Maverick Hospice Care

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure coordination of care with the Interdisciplinary Group when there were changes in the patient’s condition. AGENCY POLICY: The hospice’s policy entitled, “Communication,” dated 4Q2021, included in part “...Purpose: To document communication regarding patient care, the actions taken and any follow through and promote interdisciplinary group coordination. The hospice must designate a registered nurse (RN) that is a member of the interdisciplinary group (IDG) to provide coordination of care ...ensure the ongoing and sharing of information between all disciplines providing care and services in all settings...If any changes in the POC need to be made, the appropriate clinician will document his/her communication with the IDG and participation in the change.” CLINICAL RECORD 8: The patient’s election of benefits was 07/08/2025 with diagnosis of end stage heart failure, end stage renal disease, renal dialysis, and gastrostomy. A review of the clinical record included a communication note dated 07/31/2025 documented by the Registered Nurse (RN) and read “Patient’s care giver (CG) notified office via phone call to state that he had tested positive for COVID 19 and so had his sister-in-law and brother. CG self-tested patient at home and patient is negative...” Then on 08/03/2025 another communication note was entered into the clinical record by the RN and included in part that “Patient’s CG called to notify that patient was retested for COVID-19 today and got a positive result. CG reports patient is showing minimal s/s of infection...MD (name) notified...” A physician’s order dated 07/31/2025 included a nebulizer machine and the following new medications: Ipratropium Bromide Inhalation Solution 0.02% - 1 vial via neb twice a day for shortness of breath or congestion; guaifenesin oral tablet 400mg - 1 to 2 tablets via PEG tube every 4 hours as needed for cough or congestion; and Albuterol Sulfate Inhalation Solution 2.5mg/3ml) 0.083% - 1 vial via nebulizer 4 times a day as needed for cough or congestion. Visits were made by the RN on 08/04/2025, 08/07/2025, and 08/12/2025. There was no documented evidence of any further collaboration with the Interdisciplinary Group. During the Interdisciplinary Group (IDG) Meeting on 08/15/2025, the nurse documented that the “Pt/family reported/noted with no signs or symptoms of COVID-19...and have not been in contact with COVID-19 positive person in the past 14 days...” There was no documentation of the patient and family’s recent COVID-19 infections or any follow-up. No further communication notes were documented after 08/03/2025 regarding the COVID-19 infections in the home. The hospice aide’s and the homemaker’s care plans were not updated to reflect a change in precautions, with visits made by each discipline from the hospice aide twice and homemaker five times weekly. There was no documented evidence of an infection control report. A joint clinical record review and interview with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3) on 09/12/2024, confirmed the evidence and lack of an infection control report.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 3: The patient’s election of the hospice benefit was 03/20/2025 with diagnosis of malignant neoplasm of colon and neoplasm intrabdominal lymph nodes, and colostomy. During the registered nurse’s initial assessment for malignant neoplasm of the colon on 03/20/2025, she noted the patient rated his pain at a 4/10 emanating from his right lower abdomen that occurred frequently and was described as a dull ache that was relieved with rest and medication and worsened by movement. His stated pain goal during that visit was 0, with a score of 5 warranting further attention. A physician order dated 03/20/2025 included Tramadol 50mg - 1 tablet by mouth every 8 hours as needed for pain and Morphine Sulfate ER Beads Oral Capsules (ER 24H/30mg) - 1 capsule by mouth every 6 hours as needed for pain. Another order was documented on 04/25/2025 for Hydrocodone - Acetaminophen 10mg/325mg - 1 tablet by mouth every 4-6 hours as needed for pain. During the RN’s visit on 06/17/2025, the patient rated his pain a 3/10 and told the nurse that it was now a continuous dull ache to right lower quadrant. He stated his pain goal of 2. The plans of care for the benefit periods 03/20/2025 to 06/17/2025 and 06/18/2025 to 09/15/2025 included an identified problem for pain initiated 03/20/2025. The pain goals documented were that patient would report his pain is managed with the present medication management and will verbalize an understanding of the medication regimen. The patient’s stated pain goal on 03/20/2025 was 0 but on 06/17/2025 he changed his stated goal to 2. The goals as documented in the plan of care did not specify patient’s stated goal and were not measurable. During a joint clinical record review and interview with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3) on 09/11/2025, the findings were confirmed.