Corsocare Hospice

“It is required that a hospice aide provides services: 1. Ordered by the Interdisciplinary Group; 2. Included in the plan of care; 3. Permitted to be performed under state law and regulation; and 4. Consistent with the hospice aide training. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review and interview which revealed the agency failed to ensure that: 1. Hospice Aides reported changes in the patient’s status relating to the plans of care to a Registered Nurse and documented the notification in the clinical record (HCDT.18.I/L628); 2. Hospice Aide supervisory assessments by a Registered Nurse, to accurately assess the quality of care and services provided, were conducted on-site no less frequently than every 14 days (HSRM.25.I/L629); and 3. Hospice Aide competencies were assessed in accordance with agency policy and the requirements of federal regulation (HSRM.9.I/L615). The cumulative effect of these deficiencies indicates a lack of effective oversight and could result in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.76 Hospice Aide and Homemaker Services. The deficient practice demonstrates systemic process failures that have the potential to affect all patients cared for by the home health agency.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization 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; conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise 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. A review of the agency’s Emergency/Disaster Preparedness and Procedures (page 5) identified a requirement stating in part, that certain preparedness activities, including office fire and evacuation drills, are to be conducted annually in accordance with regulatory requirements. There was no documented evidence that a fire or evacuation drill was conducted in calendar year 2024. During an interview conducted on 06/02/2026, the Administrator (Personnel Record 2) confirmed that there was no documented evidence that a fire or evacuation drill was conducted in calendar year 2024. The Administrator reported that her employment with the agency began at the end of October 2024, and therefore, she was unable to provide additional details regarding the absence of a documented drill prior to her hire date. A review of the agency’s Emergency/Disaster Preparedness and Procedures (page 5) identified a requirement stating, in part, that certain preparedness activities, including office fire and evacuation drills, are to be conducted annually in accordance with regulatory requirements. During an interview conducted on 06/02/2026, the Administrator (Personnel Record 2) confirmed that there is no documented evidence that a fire or evacuation drill was conducted in calendar year 2024. The Administrator reported that her employment with the agency began at the end of October 2024, and therefore, she was unable to provide additional details regarding the absence of a documented drill prior to her hire date.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 23 (9%) clinical records reviewed revealed that the agency did not ensure that the goals identified in the patient’s plan of care were specific and measurable in order to measure progress. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/18/2026 with a terminal diagnosis of Multiple Sclerosis. A review of the benefit periods 02/18/2026–05/18/2026 and 05/19/2026–08/16/2026 identified significant psychosocial and emotional concerns that were not adequately translated into individualized, measurable goals within the plan of care. During a Registered Nurse (RN) visit on 05/06/2026, the patient expressed worsening depression related to increasing dependence and inability to perform self-care, stating he was “ready to give up and die.” On 05/11/2026, the Social Worker documented that the patient remained alert and oriented but continued to demonstrate ongoing depression despite pharmacologic treatment, with observed signs including isolation, blunt affect, and negative thought patterns. The patient’s medication regimen included multiple antidepressants, including Wellbutrin XL 300 mg daily, Venlafaxine HCL 75 mg daily, Doxepin HCL 25 mg at bedtime, and Duloxetine HCL 20 mg at bedtime, indicating active management of depressive symptoms. Although the plan of care identified problems related to Multiple Sclerosis, the need for counseling, and depression—with corresponding interventions such as interdisciplinary collaboration, symptom assessment, counseling, and patient/family education—the established goals lacked specificity and measurability. For example, goals referenced general outcomes such as “effective management of distressing symptoms”, “realizing emotional and psychological support”, and “sufficient caregiver support,” without defined, patient-centered indicators to evaluate progress. During the Interdisciplinary Group (IDG) review on 05/13/2026, progress toward these goals was documented as “some” or “moderate”, however, the underlying concerns identified in nursing and social work assessments, including verbalization of a desire to die, withdrawal, and persistent depressive symptoms, were not clearly addressed through targeted interventions or measurable goals. