Volunteer Hospice

“Based on policy review, medical record review, and interview, the agency failed to ensure the Interdisciplinary Group developed and implemented Plans of Care when they failed to ensure the scope and frequencies of services were included on the Plan of Care for 3 of 10 (Patient #5, #6, and #10) sampled active hospice patients and failed to ensure services were provided according to the Plan of Care for 6 of 10 (Patient #1, #2, #3, #7, #8, and #9) sampled active hospice patients. The findings included: 1.The agency failed to ensure Patient Plans of Care included the scope and frequency of services needed for 3 of 10 (Patient #5, #6, and #10) active patients. The facility was unable to provide physician’s orders or updated Plans of Care for skilled nursing services, hospice aide services, medical social worker services, and spiritual counseling services provided to the patients.Refer to L547 2. The agency failed to ensure care and services were provided according to the Plan of Care and/or physician’s orders for 6 of 10 (Patient #1, #2, #3, #7, #8 and #9) active patients. The facility failed to provide skilled nursing visits, hospice aide visits, and spiritual counseling visits as ordered by the physician and made extra hospice aide visits without a physician’s order. Refer to L555”

“Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure an updated and accurate medication profile for 3 of 3 (Patient #1, #2, and #3) sampled patients with home visits. The findings included: 1. Review of the agency’s “Medication Policies” dated 10/2017 revealed, “...The Monthly Medication Review form is to provide evidence of the review of medications with the patient/family and notes the current medications and dosage.” 2. Medical record review for Patient #1 revealed a start of care date of 10/25/2025 with diagnoses which included Atherosclerotic Heart Disease. Review of the Medication Profile for Patient #1 effective 10/20/2025 through 12/18/2025 revealed:a. Clonazepam (medication used to treat seizure disorders and panic disorder) 1 milligram (mg) by mouth 3 times a day as needed.b. Oxycodone-Acetaminophen (medication used to treat moderate to severe pain) 10/325 mg 1 tablet by mouth every 6 hours as needed. Observations in Patient #1’s home on 12/1/2025 at 4:00 PM, revealed:a. Clonazepam 1 mg tablet by mouth every 4 hours (6 times a day) as needed instead of 3 times a day as indicated on the Medication Profile.b. Oxycodone-Acetaminophen 10/325 mg 1 tablet by mouth every 4 hours as needed instead of every 6 hours as indicated on the Medication Profile. The following medications were observed in Patient #1’s home which were not included on the Medication Profile:a. Loratadine (medication used to treat allergies) 10 mg once a dayb. Docusate Sodium (stool softener laxative) 100 mg once a dayc. Azo Cranberry Supplement (used to support urinary tract health) once a dayd. Nitrofurantoin (used to treat and prevent urinary tract infections) 100 mg once a daye. Esomeprazole Magnesium (used to treat excessive stomach acid) 20 mg once a dayf. Tramadol (used to treat moderate to severe pain) 50 mg 1 tablet by mouth every 6 hours During an interview on 12/1/2025 at 4:24 PM, Patient #1’s husband confirmed the Patient was taking all of the above medications. 3. Medical record review for Patient #2 revealed a start of care date of 10/17/2024 with diagnoses which included Chronic Atrial Fibrillation. Observations in Patient #2’s home, a skilled nursing facility, on 12/2/2025 at 8:30 AM, revealed the Patient was taking the following medications which were not included on the Medication Profile:a. Colchicine (used to treat inflammation) 0.6 mg once a dayb. Docusate sodium 100 mg twice a dayc. Escitalopram (antidepressant) oxalate 20 mg once a dayd. Furosemide (used to treat excessive fluid in the body) 20 mg once a daye. Levothyroxine (used to treat low thyroid levels) 50 micrograms (mcg) once a dayf. Metoprolol succinate (used to treat high blood pressure) 25 mg once a dayg. Mirtazapine (antidepressant) 7.5 mg once a day at bedtimeh. Allopurinol 100 mg, 2 tablets once a dayi. Claritin (loratadine) once a dayj. Melatonin (used to help regulate sleep) 3 mg once a day at bedtimek. Gabapentin (used to treat seizures and nerve pain) 300 mg three times a dayl. Acetaminophen (used to treat mild to moderate pain) 650 mg every 4 hours as needed for pain or feverm. Albuterol sulfate (used to treat wheezing and difficulty breathing) 90 mcg inhalation every 4 hours as neededn. Bisacodyl (laxative) suppository once a day as needed for constipationo. Fleet enema once a day as needed for constipationp. Milk of Magnesia 30 milliliters (ml) once a day as needed for constipationq. Promethazine gel 0.5 ml topically every 4 hours as needed for nausea/vomitingr. Hydrocodone-acetaminophen 7.5-325 mg every 4 hours as needed for pain During an interview on 12/2/2025 at 8:35 AM, the Director of Nursing at the skilled nursing facility verified Patient #2 was taking all of the above medications that were not included on the Patient’s hospice Medication Profile. 4. Medical record review for Patient #3 revealed a start of care date of 8/12/2025 with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the Medication Profile for Patient #3 effective 9/10/2025 through 12/8/2025, revealed Temazepam (used to treat insomnia) 15 mg once daily at bedtime. Observations in Patient #3’s home on 12/2/2025 at 1:20 PM, revealed no Temazepam was in the home. During an interview on 12/2/2025 at 1:30 PM, Patient #3’s wife stated the Patient had not been taking the Temazepam since he started receiving hospice services [6/12/2025]. 5. During an interview on 12/3/2025 at 1:26 PM, the Clinical Administrator (CA) was asked if Medication Profiles should be accurate and match what the patients were actually taking. The CA stated, “Yes.” The CA was asked if nursing staff reviewed medications in the home and compared them with the Medication Profile to ensure they were accurate. The CA stated, “they are supposed to.””

