Mays Hospice Care, Inc.

“Based on record review and interview, the hospice failed to ensure patient pain control for one (Pt #4) patient of 14 patients. Findings: Pt #4A review of a plan of care dated 03/11/26 to 06/08/26 with IDG updates dated 03/25/26, 04/08/26, 04/22/26, 05/06/26, 05/20/26, 06/03/26, 06/17/26, and 07/01/26 did not show what level of pain a nurse should notify the physician. Nurses’ notes showed patient reported pain goal score of 5 of 10. The record showed: 1. A review of a nurse’s note dated 03/17/26, showed a reported pain level of 8. The nurse’s note showed no nursing interventions, physician notification of pain rate above 5, or IDG notification of increased pain level.2. A review of a nurse’s note dated 03/24/26, showed a reported pain level of 7. The nurse’s note showed no nursing interventions, physician notification of pain rate above 5, or IDG notification of increased pain level.3. A review of a nurse’s note dated 03/31/26, showed a reported pain level of 7. The nurse’s note showed no nursing interventions, physician notification of pain rate above 5, or IDG notification of increased pain level.4. A review of a nurse’s note dated 04/02/26, showed a reported a pain level of 7. The nurse’s note showed no nursing interventions, physician notification of pain rate above 5, or IDG notification of increased pain level.5. A review of a nurse’s note dated 04/09/26, showed a reported pain level of 8. The nurse’s note showed no nursing interventions, physician notification of pain rate above 5, or IDG notification of increased pain level On 07/15/26 at 10:56 a.m., Staff B stated the physician and IDG was not notified of increased pain levels and showed no changes in orders.”

“Based on record review and interview the hospice failed to ensure that wound assessments and wound care were completed as ordered for one (Pt #2) of fourteen patients. Findings: A plan of care dated 06/10/26 to 08/08/26 with IDG updates dated 06/17/26 and 07/01/26 showed orders for the nurse to assess the wound every visit and perform wound care to a pressure ulcer on the coccyx. A review of the record showed during nurse visits on 06/10/26, 06/11/26, 06/15/26, 06/17/26, 06/22/26, 06/24/26, 06/29/26, 07/01/26, 07/06/26, and 07/08/26 no wound assessments or wound care were completed. On 07/15/26 at 10:44 a.m., Staff B stated the nurse’s notes showed no wound assessments or wound care.”

“Based on record review and interview, the hospice failed to ensure care was coordinated with a patient’s residential facility for one (Pt #8) of fourteen patients. Findings: Pt #8 A review of the clinical record showed during a nurse visit on 06/16/26 a skin tear to the patient’s right hand was identified. The clinical record showed no coordination with the facility and the hospice IDG to determine who would perform wound care and if orders for wound care were obtained. Nurse visit notes dated 06/18/26, 06/23/26, and 06/25/26 showed no further information on the wound. On 07/15/26 at 11:10 a.m., Staff B stated the nurse notes after 06/16/26 showed no coordination of care between the facility staff and the hospice.”

“Based on record review and interview, the hospice failed to ensure Aide Care Plans were reviewed updated every certification period for two (pts #8, 11) of 14 patients. Findings: Pt #8 A review of the plan of care dated 04/28/26 to 06/26/26 with IDG updates dated 05/06/26, 05/20/26, 06/03/26, and 06/17/26 showed an aide visit frequency of four times for one week and five times a week for eight weeks. A review of the record showed no Aide Care Plan update since the initial Aide Care Plan on 10/30/25 and showed a different aide visit frequency. Pt #11 A review of the plan of care dated 06/06/26 to 08/04/26 with IDG updates dated 06/17/26 and 07/01/26 showed an aide visit frequency of five times a week for eight weeks and twice times a week for one week. A review of the record showed no Aide Care Plan update since the initial Aide Care Plan on 12/13/24 and a different aide visit frequency. On 07/15/26 at 11:10 a.m., Staff B stated that the Aide Care Plans were not updated every certification period.”

