Russell-Murray Hospice, Inc.

“Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated or was included as a part of the overall POC after the initial bereavement assessments for two (Patients #4 and #6) of 19 patients. Findings: Patient #4A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 03/22/24, and psychosocial and spiritual assessments on 03/26/24. A review of a POC dated 05/11/26 to 07/09/26 and IDG updates to the POC on 05/19/26, 06/02/26 and on 06/16/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in orders. Patient #6A review of the clinical record showed an election of the hospice benefit and completion of the bereavement assessment on 08/20/25, psychosocial assessment on 08/20/25 and a spiritual assessment on 08/23/25. A review of a POC dated 04/17/26 to 06/15/26 and IDG updates to the POC on 04/28/26, 05/12/26, 05/26/26 and on 06/09/26 showed no bereavement care plan and no bereavement interventions and goals included as a part of the overall POC and showed no changes in orders. On 07/01/26 from 11:02 a.m. to 11:07 a.m., Staff A stated patients #4 and #6 did not have ongoing bereavement care plans.”

“Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include:All services necessary for the palliation and management of the terminal illness for one (Patient #1) of 19 patients.Included hospice aide interventions and goals for 10 (Patients #1, 2, 5, 7, 9, 11, 12, 13, 14 and #17) of 19 patients. Findings: Patient #1A plan of care dated 05/28/26 to 07/26/26 and plan of care updates dated 06/04/26 and 06/18/26 failed to include interventions necessary for the palliation and management of the terminal illness atherosclerotic heart disease and interventions and goals for hospice aide services. On 07/01/26 at 10:50 a.m., Staff A stated:The POC did not include interventions for the palliation and management of atherosclerotic heart disease.The POC did not include interventions and goals for the hospice aide. Patient #2A plan of care dated 04/15/26 to 06/13/26 and plan of care updates dated 04/21/26, 05/05/26, 05/19/26 and 06/02/26 failed to include interventions and goals for hospice aide services. Patient #5A plan of care dated 05/25/26 to 07/23/26 and plan of care updates dated 05/26/26, 06/09/26 and 06/23/26 failed to include interventions and goals for hospice aide services. Patient #7A plan of care dated 05/05/26 to 07/03/26 and plan of care updates dated 05/12/26, and 05/26/26 failed to include interventions and goals for hospice aide services. Patient #9A plan of care dated 04/06/26 to 07/05/26 and plan of care updates dated 04/07/26, 04/21/26, 05/05/26, 05/19/26 and 06/02/26 failed to include interventions and goals for hospice aide services. Patient #11A plan of care dated 04/22/26 to 07/20/26 and plan of care updates dated 05/05/26, 05/19/26, 06/02/26 and 06/16/26 failed to include interventions and goals for hospice aide services. Patient #12A plan of care dated 05/11/26 to 07/09/26 and plan of care updates dated 05/19/26, 06/02/26 and 06/16/26 failed to include interventions and goals for hospice aide services. Patient #13A plan of care dated 05/05/26 to 07/03/26 and plan of care updates dated 05/26/26, 06/09/26 and 06/23/26 failed to include interventions and goals for hospice aide services. Patient #14A plan of care dated 04/30/26 to 06/28/26 and plan of care updates dated 05/12/26, 05/26/26, 06/09/26 and 06/23/26 failed to include interventions and goals for hospice aide services. Patient #17A plan of care dated 09/19/25 to 12/17/25 and plan of care updates dated 10/07/25, 10/21/25, 11/04/25, 11/18/25, 12/02/25 and 12/16/25 failed to include interventions and goals for hospice aide services. On 07/01/26 at 10:55 a.m. to 11:40 a.m., Staff A stated the POCs did not include interventions and goals for the hospice aide services on patients #2, 5, 7, 9, 11, 12, 13, 14 and #17.”

“Based on record review and interview, the hospice failed to ensure the plan of care was developed to include interventions and goals necessary for the identification, palliation and management of pain for two (Patient #4 and #9) of 19 patients. Findings: Patient #4A POC dated 05/11/26 to 07/09/26 and IDG plan of care updates dated 05/19/26, 06/02/26 and 06/16/26 failed to include interventions necessary for the palliation and management of pain for the hospice diagnoses of chronic obstructive pulmonary disease and multi-system degeneration of the autonomic nervous system. The POC showed pain medication of Morphine Sulfate 20 milligrams sublingual every two hours as needed for pain. On 07/01/26 at 11:02 a.m., Staff A stated the POC did not include interventions for the palliation and management of pain. Patient #9A plan of care dated 04/06/26 to 07/05/26 and plan of care updates dated 04/07/26, 04/21/26, 05/05/26, 05/19/26 and 06/02/26 failed to include interventions necessary for the palliation and management of pain for the hospice diagnoses of senile degeneration of the brain and malignant neoplasm of the prostate. The POC showed pain medication of Morphine Sulfate 20 milligrams sublingual every two hours as needed for pain. On 07/01/26 at 11:15 a.m., Staff A stated the POC did not include interventions for the palliation and management of pain.”