“Based on policy review, medical record review, and interview, the agency failed to ensure Patient Plans of Care included the scope and frequency of services needed for 3 of 10 (Patient #5, #6, and #10) sampled active hospice patients. The findings included: 1. Review of the agency’s “Plan of Care” policy dated 10/2017, revealed, “...An individualized Plan of Care will be established for each hospice patient/family prior to providing care...Information included in the Plan of Care includes...Scope and frequency of services to be provided...” 2. Medical record review for Patient #5 revealed a start of care date of 7/28/2025 with diagnoses which included Cerebral Infarction. Review of the Recertification Plan of Care for benefit period 10/26/2025 through 1/23/2026 revealed the Patient was to receive medical social worker services and spiritual counselor services one time a month for 1 month with a start date of 10/1/2025 and end date of 10/25/2025, hospice aide services and skilled nursing services 3 times a month for 1 month with a start date of 10/6/2025 and end date of 10/25/2025. Review of the electronic medical record revealed Patient #5 received skilled nursing services, hospice aide services, medical social worker services and spiritual counselor services from 10/26/2025 through 12/2/2025. There was no documentation of physician’s orders or an updated Plan of Care to reflect the services provided from 10/26/2025 through 12/2/2025. 3. Medical record review for Patient #6 revealed a start of care date of 4/26/2024 with diagnoses which included Heart Disease. Review of the Registered Nurse (RN) Recertification Assessment completed on 11/5/2025 revealed the Patient was to receive medical social worker services and spiritual counselor services once a month for 2 months with a start date of 10/1/2025 and end date of 11/13/2025, and skilled nursing services and hospice aide services twice a week for 7 weeks with a start date of 10/1/2025 and end date of 11/13/2025. Review of the electronic medical record revealed Patient #6 received skilled nursing services, hospice aide services and medical social worker services from 11/14/2025 through 12/2/2025. There was no documentation of physician’s orders or an updated Plan of Care to reflect the services provided from 11/14/2025 through 12/2/2025. 4. Medical record review for Patient #10 revealed a start of care date 9/3/2025 with diagnoses which included Chronic Diastolic Heart Failure. Review of the Initial Plan of Care for 9/3/2025, revealed the Patient was to receive medical social worker services and spiritual counselor services one time a month with a start date of 9/3/2025, hospice aide services and skilled nursing services 2 times a week with a start date of 9/3/2025. Review of the Comprehensive Plan of Care revealed Patient #10 was to receive skilled nursing services, hospice aide services, medical social worker services and spiritual counselor services from 12/02/2025 through 2/28/2025. There was no documentation of physician’s orders for visit frequencies or an updated Plan of Care to reflect the services provided from 9/3/2025 through 12/2/2025. 5. During an interview on 12/3/2025 at 1:26 PM, the Clinical Administrator stated she was unable to provide updated Plans of Care or physician’s orders to reflect the frequencies of the services provided for Patient #5, #6, and #10.”