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan. no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s plan of care was updated to accurately reflect changes in the patient’s assessment. CLINICAL RECORD 8: The patient’s election of benefits was 07/08/2025 with diagnosis of end stage heart failure, end stage renal disease, renal dialysis, and gastrostomy. A review of the clinical record revealed a communication note dated 07/31/2025 documented by the registered nurse (RN) read “Patient’s caregiver (CG) notified office via phone call to state that he had tested positive for COVID 19 and so had his sister- in -law and brother. CG self-tested patient at home and patient is negative...” Then on 08/03/2025 another communication note was entered into the clinical record by the RN and included in part that “Patient’s CG called to notify that patient was retested for COVID-19 today and got a positive result. CG reports patient is showing minimal s/s of infection...MD (name) notified...” A physician’s order dated 07/31/2025 included a nebulizer machine and the following new medications: Ipratropium Bromide Inhalation Solution 0.02% - 1 vial via neb twice a day for shortness of breath or congestion; guaifenesin oral tablet 400mg - 1 to 2 tablets via PEG tube every 4 hours as needed for cough or congestion; and Albuterol Sulfate Inhalation Solution 2.5mg/3ml) 0.083% - 1 vial via nebulizer 4 times a day as needed for cough or congestion. Visits were made by the RN on 08/04/2025, 08/07/2025, and 08/12/2025. There was no documented evidence of any further collaboration with the Interdisciplinary Group . During the Interdisciplinary Group (IDG) Meeting on 08/15/2025, the nurse documented that the “Pt/family reported/noted with no signs or symptoms of COVID-19...and have not been in contact with COVID-19 positive person in the past 14 days...” There was no documentation of the patient and family’s recent COVID-19 infections or any follow-up. No further communication notes were documented after 08/03/2025 regarding the COVID-19 infections in the home. The hospice aide’s and the homemaker’s care plans were not updated to reflect a change in precautions, with visits made by each discipline from (hospice aide 7/30 - 8/13) (homemaker 5w Monday Friday). There was no documented evidence of an infection control report. There was no documented evidence that the plan of care was not updated to reflect a change in the patient’s assessment. During a joint clinical record review and interview on 09/12/2025 with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3), the evidence was confirmed.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure an exchange of patient information to assist with coordination of services. AGENCY POLICY: Communication 4Q2021 “...Purpose: To document communication regarding patient care, the actions taken and any follow through and promote interdisciplinary group coordination. The hospice must designate a registered nurse (RN) that is a member of the interdisciplinary group (IDG) to provide coordination of care ...ensure the ongoing and sharing of information between all disciplines providing care and services in all settings...If any changes in the POC need to be made, the appropriate clinician will document his/her communication with the IDG and participation in the change..” CLINICAL RECORD 8: The patient’s election of benefits was 07/08/2025 with diagnosis of end stage heart failure, end stage renal disease, renal dialysis, and gastrostomy. Upon review of the clinical record a communication note dated 07/31/2025 documented by the Registered Nurse (RN) read “Patient’s CG notified office via phone call to state that he had tested positive for COVID 19 and so had his sister in law and brother. CG self-tested patient at home and patient is negative...” Then on 08/03/2025 another communication note was entered into the clinical record by the RN and included in part that “Patient’s CG called to notify that patient was retested for COVID-19 today and got a positive result. CG reports patient is showing minimal s/s of infection...MD (name) notified...” A physician’s order dated 07/31/2025 included a nebulizer machine and the following new medications: Ipratropium Bromide Inhalation Solution 0.02% - 1 vial via neb twice a day for shortness of breath or congestion; guaifenesin oral tablet 400mg - 1 to 2 tablets via PEG tube every 4 hours as needed for cough or congestion; and Albuterol Sulfate Inhalation Solution 2.5mg/3ml) 0.083% - 1 vial via nebulizer 4 times a day as needed for cough or congestion. Visits were made by the RN on 08/04/2025, 08/07/2025, and 08/12/2025. No mention of any further collaboration with the Interdisciplinary Group was noted. During the Interdisciplinary Group (IDG) Meeting on 08/15/2025, the nurse documented that the “Pt/family reported/noted with no signs or symptoms of COVID-19...and have not been in contact with COVID-19 positive person in the past 14 days...” There was no documentation of the patient and family’s recent COVID-19 infections or any follow-up. No further communication notes were documented after 08/03/2025 regarding the COVID-19 infections in the home. The Hospice Aide’s and the Homemaker’s care plans were not updated to reflect a change in precautions, with visits made by each discipline from (hospice aide 7/30 - 8/13) (homemaker 5w Monday-Friday). There was no documented evidence for the exchange of patient information to assist with coordination of services in accordance with the agency policy. During a joint clinical record review and interview on 09/12/2025 with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3), the evidence was confirmed.”