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/24/2026 with a primary diagnosis of end-stage heart failure and a secondary diagnosis of shortness of breath. A review of the benefit periods 03/24/2026–05/22/2026 and 05/23/2026–07/21/2026 identified ongoing, significant cardiopulmonary symptoms, including dyspnea at rest, progressive edema, unstable symptom control, and repeated hospitalizations prior to admission. During the RN admission visit on 03/24/2026, the nurse documented that the patient presented with oxygen saturation as low as 72% on room air prior to hospice admission, requiring an emergency room visit. A productive cough, expiratory wheezing, diminished breath sounds, and bilateral lower extremity edema, with oxygen saturation decreasing further with ambulation, were assessed. Despite initiation of hospice services and multiple interventions, subsequent documentation reflected continued symptom burden and decline. On 04/23/2026, an on-call RN documented worsening edema, dyspnea at rest, and an intractable cough and noted that symptom relief was only partial and remained unstable. On 05/13/2026, the patient reported feeling unwell without the ability to further describe symptoms, while the caregiver reported ongoing shortness of breath episodes, medication management challenges, and increasing concern requiring overnight supervision. Although the plan of care appropriately identified problems related to end-stage heart failure and shortness of breath and included clinically appropriate interventions, such as diuretic management, oxygen therapy, respiratory assessments, positioning, and symptom monitoring, the goals established within the plan of care lacked specificity and measurability. Goals were broadly defined, including “effective management of pain and other distressing symptoms” and “improvement in caregiver feedback on respiratory comfort,” without clear, patient-centered indicators to evaluate progress. IDG documentation on 04/30/2026 and 05/14/2026 consistently reflected only “moderate” or “some” progress, while simultaneously identifying ongoing deterioration, inconsistent symptom management, and unresolved deficits. Despite clear evidence of persistent and worsening symptoms, including dyspnea at rest, escalating edema (up to 4+), cough, oxygen refusal, medication adherence concerns, and increased caregiver burden, the plan of care did not include individualized, measurable goals that would allow the care team to effectively evaluate response to treatment or guide adjustments in care. An interview conducted on 06/04/2026 with the Director of Clinical Services, the Regional Director of Compliance, and the Administrator (Personnel Record 2) included a detailed review of the patient’s documented plan of care goals in the cited clinical records. During the discussion, leadership acknowledged that the documented goals are not objective, patient-specific, or measurable, and confirmed that they do not clearly define expected outcomes in a manner that enables accurate evaluation of the patient’s progress over time.”

“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. 1 of 2 (50%) Hospice Aide (HA) personnel records reviewed revealed that the agency did not ensure that the aide’s competency was verified through observation of the aide with a patient. The hospice’s policy “Staff Competency Program (HR 04.26),” last reviewed/updated 08/29/2023, read in part, “...Hospice Aides will be competency assessed by an RN at least annually (every 12 months) onsite at the location where the patient is receiving care. Hospice may utilize pseudo-patients to test the competency of Aides in those tasks that currently must be observed being performed on an actual patient.” PERSONNEL RECORD 9: A review of the personnel file for a HA, hired on 08/20/2024, confirmed completion of an Initial Competency Assessment dated 08/26/2024, which included all required skills observed with a patient and documented by a Registered Nurse (RN). However, a review of the 2025 Annual Onsite Competency Form dated 11/04/2025 found that, although competency was documented as completed, the evaluation did not comprehensively address all required skills. The form indicated competency (“Yes”) in select areas, including reporting changes in patient condition, hospice complaint mechanisms, respect of patient property, basic home safety, interpersonal relationships with patients and families, following the plan of care, and hospice documentation. The form reflected that the evaluation occurred in a “lab” setting, however, there was no indication of pseudo-patient use or simulation methodology. Documented observed care was limited to a shower, a linen change, and trash removal, with competency affirmed for those tasks. There was no evidence that the aide’s ability to read, write, and verbally communicate clinical information was evaluated, nor was there documentation of competency validation for essential personal care and safety skills, including bed, sponge, or tub bathing; hair care (bed and tub shampooing); nail and skin care; oral hygiene; toileting and elimination care; safe transfer techniques; ambulation assistance; range of motion; or positioning. The documented annual competency assessment was limited in scope and did not include verification of all required hospice aide skills, nor did it demonstrate evaluation under conditions that reflect actual patient care. An interview conducted on 06/03/2026 with the Director of Clinical Services, the Administrator (Personnel Record 2), the Regional Director of Compliance, the Compliance Manager, and Clinical Managers confirmed that the Annual Onsite Competency Form dated 11/04/2025 was the only tool used to complete the HA’s annual competency evaluation. The group acknowledged that no additional competency checklists or supplemental assessments were performed to evaluate the full range of required HA skills.