“Based on policy review, medical record review, and interview, the agency failed to ensure care and services were provided according to the plan of care and/or physician’s orders for 6 of 10 (Patient #1, #2, #3, #7 #8, and #9) sampled active hospice patients. The findings included: 1. Review of the agency’s “Plan of Care” policy dated 10/2017 revealed, “...All interventions and care provided by hospice staff are to be consistent with the Plan of Care...Any revision documented on the Plan of Care Update is discussed with the patient/family and approved by the IDG [Interdisciplinary Group]. This document serves as a physician’s order and is carried out accordingly...” 2. Medical record review for Patient #1 revealed a start of care date of 10/25/2025 with diagnoses which included Atherosclerotic Heart Disease. Review of the Comprehensive Plan of Care effective 10/20/2025 through 12/18/2025, revealed the Patient was to receive Hospice Aide services 2 times a week beginning the week of 10/20/2025. Review of the Hospice Aide documentation revealed the Patient received Hospice Aide visits three times a week instead of the ordered 2 visits the weeks of 10/20/2025, 10/27/2025, 11/3/2025, 11/10/2025, and 11/17/2025. There was no documentation to indicate why the visits were increased and no documentation the physician was notified. 3. Medical record review for Patient #2 revealed a Start of Care date of 10/17/2024 with diagnoses which included Chronic Atrial Fibrillation. Review of the Recertification Plan of Care effective 10/12/2025 through 12/10/2025 revealed the Patient was to receive skilled nursing visits twice a week for 9 weeks beginning 10/12/2025. Review of the nursing documentation revealed only 1 skilled nursing visit was completed the weeks of 10/12/2025 and 11/23/2025. There was no documentation to indicate why the visits weren’t completed and no documentation the physician was notified. 4. Medical record review for Patient #3 revealed a start of care date of 6/12/2025 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Review of the Comprehensive Plan of Care effective 9/10/2025 through 12/8/2025, revealed the Patient was to receive Hospice Aide services 5 times a week beginning the week of 10/6/2025. Review of the Hospice Aide documentation provided revealed the Patient received Hospice Aide visits two times a week instead of the ordered 5 visits the weeks of 10/13/2025, 10/20/2025, 10/27/2025, and 11/3/2025. There was no documentation to indicate why the visits weren’t completed and no documentation the physician was notified. 5. Medical record review for Patient #7 revealed a start of care date of 10/22/2025 with diagnoses which included Cancer of the Anus and Rectum. Review of the Comprehensive Plan of Care effective 10/22/2025 through 1/19/2025 revealed the Patient was to receive Hospice Aide services 1 time a week beginning the week of 10/22/2025. Review of the Hospice Aide documentation revealed the Patient did not receive Hospice Aide visits one time a week in the weeks of 10/27/2025, 11/3/205, 11/10/2025, and 11/17/2025. There was no documentation to indicate why the visits were not completed and no documentation the physician was notified. 6. Medical record review for Patient #8 revealed a start of care date of 9/27/2024 with diagnoses which included Parkinsonism. Review of the Comprehensive Plan of Care effective 11/21/2025 through 1/19/2026, revealed the Patient was to receive Skilled Nursing services 2 times a week beginning the week of 11/21/2025. Review of the Skilled Nursing documentation provided revealed the Patient did not receive Skilled Nursing visits two times a week the weeks of 11/21/2025, 11/24/2025, and 12/1/2025. There was no documentation to indicate why the visits were not completed and no documentation the physician was notified. 7. Medical record review for Patient #9 revealed a start of care date of 6/7/2024 with diagnoses which included Alzheimer’s Disease. Review of the Physician Order dated 10/1/2025, revealed the Patient was to receive Spiritual Counseling services 1 time a month for 2 months effective 10/1/2025 through 11/28/2025. Review of the Spiritual Counseling documentation revealed no Spiritual Counseling visits were completed the month of November 2025. There was no documentation to indicate why the visit was not completed and no documentation the physician was notified. 8. During an interview on 12/3/2025 at 1:16 PM, the Clinical Administrator verified all disciplines should follow the Plan of Care and/or Physician’s orders for visit frequencies and should document the reason why any visits were missed.”

“Based on policy review, agency document review, medical record review and interview, the agency failed to ensure staff followed their policy for Revocation of services for 7 of 10 (Patient #1, #2, #3, #4, #5, #6, and #10) sampled active hospice patients and failed to send Discharge Summaries to the attending physician for 2 of 2 (Patient #11 and #12) sampled patients who revoked their hospice benefits. The findings included: 1. Review of the agency’s “Revocation” policy dated 10/2017, revealed, “...patients or Medicare patients may revoke the Medicare Hospice Benefit at any time...Complete the Hospice Revocation form stating date of revocation, reason for revocation and signed by the patient/caregiver. The [Hospice agency #1] RN [Registered Nurse] will witness signatures...” 2. Review of the agency’s Patient Census report revealed Patient #1, #2, #3, #4, #5, #6, and #10 were active patients. 3. Medical record review for Patient #1 revealed a start of care date of 10/25/2024 with diagnoses which included Atherosclerotic Heart Disease. Review of the admission paperwork completed on 10/25/2024, revealed both Patient #1 and RN #2 signed the Revocation form. The date the signatures were obtained was left blank. 