Suncrest Hospice

“Based on record review and interview, the hospice failed to ensure governing body oversight in the conduction of a patient centered QAPI Program for all patients and staff. A review of governing body minutes dated 01/15/24 and 02/11/25 showed no governing body review and approval of the ongoing QAPI program for the hospice in calendar years 2024 and 2025.Additional requests for information yielded no results.On 03/03/26 at 11:20 a.m., Staff A stated:1. The board secretary was not available and the requested additional governing body meeting minutes were not accessible. 2. The governing body meeting minutes did not identify the hospice by location or provider number and did not show oversight of the QA program.”

“Based on record review and interview, the hospice failed to ensure governing board appointment of the administrator for the hospice for all patients and staff. Findings:A pre-survey review of documents provided to the State Agency by the hospice showed Staff B as the administrator. During the survey entrance conference, Staff A was identified as the administrator of the hospice.A review of administrative records showed no appointment of the administrator by the governing body.Request for additional governing body meeting records yielded a typed and unsigned memorandum dated 09/10/25 which showed governing body appointment of Staff A as the administrator and Staff B as the alternate administrator for the hospice.On 03/03/26 at 9:00am, Staff A stated she has been the hospice administrator since May of 2023.On 03/03/26 at 2:00 pm, Staff B Stated:She was the administrator of record for the hospice and Staff A was the backup administrator until September of 2025.The governing board had not designated the administrator or alternate administrator until 09/10/25.”

“Based on interview, record review, and facility policy review, the facility failed to have volunteer hours that equaled five (5) percent (%) of the total patient care hours of paid employees and contract staff. This had the potential to affect all 155 patients receiving hospice services.Findings include:Review of an untitled and undated document, provided by the agency, revealed the agency currently had seven volunteers scheduled for the month of February 2026 with visits planned for 32 patients.During an interview on 02/20/26 at 4:00 PM, the Director of Clinical Services (DCS) confirmed the agency did not have volunteer hours to meet the 5% requirement. He/She further revealed for the year 2025, their average percentage of volunteers was 1.19% and for January 2026, the average percentage was 0.89%. The DCS revealed they hand out brochures at churches, libraries, attend the local colleges, and go to nursing schools in attempts to recruit volunteers.Review of the facility policy titled, “Volunteer Services,” revised December 2025, revealed, “. . . The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel . . .””

“Based on interview, record review, and review of facility policy, the facility failed to ensure discharge summaries were sent to the primary care physician (PCP) for two of four patients (Patient (P) 13 and P15) reviewed for discharge out of a total sample of 15. This had the potential for continuity of care not being met. Findings include: 1. Review of P13’s “Hospice Certification and Plan of Care,” provided by the facility, revealed a start of care date of 08/21/25 with a primary diagnosis of sarcopenia (loss of skeletal muscle mass, strength, and function). The patient revoked hospice services on 09/04/25. Review of the untitled hospital document, dated 08/20/25 and provided by the agency, revealed P15 did have a PCP listed, and a follow up appointment was scheduled with them for 08/26/25. Review of P13’s “Discharge Summary,” dated 09/04/25 and provided by the facility, revealed P13 revoked hospice services on 09/04/25. There was no evidence the patient’s PCP was provided a copy of the discharge summary. The summary listed the hospice agency’s Medical Director as the patient’s physician. The patient’s PCP was not listed on the summary. 2. Review of P15’s “Hospice Certification and Plan of Care,” provided by the facility, revealed a start of care date of 06/13/25 with a primary diagnosis of unspecified protein-calorie malnutrition. The patient revoked hospice services on 07/16/25. Review of an untitled and undated hospital document, provided by the facility, revealed P15 had been admitted to the hospital on 05/29/25 prior to being admitted to hospice services. The hospital document revealed a request was made to the hospice agency to begin hospice services on 06/12/25 or as soon as possible. The document further revealed the patient had a PCP. Review of P15’s “Discharge Summary,” dated 07/16/25 and provided by the facility, revealed P15 revoked hospice services on 07/16/25. The summary indicated the patient would follow up with their PCP. There was no evidence the patient’s PCP was provided a copy of the discharge summary. The summary listed the hospice agency’s Medical Director as the patient’s physician. The patient’s PCP was not listed on the summary. During an interview on 02/20/26 at 3:45 PM, the Senior Director of Clinical Quality (SDCQ) confirmed the discharge summaries for P13 and P15 were not sent to the patient’s PCP. Review of the facility’s policy titled, “Discharge from Hospice Program,” revised June 2022, revealed, “Purpose; to establish standards and a process by which patients are discharged from the hospice program . . . 8. A copy of the discharge summary will be sent to the attending physician.””