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure the Hospice Aide (HA) followed the plan of care as written and reported changes to the Registered Nurse (RN). CLINICAL RECORD 2: A review of the patient’s plans of care (POC) for the benefit periods 02/02/2026–04/02/2026 and 04/03/2026–06/01/2026 identified physician-ordered HA visits twice weekly. The HA care plan for these periods directed the aide to perform personal care at each visit, including: standby assistance with toileting, assistance with dressing/undressing, oral care, foot care, fingernail care, perineal care, showering with a shower chair, shampooing hair, provision of skin care, assessment of pressure areas, and reporting concerns to the RN. Documentation from HA visits reflects observations of clinically significant changes in the patient’s condition without evidence of RN notification, as required by the POC and standard practice. Specifically, on 03/13/2026, the HA documented the patient “…was in some pain in the shoulder area on both sides.” Then on 04/10/2026, the HA again documented shoulder pain, and on 05/12/2026, the HA documented “…Pt has a small red area on the bottom.” Across these documented visits, there is no evidence that the RN was notified of the patient’s pain or the newly identified skin concern, despite explicit direction in the HA plan of care to report abnormalities and concerns. CLINICAL RECORD 4: A review of the patient’s POCs for the benefit periods 03/15/2026–05/13/2026 and 05/14/2026–07/12/2026 identified physician orders for HA visits twice weekly. The HA plan of care for these periods directed the aide to perform personal care and observation activities at each visit, including: application of barrier products following perineal care, brief changes, assessment of pressure areas with direction to report concerns to the RN. nail care, assistance with dressing/undressing, foot care, oral care, perineal care, showering with a shower chair, skin care, and shampooing hair. HA visit documentation reflects multiple observations of changes in the patient’s cognitive status, mood, and physical condition without evidence of RN notification, as required by the POC. Specific entries include: on 03/26/2026, the HA documented the patient became angry and resistant to care following confusion regarding the visit time, requiring multiple attempts before care could be completed; on 03/31/2026, the HA documented the patient was “…starting to confuse staff” and expressed frustration related to perceived communication issues; on 04/30/2026, the HA documented the patient engaged in minimal conversation and appeared “very withdrawn;” on 05/11/2026, the HA documented the patient was “sleepier than normal;” and on 05/21/2026, the HA documented the patient was “very stiff this AM, becoming more sleepy.” Across these documented encounters, there is no evidence that the RN was notified of the patient’s behavioral changes, increasing confusion, withdrawal, or functional decline. CLINICAL RECORD 5: A review of the patient’s POC for the benefit period 04/29/2026–06/27/2026 identified physician orders for HA visits twice weekly. The HA plan of care directed the aide to provide personal care and observation at each visit, including applying barrier products after perineal care, changing adult briefs, cleaning and filing fingernails, assisting with dressing/undressing, providing oral care, showering with a shower chair, and shampooing hair. HA documentation identified a significant change in the patient’s behavioral status and safety during care, without evidence of RN notification when, on 05/20/2026, the HA documented: “Pt extremely anxious during shower. Pt tried getting up several times; assistance from a facility aide was required.” There is no documentation indicating the RN was notified of the patient’s acute anxiety, unsafe attempts to rise during showering, or need for additional assistance to complete care. CLINICAL RECORD 8: A review of the patient’s POC for the benefit period 03/10/2026–06/07/2026 identified physician orders for HA visits three times weekly. The HA plan of care directed the aide to perform personal care and observation at each visit, including: assistance with standby toileting needs, changing adult briefs, assessing pressure areas with direction to report concerns to the RN, cleaning and filing fingernails, providing oral care, showering with a shower bench, skin care, and shampooing hair. HA visit documentation reflects multiple