“Based on record review and interview, the hospice failed to ensure patient refusal of hospice aide and nursing visits were communicated and addressed by the IDG for two (Patients #1 and #2) of 19 patients. Findings: Patient #1 A plan of care dated 05/28/26 to 07/26/26 and plan of care updates dated 06/04/26 and 06/18/26 showed a hospice aide visit frequency of one time a week and a nursing visit frequency of one time a week. A review of the clinical record showed hospice aide missed visits on 06/03/26, 06/10/26, 06/17/26, 06/19/26 (four visits ordered, no visits conducted) and nursing missed visits on 05/29/26 and 06/12/26 (two visits ordered, no visits conducted). The clinical record showed no attempts to reschedule the visits and showed no IDG team meeting discussions of patient refusal of the hospice aide and nursing visits and showed no changes in orders. On 07/01/26 at 10:50 a.m., Staff A stated the patient’s refusal of visits was not discussed during the IDG team meetings and there were no changes in the orders. Patient #2 A plan of care dated 04/15/26 to 06/13/26 and plan of care updates dated 04/21/26, 05/05/26, 05/19/26 and 06/02/26 showed a hospice aide visit frequency of three times a week. A review of the clinical record showed hospice aide visits were conducted two times a week from 04/21/26 to 06/12/26 (24 visits ordered, 16 visits conducted). The clinical record showed no attempts to reschedule the visits and showed no IDG team meeting discussions of the hospice aide visits and showed no changes in orders. On 07/01/26 at 10:55 a.m., Staff A stated the aide visit frequency was not discussed during the IDG team meetings and there were no changes in the orders.”

“Based on record review and interview, the hospice failed to ensure services were provided in accordance with the plan of care for four (Patients #4, 5, 6 and #19) of 19 patients. Findings: Patient #4A POC dated 05/11/26 to 07/09/26 and IDG plan of care updates dated 05/19/26, 06/02/26 and 06/16/26 ordered SN to monitor the patient’s weight or arm circumference measurements once a week. The clinical record showed no weight or arm circumference monitoring during the weeks of:05/10/26 to 05/16/26 SN visit on 05/12/2605/17/26 to 05/23/26 SN visits on 05/19/26 and 05/20/2605/24/26 to 05/30/26 SN visit on 05/26/2605/31/26 to 06/06/26 SN visit on 06/02/2606/07/26 to 06/13/26 SN visit on 06/09/2606/14/26 to 06/20/26 SN visit on 06/16/2606/21/26 to 06/27/26 SN visit on 06/23/26 The clinical record showed no patient or family refusal of monitoring and no changes in the orders. Patient #5A POC dated 05/25/26 to 07/23/26 and IDG plan of care updates dated 05/26/26, 06/09/26 and 06/23/26 ordered SN to monitor the patient’s weight monthly. The clinical record showed no weight monitoring during visits on:05/26/26, 05/28/2606/09/2606/16/2606/23/26 The clinical record showed no patient or family refusal of monitoring and no changes in the orders. On 07/01/26 at 11:02 a.m. to 11:05 a.m., Staff A stated the weight and/or arm circumference monitoring was not conducted for patients #4 and #5. Patient #6A POC dated 04/17/26 to 06/15/26 and IDG plan of care updates dated 04/28/26, 05/12/26, 05/26/26 and on 06/09/26 ordered chaplain visits once a week. The clinical record showed no chaplain visits for the weeks of:04/19/26 to 04/25/2605/24/26 to 05/30/2605/31/26 to 06/06/26 The clinical record showed no patient or family refusal of visits and no changes in the orders. On 07/01/26 at 11:07 a.m., Staff A stated the chaplain visits were not conducted as ordered. Patient #19A review of the plan of care dated 09/10/25 to 10/13/25 ordered social work visits once a month. The clinical record showed telephone contact by the social worker to the patient on 09/18/25 and on 10/10/25 but showed no social work visits were conducted. The clinical record showed no patient or family refusal of visits and no changes in the orders. On 07/01/26 at 11:50 a.m., Staff A stated the social work visits were not conducted as ordered.”

“Based on record review and interview, the agency failed to ensure continued review and update of a hospice aide care plan for one (Patient #1) of 19 patients. Findings: Patient #11A plan of care dated 04/22/26 to 07/20/26 and plan of care updates dated 05/05/26, 05/19/26, 06/02/26 and 06/16/26 ordered hospice aide visits at a frequency of two times a week. An IDG update dated 05/19/26 changed the aide orders to two-persons assistance every visit. The hospice aide care plan last dated 04/22/26 showed no update to two-person assistance every visit. On 07/01/26 at 11:24 a.m., Staff A stated the hospice aide care plan was not updated after the orders changed.”