“Based on interview, record review, and review of facility policy, the facility failed to ensure discharge summaries were complete for three of four patients (Patient (P) 8, P13, and P15) reviewed for discharge out of a total sample of 15. This had the potential for continuity of care not being met. Findings include: 1. Review of P8’s “Hospice Certification and Plan of Care,” provided by the facility, revealed a start of care date of 08/29/25 with a primary diagnosis of sarcopenia (loss of skeletal muscle mass, strength, and function). Durable Medical Equipment (DME) included a walker, oxygen concentrator, and a shower chair. The patient received hospice services in the home. Review of P8’s “Discharge Summary,” dated 10/17/25 and provided by the facility, revealed P8 revoked hospice services on 10/16/25. The summary indicated that P8s’ primary care physician (PCP) would assume care and hospice could be resumed when the patient chose to stop treatment. There was no documentation included in the summary of care received, post discharge goals, treatment preferences, any DME needed or referrals for DME, drugs or biologicals still needed, any education provided to the patient, or any pain management plan. During an interview on 02/20/26 at 4:30 PM, the Director of Clinical Services (DCS) confirmed the discharge summary for R8 was not complete and lacked information regarding the summary of care received, post discharge goals, treatment preference, or any pain management plan. 2. Review of P13’s “Hospice Certification and Plan of Care,” provided by the facility, revealed a start of care date of 08/21/25 with a primary diagnosis of sarcopenia (loss of skeletal muscle mass, strength, and function). DME included an overbed table, rolling walker, bed rails, and a hospital bed. The patient received hospice services in the home. Review of P13’s “Discharge Summary,” dated 09/04/25 and provided by the facility, revealed P13 revoked hospice services on 09/04/25. The summary indicated that P13 chose to revoke hospice services in order to seek treatment. There were no discharge instructions listed, a summary of care received, post discharge goals, treatment preferences, any DME needed or referrals for DME, drugs or biologicals still needed, any education provided to the patient, or any pain management plan included on the summary. 3. Review of P15’s “Hospice Certification and Plan of Care,” provided by the facility, revealed a start of care date of 06/13/25 with a primary diagnosis of unspecified protein-calorie malnutrition. DME included a wheelchair, bedside commode, and a wheelchair cushion. The patient received hospice services in the home. Review of P15’s “Discharge Summary,” dated 07/16/25 and provided by the facility, revealed P15 revoked hospice services on 07/16/25. The summary indicated that P15 chose to revoke hospice services as they did not feel that they needed hospice services at that time. The summary indicated the patient would follow up with their PCP. There were no discharge instructions listed, a summary of care received, post discharge goals, treatment preferences, any DME needed or referrals for DME, drugs or biologicals still needed, any education provided to the patient, or any pain management plan included on the summary. During an interview on 02/20/26 at 3:45 PM, the Senior Director of Clinical Quality (SDCQ) confirmed the discharge summaries for P13 and P15 were not complete and lacked information regarding the summary of care received, post discharge goals, treatment preference, or any pain management plan. Review of the facility’s policy titled, “Discharge from Hospice Program,” revised June 2022, revealed, “Procedure, the hospice interdisciplinary group will develop a discharge plan . . . 3. When a patient is discharged, transferred, or referred to another organization, relevant information will include . . . B. Physical anti-psychosocial status at the time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services . . . G. Continuing symptom management needs, e.g., pain, nausea, or dyspnea . . . J. Summary of patient education provided to the patient and his/her comprehension of that information . . . L. Recommendations for resources, such as access to durable medical equipment, drugs, and biologicals still needed in self-care post-discharge.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. 1 of 19 (5%) clinical records reviewed revealed the agency failed to ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 2/CCLINICAL RECORD 9: The patient elected the hospice benefit on 04/27/2024. The Medication Profile, printed on 12/02/2025, listed bismuth subsalicylate 262 mg oral tablet, chewable 262 mg oral tablet, chewable, chew 2 tab(s) oral 1 to 3 times a day as needed for abdominal pain started 08/03/2024; Qulipta 60 mg oral tablet, take 1 tab(s) orally once a day for migraine, started 08/03/2024; Refresh Plus ophthalmic solution, apply 1 drop(s) in each eye 4 times a day for dry eyes, started 08/03/2024; Vyzulta 0.024% ophthalmic solution, apply 1 drop(s) in each eye once a day (in the evening) for glaucoma, started 08/03/2024; bismuth 262 mg tablet, chewable, take 2 tab(s) by mouth three times daily as needed for diarrhea, give doses at least one hour apart, started 11/17/2025; Qulipta 60 mg oral tablet 60 mg tablet, take 1 tab(s) by mouth once daily **crush in applesauce**, started 11/17/2025; Refresh artificial tears 0.5% solution, apply 1 drop(s) in each eye four times a day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM for dry eyes, started 11/17/2025; and Vyzulta 0.024% ophthalmic solution drops, administer 1 drop(s) in affected eye(s) at bedtime, keep refrigerated. 1 drop to each eye, started 11/17/2025. During the observed home visit with the Medical Social Worker (PERSONNEL RECORD 6) on 12/03/2025, the medication profile at the assisted living facility (ALF) listed lorazepam oral concentrate 2 mg/ml, 1 prefilled syringe by mouth daily every day at 9:00 PM, started 10/31/2025, bismuth 262 mg tablet, chewable, take 2 tab(s) by mouth three times daily as needed for diarrhea, give doses at least one hour apart; Qulipta 60 mg oral tablet 60 mg tablet, take 1 tab(s) by mouth once daily **crush in applesauce**; Refresh artificial tears 0.5% solution, apply 1 drop(s) in each eye four times a day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM for dry eyes; and Vyzulta 0,024% ophthalmic solution drops, administer 1 drop(s) in affected eye(s) at bedtime, keep refrigerated. 1 drop to each eye. The medications were verified with the medication aide at the ALF. The medication aide stated that the dose for the lorazepam was 0.25 mg per the patient’s record. The most recent comprehensive nursing assessments were competed on 11/25/2025 and 12/02/2025. The agency medication profile contained duplicate drugs and lacked the scheduled lorazepam. During a joint clinical record review and interview on 12/03/2025, the Senior Director of Clinical Quality confirmed that there was no documented evidence that the medication profile was updated at the time of each comprehensive assessment and/or when a new medication was added, or changes were made to existing medications.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) records reviewed with a discharge due to death, revealed the hospice failed to ensure that bereavement services were provided to the bereaved. CLINICAL RECORD 18: The patient’s date of death was 05/22/2025. The communication prep note dated 05/25/2025 documented a condolence call to the primary caregiver and the low-risk bereavement plan of care that included mailings at 1-, 3-, 6-, 9-, and 12-months and/or a phone call support available when requested. The bereavement software program lacked evidence that the bereaved received any phone calls or the 1-, 3-, and 6-month mailings. CLINICAL RECORD 19: The patient’s date of death was 08/02/2025. The communication prep note dated 08/05/2025 documented a condolence call to the primary caregiver and the low-risk bereavement plan of care that included mailings at 1-, 3-, 6-, 9-, and 12-months and/or a phone call support available when requested. The bereavement software program lacked evidence that the bereaved received any phone calls or the 1-, and 3-month mailings. During a joint clinical record review and an interview on 12/04/2025, the corporate Bereavement Coordinator confirmed that there was no documented evidence of full bereavement services being provided. The corporate Bereavement Coordinator stated that a bereavement report is run that includes the patient’s name, the bereaved contact’s name and information, and whether the contact wants bereavement services. In the electronic medical record, each personal contact has an area for an address, phone number and an “Include in Mailings” that has two radial buttons for “yes” or “no.” The Bereavement Coordinator stated that contacts who wanted bereavement would have the “yes” radial button selected and would be added to a bereavement software program used to schedule phone calls and send email mailings. All personal contacts for the two bereavement records, had the “no” radial buttons selected. The corporate Bereavement Coordinator stated that the initial bereavement process starts with the assigned chaplain, or social worker, completing the condolence call and verifing that each contact has the appropriate radial button selected for the requested bereavement follow-up. The corporate Bereavement Coordinator stated that any contacts with a “no” were usually highlighted and forwarded to the local office to verify that they declined bereavement. The corporate Bereavement Coordiantor did not have evidence that this process occurred for the two bereavement records reviewed. During a joint clinical record review and interview on 12/04/2025, the Senior Director of Clinical Quality confirmed that the bereavement records lacked evidence that the bereaved received the services identified in the bereavement plan of care.”