instances in which ordered services were not fully provided, and there is no evidence that the RN was notified to evaluate or revise the plan of care. Specifically: on 04/14/2026, the HA documented that the visit consisted only of brief conversation, noting the patient declined additional care due to having received a bath the prior evening; on 04/21/2026, the HA documented the patient had already been toileted and showered earlier by facility staff; on 04/30/2026, the HA documented the patient was initially unavailable due to being out of the facility and returning after receiving a bed bath earlier that day. Upon return, minimal care was provided and the patient “didn’t need much.” Across these visits, there is no documentation indicating the RN was notified that ordered aide services were not delivered as planned, nor that coordination occurred to ensure patient needs were met or to evaluate the continued appropriateness of the existing POC. CLINICAL RECORD 15: A review of the patient’s POC for the identified benefit period revealed physician orders for HA visits twice weekly. The HA plan of care directed the aide to provide personal care and observation at each visit, including: application of barrier products after perineal care, incontinence care, assessment of pressure areas with instruction to report findings to the RN, nail care, assistance with dressing/undressing, foot care, oral care, perineal care, showering with a shower chair, and skin care. HA documentation reflects care encounters in which changes in patient condition and deviations from the plan of care occurred without evidence of RN notification. Specifically: on 05/15/2026, the HA documented the patient expressed reluctance regarding bathing and subsequently fell asleep, with the aide completing only environmental checks and light tasks. The ordered hygiene interventions were not performed as outlined in the POC; on 05/18/2026, the HA documented the patient experienced “minor pain when walking because his legs are aching”. The aide further documented providing the patient with a non-clinical explanation, stating that aging could be the cause of the pain. There is no documentation indicating that the RN was notified of the patient’s reported pain, change in functional status, or incomplete provision of ordered care. An interview conducted on 06/04/2025 with the Director of Compliance, the Regional Director of Compliance, the Director of Clinical Services, and the Administrator (Personnel Record 2) confirmed the record review findings. Leadership representatives confirmed that the clinical record did not contain documentation showing that HAs notified the RN of observed changes in the patient’s condition or instances of incomplete POC implementation.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. 5 of 23 (22%) clinical records reviewed, where all 23 patients accepted Hospice Aide (HA) services, revealed that the agency did not ensure that the Registered Nurse(s) (RN) documented accurate HA supervision, assessing the quality of care and services provided by the HA. CLINICAL RECORD 2: A review of the patient’s plans of care (POC) for the benefit periods dated 02/02/2026 to 04/02/2026 and 04/03/2026 to 06/01/2026 revealed orders for the HA to see the patient twice a week. The HA POC for the same benefit periods included the following hygiene tasks to be completed each visit: standby assistance for bathroom needs, help undress and dress the patient, provide oral care, foot care, fingernail care, perineal care, shower with a shower chair, shampoo hair, skin care, check pressure areas, and report concerns to the RN. During the HA visit on 03/13/2026, the aide noted that the “...pt was in some pain in the shoulder area on both sides,” and on 04/10/2026, the aide again documented shoulder pain. On 05/12/2026, it was noted that the “...Pt has a small red area on the bottom.” None of these visits included any notation that the RN was notified about the patient’s condition. During the RN’s supervision visits on 03/19/2026, 04/16/2026, and 05/18/2026, following these HA visits, the nurse noted that the HA was following the POC and “regularly and quickly notifying the care team of any changes in condition” despite the HA documenting pain and a red area on the patient’s bottom without any notation that the RN was notified. CLINICAL RECORD 4: A review of the patient’s POCs for the benefit periods 03/15/2026–05/13/2026 and 05/14/2026–07/12/2026 identified physician orders for HA visits twice weekly, with clearly defined responsibilities at each visit. These included application of barrier products following perineal care, brief changes, assessment of pressure areas with instruction to report concerns to the RN, nail care, assistance with dressing/undressing, foot care, oral care, perineal care, showering with a shower chair, skin care, and shampooing hair. Review of HA documentation identified multiple observations suggestive of changes in the patient’s cognitive, behavioral, and functional status without evidence of RN notification. On 03/26/2026, the aide documented that the patient became angry and resistant to care, necessitating repeated attempts to complete care. On 