospice staff.There were no wound care orders in the hospice plan of care to the left and right forearm wounds.Hospice nursing visits form 10/29/2025 through 12/29/2026 lacked documentation on status of left and right forearm wounds and status and measurements to right calf wound. The hospice nurse documented the right calf wound care was provided by the facility staff and dressing changes are not completed by the hospice nurse.On 01/06/2026 the surveyor requested for a written agreement the agency has with skilled nursing facilities; On 01/07/2026 at 2 PM, the agency provided the surveyor with a written agreement titled “Agreement for Hospice Care for Skilled Nursing Facility Residents and Respite Care Services” dated 02/03/2025.The agreement included:-Hospice provider will furnish skilled nursing facility with a copy of the Hospice Provider Plan of Care after admission to hospice and will identify the services to be provided by hospice.-IDG meeting updates will be communicated with the skilled nursing facility.-Hospice Provider may request that skilled nursing facility participate in IDG conferences.-Hospice provider will hold case conferences with skilled nursing facility on a as needed basis.Hospice will provide the skilled nursing facility with most recent hospice provider plan of care.The 10/29/2025, 11/12/2025, 11/26/2025, 12/10/2025, and 01/06/2026 IDG meeting plan of care revealed non-healing wound to right calf. No other wounds sites were reviewed or who was providing and managing wound care. There was no evidence the plan was coordinated with the SNF plan of care.The 10/28/2025 hospice plan of care failed to:- Have wound care orders in place to the right and left forearm.- Coordinate wound care orders to ensure hospice plan of care had the same order in place.-Identify all care and services being provided by the hospice and by the SNF. -Clarify whether it was the hospice, or the SNF, that were responsible for performing the respective functions.-Include a copy of the SNF care plan, along with the hospice care plan, to clarify the functions of each.During interview on 01/09/2025 at 9:30 AM, the Director of Hospice Services and Admissions Team Manager stated the SNF has a wound care team that determines wound care needs for the patient. They stated no one from the skilled facility had been invited to the hospice IDG meetings for case conference and no one from the hospice has participated in the SNF case conferences. The case manager stated they had not coordinated status of wound care with the wound team at the SNF.”

“Based on clinical record review and interview with agency staff, for one (1) of one (1) patients (Patient #4) receiving services from a non-hospice provider, the hospice failed to ensure ongoing sharing of information and collaboration exists between the hospice and the non-hospice provider. Failure to ensure effective communication occurs between all healthcare providers to facilitate the coordination of care has the potential to result in negative patient outcomes. The hospice failed to ensure ongoing sharing of information and collaboration between the hospice and the non-hospice provider as evidenced by the following: Patient #4 – This 89-year-old patient with a terminal diagnosis of nontraumatic intracerebral hemorrhage, residing in a skilled nursing facility, was admitted to the hospice on 11/22/2023. A.) Review of the Physicians Plan of Care dated 11/22/2023 revealed a new order for Morphine Concentrate, 20 milligrams per milliliter solution, take 5 milligrams by mouth every four (4) hours as needed for pain. Review of the Registered Nurse Assessment dated 11/22/2023 revealed the Registered Nurse documented the patient began using liquid morphine as of 11/22/2023 for comfort and has had more grimacing and episodes of sleeping. Review of the clinical record from the 11/22/2023 initial Registered Nurse Assessment and development of the plan of care lacks documentation of collaboration with the skilled nursing facility staff regarding the new morphine being initiated, goals of pain control and signs and symptoms to report to the hospice nurse and/or physician. During interview on 12/12/2023 at 12:25 PM, the Registered Nurse stated collaboration occurred with the skilled nursing facility staff at the 11/22/2023 visit but was not documented. B.) Review of the Registered Nurse Assessment dated 11/22/2023 revealed the Registered Nurse documented the date of the patients last bowel movement was unknown. The assessment lacks documentation of collaboration with the skilled nursing facility staff regarding when the patient last had a bowel movement. During interview on 12/12/2023 at 12:20 PM, the Registered Nurse stated the skilled nursing facility staff were consulted with regarding the patients last tracked bowel movement but was not documented.”