“It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by interview and personnel record review. 1 of 2 (50%) personnel records of hospice aides reviewed revealed the agency failed to ensure that a competency evaluation was completed prior to the aide performing care independently. PERSONNEL RECORD 9: The employee’s date of hire was 12/01/2023. The initial hospice aide competency assessment was completed by a Licensed Practical Nurse on 12/06/2023 and not a Registered Nurse. During a joint personnel record review and an interview on 12/03/2025, the Senior Director of Clinical Quality confirmed that the initial hospice aide competency assessment was completed by a Licensed Practical Nurse. Additionally, the Senior Director of Clinical Quality stated that the local agency completed a competency evaluation by a registered nurse on 11/18/2025, 11/19/2025, and 12/02/2025 to “replace” the initial competency evaluation in 2023, the annual on-site visit for 2024, and for the current year.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. 1 of 2 (50%) personnel records of hospice aides reviewed revealed that the agency failed to ensure that a registered nurse made an annual on-site visit to observe and assess the hospice aide. PERSONNEL RECORD 9: The employee’s date of employment was 12/01/2023. The record lacked evidence that the registered nurse made an annual on-site visit to observe and assess the hospice aide for 2024. During a joint personnel record review and interview on 12/03/2025, the Senior Director of Clinical Quality confirmed that the record lacked evidence of an annual on-site aide supervisory visit for 2024. Additionally, the Senior Director of Clinical Quality stated that the local agency completed a competency evaluation by a registered nurse on 11/18/2025, 11/19/2025, and 12/02/2025 to “replace” the initial competency evaluation in 2023, the annual on-site visit for 2024, and for the current year.”