03/31/2026, the aide noted the patient was “starting to confuse staff” and expressed frustration. On 04/30/2026, the patient was described as engaging in little conversation and appearing “very withdrawn.” On 05/11/2026, the aide documented that the patient was sleepier than normal, and on 05/21/2026, the patient was noted to be “very stiff this AM, becoming more sleepy.” There was no documentation indicating that the RN was notified of these changes, despite clear direction in the plan of care to report concerns. Upon review of the RN supervisory visit documentation, inconsistencies in both the frequency and accuracy of oversight were noted. HA supervision was documented on 03/09/2026, followed by a 16-day gap until the next supervision visit on 03/25/2026, and a subsequent 20-day gap before supervision on 04/14/2026. During this period, the RN consistently documented that the HA was following the POC accurately and “expediently notifying the necessary personnel of any changes in condition.” This pattern continued in subsequent RN visits, including 05/05/2026, 05/12/2026, and 05/27/2026, during which RN documentation stated that the HA was promptly reporting changes, despite no corresponding evidence of such communication in the HA records. CLINICAL RECORD 5: A review of the patient’s POC for the benefit period 04/29/2026–06/27/2026 identified physician orders for HA visits twice weekly, with assigned responsibilities at each visit including application of barrier products following perineal care, changing adult briefs, nail care, assistance with dressing/undressing, oral care, showering with a shower chair, and shampooing hair. HA documentation on 05/20/2026 identified a significant change in the patient’s condition and safety during care, noting: “Pt extremely anxious during shower. Pt tried getting up several times; assistance from a facility aide was required.” This documentation reflects increased anxiety and unsafe behavior during a high-risk activity; however, there is no evidence that the RN was notified of this change in condition, despite expectations outlined in the care plan. Subsequent RN supervisory documentation dated 05/21/2026 stated that the HA was “consistently and expediently notifying the necessary personnel of any changes in the patient’s condition.” This statement is not supported by HA documentation from the prior encounter, which does not reflect communication of the patient’s acute anxiety or unsafe behaviors. CLINICAL RECORD 8: A review of the patient’s POC for the benefit period 03/10/2026–06/07/2026 identified physician orders for HA visits three times weekly, with clearly defined responsibilities at each visit. These included assistance with standby toileting needs, changing adult briefs, checking pressure areas with directions to report concerns to the RN, nail care, oral care, showering with a shower bench, skin care, and shampooing hair. Review of the HA visit documentation identified multiple instances in which ordered services were not delivered as outlined in the POC. On 04/14/2026, the aide documented that the visit consisted only of conversation, as the patient declined care after having a bath the previous evening. On 04/21/2026, the aide noted that toileting and showering had already been completed earlier by facility staff. On 04/30/2026, the aide documented that the patient was initially unavailable and had already received a bed bath earlier in the day; upon return, minimal care was provided as the patient “didn’t need much.” Across these visits, there is no evidence that the RN was notified that ordered aide services were not completed or that care was provided by others in place of the hospice aide. In contrast, RN supervisory visit documentation dated 04/14/2026, 04/21/2026, 04/24/2026, 04/28/2026, and 05/01/2026 consistently stated that the HA was doing an excellent job following the plan of care, was thorough in completing assigned tasks, and was promptly reporting any changes in the patient’s condition. These statements are not supported by the HA documentation, which reflects deviations from the ordered care and a lack of documented communication to the RN. CLINICAL RECORD 15: A review of the patient’s POC for the identified benefit period confirmed physician orders for HA visits twice weekly, with assigned responsibilities at each visit including application of barrier products following perineal care, incontinence care, assessment of pressure areas with direction to report concerns to the RN, nail care, assistance with dressing/undressing, foot care, oral care, perineal care, showering with a shower chair, and skin care. Review of HA documentation identified instances in which ordered care was not fully performed, and changes in the patient’s condition were noted without evidence of RN notification. On 05/15/2026, the aide documented that the patient expressed reluctance to receive a shower and subsequently fell asleep, with the visit consisting primarily of environmental checks rather than completion of ordered hygiene tasks. On 05/18/2026, the aide documented that the patient was experiencing “minor pain when walking because his legs are aching” and provided an informal explanation attributing