“Based on record review and interview, the hospice failed to ensure a completed summary of care was provided to the physician at the time of discharge from the hospice for two (Patients #15 and #16) of 19 patients. Findings: Patient #15A review of the clinical record showed the patient revoked hospice services on 01/02/26 and was transferred to another hospice service provider. The clinical record showed no discharge summary was provided to the physician. Patient #16A review of the clinical record showed the patient revoked hospice services on 03/31/26 and was transferred to a hospital service provider for surgery. The clinical record showed no discharge summary was provided to the physician. On 07/01/26 at 11:34 a.m. to 11:36 a.m., Staff A stated the hospice failed to provide a completed summary of care to the physician for patients #15 and 16.”

“Based on record review and interview, the hospice failed to ensure effective pain management was provided for one (Patient #18) of 19 patients. Patient #18 A review of the plan of care dated 10/13/21 to 01/10/22 showed a primary diagnosis of cancer of the lung and documented a skilled nurse frequency of five visits per week for 13 weeks. A review of the clinical record showed the following: A skilled nurse assessment dated10/15/21 documented the patient’s pain as 9 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/16/21 documented the patient’s pain as 10 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/18/21 documented the patient’s pain as 8 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/19/21 documented the patient’s pain as 9 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/20/21 documented the patient’s pain as 9 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/21/21 documented the patient’s pain as 9 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated10/22/21 documented the patient’s pain as 9 out of 10 on the classic 1-10 pain scale. Documentation showed medication was administered with no documented follow up to the effectiveness of the pain medication. Documentation showed no other interventions provided and no physician notification of the elevated pain level. On 03/28/22 at 2:40 pm., Staff B stated pain was not managed appropriately for Patient #18.”

“Based on record review and interview, the hospice failed to ensure 1. hospice aide visits were provided in accordance with the plan of care for two (Patients #1 and 6) of 19 patients and 2. social worker visits were provided in accordance with the plan of care for one (Patient #12) of 19 patients. Patient #1 A review of the plan of care dated 12/24/23 to 02/21/24 showed a hospice aide frequency of three visits per week for 10 weeks. A review of the clinical record showed the following: A hospice aide missed visit note dated 01/08/24 documented the reason for the missed visit as “Due to being off” for the week of 01/07/24 to 01/13/24 (only two of three completed visits for this week). Documentation showed no patient or family refusal of visits and no change in the ordered frequency. Patient #6 A review of the plan of care dated 12/03/23 to 01/31/24 showed a hospice aide frequency of three visits per week for 10 weeks. A review of the clinical record showed the following: A hospice aide missed visit note dated 12/27/23 documented the reason for the missed visit as “Due to being off” for the week of 12/24/23 to 12/30/24 (only one of three completed visits for this week). Documentation showed no patient or family refusal of visits and no change in the ordered frequency. A hospice aide missed visit note dated 01/05/24 documented the reason for the missed visit as “Due to being off” for the week of 12/31/23 to 01/06/24 (only two of three completed visits for this week). Documentation showed no patient or family refusal of visits and no change in the ordered frequency. Patient #12 A review of the plan of care dated 01/27/24 to 03/26/24 showed a social worker frequency of one visit per month. A review of the clinical record showed the following: A social worker visit dated 02/23/24 documented the reason for the missed visit as “not home today” (no visits were completed for the month of February). Documentation showed no patient or family refusal of visits and no change in the ordered frequency. No documentation of attempts to reschedule the missed visit.On 03/28/24 at 2:50 p.m., Staff B stated: 1. the hospice aide frequency was not followed as ordered for Patients #1 and #6 and 2. the social worker frequency was no followed as ordered for Patient #12.”