“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. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. On review of the volunteer program, the documentation revealed that the agency failed to ensure that the total volunteer hours and total patient care hours were at least 5% during December 2024 to November 2025. The average percentage over the past 12 months was 0.97%. The agency had reviewed the volunteer program and created a performance improvement project (PIP) on 07/30/2025, but lacked specific improvement interventions. There was no evidence of improvement from the PIP. The current Volunteer Coordinator’s date of hire was 09/08/2025. The Volunteer Coordinator created SMART goals for each quarter over the next 12 months. The volunteer list contained ten new volunteers who had started in the past two months. During a joint review of the volunteer program records and an interview on 12/05/2025, the Volunteer Coordinator confirmed that the agency did not meet the 5% volunteer percentage from December 2024 to November 2025. The Volunteer Coordinator explained the SMART goals created and initiated since starting at the agency to increase the volunteer pool and volunteer hours, thereby growing the volunteer percentage. During a joint review of the volunteer program records and an interview on 12/05/2025, the Senior Director of Clinical Quality confirmed the volunteer percentage from December 2024 to November 2025 did not meet the 5% requirement. The Senior Director of Clinical Quality stated that the previous Volunteer Coordinator did not focus on recruitment and retention activities and volunteer hours, but on sitting with patients. The Senior Director of Clinical Quality said that the PIP did not contain specific details for the improvement interventions. The PIP was sent to the current Volunteer Coordinator to adjust and incorporate the SMART goals. Upon reviewing the volunteer program, the documentation revealed that the agency did not ensure that the total volunteer hours and total patient care hours were at least 5% during December 2024 to November 2025. The average percentage over the past 12 months was 0.97%. The agency had reviewed the volunteer program and created a performance improvement project (PIP) on 07/30/2025, but lacked specific improvement interventions. There was no evidence of improvement from the PIP. The current Volunteer Coordinator’s date of hire was 09/08/2025. The Volunteer Coordinator created SMART goals for each quarter over the next 12 months. The volunteer list contained ten new volunteers who had started in the past two months.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 2 (100%) clinical records of discharged patients reviewed revealed that the agency failed to ensure the discharge summary was forwarded to the patient’s attending physician. DOCUMENT 1: Agency Document “Performance Improvement Plan” stated in part, “Title: Improvement of Discharge Process for Revocations, Discharges for Cause, and Live Discharges - (Location) Team. Origination Date: November 5, 2025. Completed: Ongoing... Recent internal audits and QAPI data show inconsistencies in how revocations and discharges are processed and documented. Issues identified include: delays in notification of D/C Summaries being sent to applicable parties and gaps in documenting communication with families and other care providers during the transition... Goal: to ensure that 100% of revocations, discharges for cause, and live discharges are completed timely, documented accurately, and in accordance with hospital policy and CMS requirements by improving workflow, communication, and documentation processes.” CLINICAL RECORD 15: The patient was discharged on 03/31/2025. The discharge summary was dated 04/01/2025. The record lacked documentation that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 16: The patient was discharged on 05/14/2025. The discharge summary was dated 05/14/2025. The record lacked documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 12/05/2025, the Senior Director of Clinical Quality confirmed that the records lacked evidence that the discharge summaries were forwarded to the patients’ attending physicians. The Senior Director of Clinical Quality reported that a discharge summary performance improvement project (PIP) was initiated on 11/05/2025.”