4. Medical record review for Patient #2 revealed a Start of Care date of 10/17/2024 with diagnoses which included Chronic Atrial Fibrillation. Review of the admission paperwork completed on 8/7/2025, revealed both Patient #2 and the Clinical Administrator signed the Revocation form. The date the signatures were obtained was left blank. 5. Medical record review for Patient #3 revealed a start of care date of 6/12/2025 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Review of the admission paperwork completed on 6/12/2025, revealed both Patient #3 and RN #1 signed the Revocation form. The date the signatures were obtained was left blank. 6. Medical record review for Patient #4 revealed a start of care date of 6/1/2024 with diagnoses which included COPD. Review of the admission paperwork completed on 6/1/2024, revealed both Patient #4 and RN #3 signed the Revocation form. The date the signatures were obtained was left blank. 7. Medical record review for Patient #5 revealed a start of care date of 7/28/2025 with diagnoses which included Cerebral Infarction. Review of the admission paperwork completed on 7/28/2025, revealed both Patient #5 and the Clinical Administrator signed the Revocation form. Patient #5 signed the form on 7/28/2025. The Clinical Administrator did not document the date she signed the form. 8. Medical record review for Patient #6 revealed a start of care date of 4/26/2024 with diagnoses which included Heart Disease. Review of the readmission paperwork completed on 2/6/2025, revealed both Patient #6’s authorized representative and the Clinical Administrator signed the Revocation form. The date the signatures were obtained was left blank. 9. Medical record review for Patient #10 revealed a start of care date of 9/3/2025 with diagnoses which included Chronic Diastolic Heart Failure. Review of the admission paperwork completed on 9/3/2025, revealed both Patient #10 and Clinical Administrator signed the Revocation form. The date the signatures were obtained was left blank. 10. During an interview on 12/3/2025 at 1:26 PM, the Clinical Administrator confirmed Revocation forms were signed by the patients on the day of admission, “because we had some of the hospitals complaining and wouldn’t admit patients without the form...” 11. Medical record review for Patient #11 revealed a start of care date 4/10/2025 with diagnoses which included Infantile Cerebral Palsy. Review of the Revocation Form effective 8/19/2025, revealed Patient #11 chose to revoke hospice services for the following reason, “...pt [patient] requested discharge.” There was no documentation the agency completed a Discharge Summary and/or submitted it to the attending physician noted in Patient #11’s medical record. 12. Medical record review for Patient #12 revealed a start of care date 6/2/2020 with diagnoses which included Alzheimer’s Disease. Review of the Hospice Benefit Revocation form effective 8/6/2025, revealed Patient #12 chose to revoke the hospice benefits for the reason of “...pt’s family requested discharge. There was no documentation the agency completed a Discharge Summary and/or submitted it to the attending physician noted in Patient #12’s medical record. 13. During an interview on 12/3/2025 at 1:26 PM, the Clinical Administrator verified no Discharge Summaries were completed and/or sent to the attending physician for Patient #11 and #12. The Clinical Administrator stated, “we don’t do one [Discharge Summary] when they revoke because they requested it. We haven’t had any true discharges, just deaths.””

“Based on policy review, medical record review and interview, the agency failed to ensure discharge summaries were completed for 2 of 2 (Patient #11 and #12) sampled patients who revoked their hospice benefits. The findings included: 1. Review of the agency’s “Revocation” policy dated 10/2017 revealed, “...patients or Medicare patients may revoke the Medicare Hospice Benefit at any time...Complete the Hospice Revocation form stating date of revocation, reason for revocation and signed by the patient/caregiver...RN [Registered Nurse] will witness signatures...” Review of the agency’s “Clinical Records” policy dated 10/2017 revealed, “...The patient/family record is maintained in accordance with professional standards and contains...Discharge or death summary...” 2. Medical record review for Patient #11 revealed a start of care date 4/10/2025 with diagnoses which included Infantile Cerebral Palsy. Review of an Addendum Note written by Licensed Practical Nurse (LPN) #1 on 8/18/2025 at 10:00 AM, revealed, “Pt [Patient] declined visit per nurse; stated she was changing services to [Hospice Agency #2] ...” Review of the Social Worker Addendum Note dated 8/18/2025, revealed, “[Patient #11] called me and stated that she was not having a good day and that she is looking to transfer her hospice services to a different agency...Her new agency [Hospice Agency #2] will be following up with her...” Review of the Revocation Form effective 8/19/2025 revealed Patient #11 chose to revoke hospice services for the following reason, “...pt requested discharge.” There was no documentation a Discharge Summary was completed for Patient #11. 3. Medical record review for Patient #12 revealed a start of care date 6/2/2020 with diagnoses which included Alzheimer’s Disease. Review of the Hospice Benefit Revocation form effective 8/6/2025, revealed Patient #12 chose to revoke the hospice benefits for the reason of “...pt’s [Patient’s] family requested discharge. There was no documentation a Discharge Summary was completed for Patient #12. 4. During an interview on 12/3/2025 at 1:26 PM, the Clinical Administrator (CA) was asked who was responsible for completing discharge summaries for the patients. The CA stated, “we don’t do one [Discharge Summary] when they revoke because they requested it. We haven’t had any true discharges, just deaths.””