the pain to aging. There is no documentation indicating that the RN was notified of the patient’s reported pain or the deviation from the planned care interventions. In contrast, RN supervisory documentation dated 05/20/2026 noted that the current plan of care was being followed and that “changes in condition are being diligently and promptly reported by the HA.” This statement is not supported by the HA documentation, which reflects both incomplete care delivery and unreported patient symptoms. An interview conducted on 06/04/2026 with the Director of Clinical Services, the Compliance Manager, the Regional Director of Compliance, and the Administrator (Personnel Record 2) included a review and discussion of identified gaps in HA supervision and documentation. During the discussion, leadership acknowledged the inconsistency between HA documentation and RN supervisory notes, specifically confirming that RN supervision records indicated the aide was following the plan of care and reporting changes in patient condition, despite the absence of supporting documentation demonstrating that the RN had been notified of those changes or that all ordered care had been completed as written.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the agency’s Volunteer Program documents, along with an interview conducted on 06/02/2026 with the Volunteer Coordinator (VC - Personnel Record 10), determined that the agency has not consistently maintained the federal requirement that volunteer services account for at least five percent (5%) of total patient care hours provided by hospice staff and contracted personnel. While documentation showed the agency achieved a compliant annual average of 5.63% in calendar year 2024, performance declined in 2025, with a year-end average of 4.82%, below the required threshold. In response to this decline, the agency implemented a QAPI Performance Improvement Project (PIP) on 04/13/2026. The plan includes twice-monthly tracking of volunteer hours compared to total patient care hours, with oversight by the Volunteer Coordinator, QAPI team, and Administrator, as well as ongoing review of volunteer documentation and assignments. Year-to-date 2026 data reflect improvement, with monthly averages of 4.51% (January), 4.34% (February), 4.34% (March), 5.31% (April), and 5.06% (May). Leadership attributed part of the challenge to rapid agency growth, noting that the average daily census (ADC) increased significantly from 86 in January 2025 to 264 as of 06/04/2026, more than doubling the number of patients served. The agency has implemented a range of recruitment and retention efforts to address this gap. Recruitment strategies include online platforms such as Idealist and Handshake, as well as word-of-mouth referrals. Retention efforts include volunteer recognition activities, such as appreciation events, newsletters highlighting a “Volunteer of the Month,” onboarding support through accompanied initial visits, and tools designed to make documentation more accessible. The PIP further documented that in March and April 2026, 24 volunteer applications were received, 17 interviews were conducted, and 8 new volunteers were onboarded, pending required screenings and training. A review of the agency’s Volunteer Program documents, along with an interview conducted on 06/02/2026 with the Volunteer Coordinator (VC) (Personnel Record 10), determined that the agency has not consistently maintained the federal requirement that volunteer services account for at least five percent (5%) of total patient care hours provided by hospice staff and contracted personnel. While documentation showed the agency achieved a compliant annual average of 5.63% in calendar year 2024, performance declined in 2025, with a year-end average of 4.82%, below the required threshold. In response to this decline, the agency implemented a QAPI Performance Improvement Project (PIP) on 04/13/2026. The plan includes twice-monthly tracking of volunteer hours compared to total patient care hours, with oversight by the Volunteer Coordinator, QAPI team, and Administrator, as well as ongoing review of volunteer documentation and assignments. Year-to-date 2026 data reflect improvement, with monthly averages of 4.51% (January), 4.34% (February), 4.34% (March), 5.31% (April), and 5.06% (May). Leadership attributed part of the challenge to rapid agency growth, noting that the average daily census (ADC) increased significantly from 86 in January 2025 to 264 as of 06/04/2026, more than doubling the number of patients served. The agency has implemented a range of recruitment and retention efforts to address this gap. Recruitment strategies include online platforms such as Idealist and Handshake, as well as word-of-mouth referrals. Retention efforts include volunteer recognition activities, such as appreciation events, newsletters highlighting a “Volunteer of the Month,” onboarding support through accompanied initial visits, and tools designed to make documentation more accessible. The PIP further documented that in March and April 2026, 24 volunteer applications were received, 17 interviews were conducted, and 8 new volunteers were onboarded, pending required screenings and training.”