“Based on record review and interview, the hospice failed to ensure an individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for nineteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19) of 19 patients reviewed. Patient #1 A plan of care dated 12/24/23 to 02/21/24 documented a primary diagnosis of Alzheimer’s disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #2 A review of the plan of care dated 02/18/24 to 05/17/24 documented a primary diagnosis of cancer of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #3 A plan of care dated 01/27/24 to 03/26/24 documented a primary diagnosis of end stage renal disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 12/14/23 to 03/12/24 documented a primary diagnosis of Pompe disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #5 A plan of care dated 01/03/24 to 04/01/24 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #6 A plan of care dated 12/03/23 to 01/31/24 documented a primary diagnosis of Parkinson’s disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #7 A plan of care dated 01/22/24 to 03/21/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #8 A plan of care dated 03/12/24 to 06/09/24 documented a primary diagnosis of heart disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #9 A plan of care dated 12/25/23 to 02/22/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #10 A plan of care dated 12/04/23 to 03/02/24 documented a primary diagnosis of cancer of the prostate and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #11 A plan of care dated 01/11/24 to 04/09/24 documented a primary diagnosis of abdominal aortic aneurysm and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #12 A plan of care dated 01/27/24 to 03/26/24 documented a primary diagnosis of amyotrophic lateral sclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #13 A plan of care dated 01/22/24 to 03/21/24 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #14 A plan of care dated 12/25/23 to 02/22/24 documented a primary diagnosis of chronic obstructive pulmonary disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #15 A plan of care dated 02/16/24 to 05/15/24 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #16 A plan of care dated 01/11/24 to 03/10/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #17 A plan of care dated 03/13/24 to 05/11/24 documented a primary diagnosis of amyotrophic lateral sclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #18 A plan of care dated 10/13/23 to 01/10/24 documented a primary diagnosis of cancer of the lung and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #19 A plan of care dated 01/27/24 to 03/26/24 documented a primary diagnosis of Alzheimer’s disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 03/28/24 at 2:35 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19 failed to include services necessary for the palliation and management of the terminal illness.”

“Based on record review and interview, the agency failed to ensure services were coordinated with the physician regarding missed visits for six (Patients #4, 6, 9, 10, 12 and 14) of 19 patients. Patient #4 A plan of care dated 12/14/23 to 03/12/24 showed a skilled nurse frequency of two visits per week for 14 weeks and a hospice aide frequency of one visit per week for 14 weeks. A review of the clinical records showed the following: A hospice aide missed visit note dated 12/22/23 documented the physician was not notified of the missed visit. A skilled nurse missed visit note dated 12/22/23 documented the physician was not notified of the missed visit. A skilled nurse missed visit note dated 01/02/24 documented the physician was not notified of the missed visit. A skilled nurse missed visit note dated 01/05/24 documented the physician was not notified of the missed visit. A skilled nurse missed visit note dated 02/02/24 documented the physician was not notified of the missed visit. Patient #6 A plan of care dated 12/03/23 to 01/31/24 showed a hospice aide frequency of three visits per week for 10 weeks. A review of the clinical records showed the following: A hospice aide missed visit note dated 12/25/23 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 12/27/23 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/01/24 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/05/24 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/31/24 documented the physician was not notified of the missed visit. Patient #9 A plan of care dated 12/25/23 to 02/22/24 showed a hospice aide frequency of three visits per week for 10 weeks. A review of the clinical records showed the following: A hospice aide missed visit note dated 12/25/23 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/01/24 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/03/24 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/15/24 documented the physician was not notified of the missed visit. A hospice aide missed visit note dated 01/31/24 documented the physician was not notified of the missed visit. Patient #10 A plan of care dated 12/04/23 to 03/02/24 showed a social worker visit frequency of one visit per month. A review of the clinical record showed the following: A social worker missed visit note dated 01/08/24 documented the physician was not notified of the missed visit. Patient #12 A plan of care dated 01/27/24 to 03/26/24 showed a social worker visit frequency of one visit per month. A review of the clinical record showed the following: A social worker missed visit note dated 02/23/24 documented the physician was not notified of the missed visit. Patient #14 A plan of care dated 12/25/23 to 02/22/24 showed a social worker visit frequency of one visit per month. A review of the clinical record showed the following: A social worker missed visit note dated 02/19/24 documented the physician was not notified of the missed visit. On 03/28/24 at 3:15 pm., Staff stated there was no documentation of the physician notification of missed visits for Patients #4, 6, 9, 10, 12 and 14.”

“Based on record review and interview, the hospice failed to the ensure plans of care was coordinated with the long-term care facility for four (Patients #1, 6, 7 and 8) of 19 patients reviewed. Patient #1 A plan of care dated 12/24/23 to 02/21/24 showed a primary diagnosis of Alzheimer’s disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #6 A plan of care dated 12/03/23 to 01/31/24 showed a primary diagnosis of Parkinson’s disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #7 A plan of care dated 01/22/24 to 03/21/24 showed a primary diagnosis of senile degeneration of the brain and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. Patient #8 A plan of care dated 03/12/24 to 06/09/24 showed a primary diagnosis of heart disease and documented no patient specific interventions to be provided by the nursing home or the hospice for the palliation and management of the terminal illness. On 03/28/24 at 2:50 pm, Staff stated the plan of care for Patients #1, 6, 7 and 8 did not outline the patient specific interventions to be to be provided by the nursing home or the hospice for the palliation and management of the terminal illness.”