Signature Hospice LLC

“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. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients/families who elected bereavement services revealed that the agency did not ensure development of a bereavement plan of care, that included the types of bereavement services to be offered and the frequency of service delivery, was in place for the bereaved. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/10/2025 and died on 07/22/2025. The clinical record evidenced documented bereavement activities, mailings, letters, and phone call, but there was no bereavement plan of care present in the record. CLINICAL RECORD 12: The patient elected the hospice benefit on 12/09/2025 and died on 01/05/2026. The clinical record evidenced documented bereavement activities, mailings, letters, and phone call, but there was no bereavement plan of care present in the record. During an interview with the Bereavement Coordinator (Personnel Record 4) on 07/16/2026, he stated that he has been doing bereavement for a long time so he has a process and he knew that he had to track the bereavement activities but could not find where to generate the bereavement plan of care in the current electronic medical record and he just dropped the ball but that he would be updating the process and generating a bereavement plan of care even if it needs to be done on paper until the new electronic medical record is ready. During an interview with the Clinical Director (Personnel Record 7) on 07/16/2026, she stated that they keep a spreadsheet to track bereavement activities and document their completion in the clinical record. However, she is not aware of how to add that to the current electronic medical record; they are changing to a different system in a couple of weeks. She does state that the previous Administrator had dropped the ball in a few areas, and they are working on getting everything to where it is supposed to be.”

“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; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed of patients who accepted hospice aide services revealed the agency did not ensure a registered nurse (RN) made an on-site supervisory 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 and ensure that services ordered by the hospice IDG meet the patients’ needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/30/2026. The initial plan of care (POC) ordered hospice aide visits 3 times a week. Hospice Aide services commenced on 03/31/2026. Hospice aide supervisory visits were documented on 04/14/2026 (15 days), 04/27/2026, 05/11/2026, 05/26/2026 (15 days), 06/08/2026, and 06/22/2026. The clinical record lacked evidence that the hospice aide was supervised by a RN with an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/19/2026. The initial POC ordered hospice aide services 3 times a week. Hospice Aide services commenced on 06/22/2026. Hospice aide supervisory visits were documented on 06/29/2026 and 07/14/2026 (15 days). The clinical record lacked evidence that the hospice aide was supervised by a RN with an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/18/2025. Hospice aide visits were completed 2 times a week as ordered on the current POC, effective 06/13/2026, starting 06/16/2026. Hospice aide supervisory visits were documented on 06/01/2026 (previous POC, effective 04/14/2026-06/12/2026), 06/17/2026 (16 days), and 07/01/2026.The clinical record lacked evidence that the hospice aide was supervised by a RN with an on-site visit to the patient’s home no less frequently than every 14 days. During an interview with the Clinical Director (Personnel Record 7) on 07/15/2026, she stated that she was aware of some of the missed supervisory visits due to visits being moved to the next day, however, she stated that she is going to educate her staff to do a supervisory visit every week instead of every 14 days.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed of patients who accepted volunteer services revealed that the agency did not ensure the volunteer services were included in the plans of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/18/2025. There was documentation in the clinical record of a volunteer initial assessment dated 03/11/2026 and volunteer visit notes dated 04/01/2026, 04/16/2026, 04/23/2026, and 05/28/2026. The plans of care dated 02/13/2026 to 04/13/2026 and 04/14/2026 to 06/12/2026 did not include the volunteer visit frequency or define problems with goals or interventions related to volunteer services. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/27/2024. There was documentation of a volunteer initial assessment dated 02/19/2026 and volunteer visit notes dated 02/25/2026, 03/05/2026, 03/12/2026, 03/19/2026, 03/26/2026, 04/16/2026, 04/23/2026, and 05/28/2026. The plans of care dated 01/18/2026 to 03/18/2026, 03/19/2026 to 05/17/2026, and 05/18/2026 to 07/16/2026 do not include the volunteer visit frequency or define problems with goals or interventions related to volunteer services. During an interview with the Clinical Director (Personnel Record 7) on 07/15/2026, she stated that they have had difficulty adding volunteer services to the plans of care in the current electronic medical record (EMR), and they are switching to another EMR in a few months.”

“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. During a review of the volunteer program, it was identified that the agency did not meet the 5% minimum for total patient care hours, day-to-day administrative work, or direct patient care services. There was an absence of documented volunteer hours for July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, and June 2026. The volunteer percentages for 2026 through May are as follows: January 2026 1.25%, February 2026 1.7%, March 2026 3.11%, April 2026 4.6%, and May 2026 0.17%, for an annual average percentage rate for July 1, 2025-May 31, 2026 of 0.9%. During an interview with the Volunteer Coordinator (Personnel Record 6) on 07/16/2026, she stated that she has been working on the volunteer program since her hire (11/03/2025) and that it has come a long way, but still has a way to go. They are looking forward to meeting and exceeding the 5% requirement.”

“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 and interview. 1 of 2 (50%) clinical records reviewed of patients who were discharged from the hospice benefit revealed the agency did not ensure that a copy of the hospice discharge summary and the patient’s record, if requested, was forwarded to the patient’s attending physician. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/10/2026 and chose to revoke the benefit on 04/08/2026. A discharge summary was generated on 04/08/2026, however, there was no documentation that the attending physician was forwarded a copy of the discharge summary. The clinical record review lacked evidence that the agency forwarded a copy of the hospice discharge summary to the patient’s attending physician. During an interview with the Clinical Director (Personnel Record 7) on 07/16/2026, she stated that they have difficulty ensuring compliance with regulatory requirements using the current system. They are changing electronic medical records soon and will review the current process and make changes as needed.”