“It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home and the plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review and interview. 23 of 23 (100%) clinical records reviewed revealed that the agency did not ensure that the patient’s clinical record included documentation by the Interdisciplinary Group regarding the safe self/family/caregiver administration of medications. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/08/2025 and resides in an Assisted Living Facility (ALF). A review of the plans of care for the benefit periods 03/04/2026 to 05/02/2026 and 05/03/2026 to 07/01/2026 revealed that the hospice did not ensure there was documentation that the Interdisciplinary Group (IDG) evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/07/2025 and resides in an ALF. A review of the plans of care for the benefit periods 04/03/2026 to 06/01/2026 and 02/02/2026 to 04/02/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 3: The hospice benefit election date was 04/10/2026; the patient resides in an ALF. A review of the initial plan of care for the benefit period 04/10/2026 to 07/28/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 4: The hospice benefit election date was 09/16/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 05/14/2026 to 07/12/2026 and 03/15/2026 to 05/13/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 5: The hospice benefit election date was 10/31/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 04/29/2026 to 06/27/2026 and 02/28/2026 to 04/28/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/29/2026 and resides at home. A review of the plan of care for the benefit period 05/29/2026 to 08/26/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/18/2026 and resides in an ALF. A review of the plans of care for the benefit periods 05/19/2026 to 08/16/2026 and 02/18/2026 to 05/18/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 8: The hospice benefit election date was 03/10/2026; the patient resides in an ALF. A review of the initial plan of care for the benefit period 03/10/2026 to 06/07/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/09/2025 and resides in an ALF. A review of the plans of care for the benefit periods 04/07/2026 to 06/05/2026 and 01/07/2026 to 04/06/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/10/2026 and resides in an ALF. A review of the initial plan of care for the benefit period 03/10/2026 to 06/07/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 11: The hospice benefit was elected on 04/05/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 05/30/2026 to 07/28/2026 and 03/31/2026 to 05/29/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 12: The hospice benefit was elected on 02/19/2026; the patient resides at home. A review of the plans of care for the benefit periods 05/20/2026 to 08/17/2026 and 02/19/2026 to 05/19/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/24/2026 and resides in an ALF. A review of the plans of care for the benefit periods 05/23/2026 to 07/21/2026 and 03/24/2026 to 05/22/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 14: The hospice benefit was elected on 01/10/2026; the patient resides in an ALF. A review of the plans of care for the benefit periods 04/1020/26 to 07/08/2026 and 01/10/2026 to 04/09/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 15: The hospice benefit was elected on 06/24/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 04/2020/26 to 06/18/2026 and 02/19/2026 to 04/19/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 16: The hospice benefit was elected on 04/14/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 04/09/2026 to 06/07/2026 and 02/08/2026 to 04/08/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 17: The hospice benefit election date was 01/28/2025; the patient resides in an ALF. A review of the plans of care for the benefit periods 04/23/2026 to 06/21/2026 and 02/22/2026 to 04/22/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 18: The patient elected the hospice benefit on 04/08/2026 and resides in an ALF. A review of the initial plan of care for the benefit period 04/08/2026 to 07/06/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 19: The patient, who resided in an ALF, elected the hospice benefit on 06/25/2025 and revoked on 03/07/2026. A review of the plans of care for the benefit periods 02/21/2026 to 04/21/2026 and 12/23/2025 to 02/20/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 20: The patient, who resided in an ALF, elected the hospice benefit on 01/30/2026 and was transferred/discharged on 04/09/2026. A review of the plans of care for the benefit periods 01/3020/26 to 04/29/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 21: The hospice benefit election date was 12/08/2024 for this patient who resided in an ALF. The patient died on 01/26/2026. A review of the plans of care for the benefit periods 12/14/2025 to 02/11/2026 and 10/15/2025 to 12/13/2025 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 22: The hospice benefit election date was 05/10/2025 for this patient who resided in an ALF. The patient died on 03/08/2026. A review of the plans of care for the benefit periods 03/06/2026 to 05/04/2026 and 01/05/2026 to 03/05/2026 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. CLINICAL RECORD 23: The patient elected the hospice benefit on 09/24/2025 and resided in an ALF. The patient died on 12/11/2025. A review of the plans of care for the benefit periods 11/23/2025 to 01/21/2026 and 09/24/2025 to 11/22/2025 revealed that the hospice did not ensure there was documentation that the IDG evaluated the ability of the patient and/or caregiver to safely administer medications in the home setting and whether self-administration or caregiver administration was appropriate. An interview conducted on 06/02/2026 with the Regional Director of Compliance, the Compliance Manager, and the Administrator (Personnel Record 2) confirmed the findings regarding documentation and care-process gaps within the electronic medical record (EMR). Leadership confirmed that the EMR does not currently include a designated field or structured section to document the assessment of who can safely administer the patient’s medications in the home setting. NOTE: The leadership outlined corrective actions taken in response to the identified gap, including notifying the vendor to develop a system-level solution that incorporates appropriate documentation fields. An interim workaround was implemented, including adding IDG intervention language to capture medication-administration safety assessments within the plans of care. And as of 06/03/2026, the admission process was revised to include assessment of medication administration safety, with a corresponding intervention added to the plan of care for all new admissions.”