“Based on record review and interview, the hospice failed to ensure reports on the cost savings of volunteers in calendar year 2024 and 2025:1. Identified volunteer roles for two (Staff K and L) of two volunteers.2. The estimate of the dollar costs the hospice would have incurred if paid employees provided the services for two (Staff K and L) of two volunteers. Findings: A review of volunteer cost savings records and volunteer hours showed: 1. No differentiation between administrative and clinical volunteer hours.2. The estimate of the dollar costs the hospice would have incurred if paid employees had provided the services. 07/15/26 at 9:52 a.m., Staff A stated the roles of volunteers were not identified, and the dollar costs were not included on the reports.”

“Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for calendar years 2024 and 2025 for all patients and staff. Findings: A review of volunteer records and volunteer hours showed: 1. Calendar year 2024 - 1.01 % cost savings.2. Calendar year 2025 - 0.10% cost savings.The reports showed no differentiation between administrative and clinical volunteer hours. 07/15/26 at 9:52 a.m., Staff A stated the reports for 2024 and 2025 had a cost savings of less than 5%.”

“Based on record review and interview, the hospice failed to ensure personnel records included orientation to the hospice philosophy for eight (Staff E, F, G, H, I, J, K, and L) of eight personnel. Findings: Staff EA review of the personnel record showed no orientation to the hospice philosophy. Staff FA review of the personnel record showed no orientation to the hospice philosophy. Staff GA review of the personnel record showed no orientation to the hospice philosophy. Staff HA review of the personnel record showed no orientation to the hospice philosophy. Staff IA review of the personnel record showed no orientation to the hospice philosophy. Staff JA review of the personnel record showed no orientation to the hospice philosophy. Staff KA review of the personnel record showed no orientation to the hospice philosophy. Staff LA review of the personnel record showed no orientation to the hospice philosophy. On 07/15/26 at 10:05 a.m., Staff B stated they had no documentation that Staff E, F, G, H, I, J, K, and L had hospice philosophy training.”

“Based on record review and interview, the IDG failed to ensure the comprehensive assessment was completed within 5 days of the election of hospice care for four (#1, #8, #11 and #18) of nineteen (#1 -#19) records reviewed. Patient #1 Review of clinical record #1 for certification periods 04/04/24 - 07/02/24 revealed a primary diagnosis of Atherosclerotic Heart Disease and a SOC date of 04/04/24. Further review of Clinical Visit Notes indicated a Social Work Evaluation and the Bereavement Risk Assessment were conducted on 04/10/24 (1 day late). Patient #8 Review of clinical record #8 for certification periods 03/08/24 - 06/05/24 revealed a primary diagnosis of Malignant Neoplasm of the Lung and a SOC date of 03/08/24. Further review of the Client Medication Report indicated a review of the Patient’s current medications by the RN was conducted on 03/15/24 (2 days late). Patient # 11 Review of clinical record #11 for certification periods 03/15/24 - 05/13/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a SOC date of 03/15/24. Further review of Clinical Visit Notes indicated the Bereavement Risk Assessment was completed on 03/21/24 (1 day late). Patient # 18 Review of clinical record #18 for certification periods 02/01/24 - 04/05/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a SOC date of 02/01/24. Further review of Clinical Visit Notes indicated the Bereavement Risk Assessment was completed on 02/29/24 (23 days late). During an interview on 04/24/24 at 10:30 AM, the Director of Nursing stated the IDG members failed to ensure the comprehensive assessment was completed within 5 days as required for Patients #1, #8, #11 and #18.”

“Based on record review and interview, the IDG failed to conduct a Bereavement Risk Assessment to identify needs of the patient and family and to incorporate that information into the hospice bereavement plan of care for five (#2, #13, #16, #17 and #19) of nineteen (#1 -#19) records reviewed. Review of clinical records for Patients #2, #13, #16, #17 and #19, failed to provide evidence of a Bereavement Risk assessment. On 04/24/24 at 10:30 AM, review of a Bereavement Program Client report conducted in coordination with the Director of Nursing and the Vice President failed to provide evidence of Bereavement Risk Assessments for Patients #2, #13, #16, #17 and #19. The Director of Nursing stated the Bereavement Risk Assessments were not completed for the five Patients. (#2, #13, #16, #17 and #19)”