“It is required that the hospice provides infection control education to employees, contracted providers, patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that infection control education was provided to the patient and family. AGENCY POLICY: Infection Prevention & Control in the Home Setting 2Q24 “...All persons attending the patient will be instructed on transmission-based precautions to be used in addition to standard precautions when indicated...The agency shall provide infection control education to...patients, family members...” “...Infection control education to patients and caregivers shall be provided to include standard precautions and prevention and control of infection, specific to the patient’s plan of care, health condition...reviewed with the patient and his/her representative...” CLINICAL RECORD 8: The patient’s election of benefits was 07/08/2025 with diagnosis of end stage heart failure, end stage renal disease, renal dialysis, and gastrostomy. The review of the clinical record included a communication note dated 07/31/2025 was documented by the registered nurse (RN) that read “Patient’s caregiver (CG) notified office via phone call to state that he had tested positive for COVID 19 and so had his sister-in-law and brother. CG self-tested patient at home and patient is negative...” Then on 08/03/2025 another communication note was entered into the clinical record by the RN and included in part that “Patient’s CG called to notify that patient was retested for COVID-19 today and got a positive result. CG reports patient is showing minimal s/s of infection...MD (name) notified...” During the RN visits on 08/04/2025, 08/07/2025, and 08/12/2025 there was no documented evidence of education on COVID-19 or infection control provided to the patient and family. During a joint clinical record review and interview with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3) on 09/12/2025, the lack of infection control education provided to the patient and family was confirmed.”

“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, document review, and interview. In 1 of 2 (50%) bereavement clinical records reviewed revealed the agency did not ensure that a bereavement plan of care was documented upon the patient’s death. AGENCY POLICY: The agency’s policy “Bereavement Services and Coordination” dated 4Q2021 read in part that “...The bereavement plan of care will note the kind of bereavement services to be offered and the frequency of service delivery. The goals of the bereavement program are to provide the bereaved with information about the normal grief process; to provide the bereaved a supportive opportunity to review and reflect upon the experiences of caring for their loved one and their loss experiences; to assess and monitor individual coping ability, risk and stress levels, and any available support the bereaved may have...” CLINICAL RECORD 13: The patient elected the hospice benefit on 01/20/2025 and died on hospice services on 06/21/2025. There was no bereavement plan of care documented or scanned into the clinical record for the bereavement period 06/22/2025 to 07/22/2025. During a joint clinical record review and interview with the Quality Nurse (Personnel Record 3) on 09/11/2025, she confirmed that no plan of care was documented into the clinical record. The Chaplain was hired 06/17/2025 and this death occurred just after his beginning with the agency.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed a training and competency evaluation program described below. The competency evaluation addresses each of the following subject areas, and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including reading and recording temperature, pulse, and respiration. The appropriate and safe techniques in performing personal hygiene and grooming tasks, including bed bath, hair shampoo (sink, tub, and bed), toileting and elimination, and safe transfer techniques and ambulation. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) Hospice Aide personnel files reviewed revealed the agency did not ensure documentation of the hospice aide’s competency by direct observation of the aide performing personal hygiene/grooming skills on the initial or subsequent annual competency assessment. AGENCY POLICY: The agency’s policy entitled, “Competency and Training” and dated 4Q2021 read in part that “...The RN Clinical Manager or qualified designee who is a registered nurse will evaluate and perform nursing and aide competency assessments...” AGENCY POLICY: The hospice’s policy “Aide & Homemaker Criteria for Employment and Competency,” dated 4Q2021 read in part that the “...Hospice aide qualifications...A competency evaluation program that meets the training requirements listed in this policy and includes evaluation by observation of the aide’s performance with a patient...Training will address each of the following...Communication skills...Requires observation and evaluation of performance with an actual or pseudo patient as part of a simulation...Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath, sponge, tub, and shower bath, hair shampoo (sink, tub, bed), nail and skin care, oral hygiene, toileting and elimination. Requires observation and evaluation of performance with an actual or pseudo-patient as part of a simulation: safe transfer technique and ambulation, normal range of motion and positioning...” AGENCY POLICY: Periodic Evaluation of All Workers 4Q2021 All performance evaluations will be completed annually...documentation of regulatory required on-site supervisory visits may be included. STATE REGULATIONS: Hospice Aide Supervision during an On-Site Visit - During an on-site visit, the RN must assess the aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria including: following the client’s plan of care for completion of tasks assigned to the hospice aide by an RN; creating successful interpersonal relationships with the client and the client’s family; demonstrating competency with assigned tasks; complying with infection control policies and procedures; and reporting changes in the client’s condition. PERSONNEL RECORD 7: The personnel record for the hospice aide hired on 05/16/2024 was reviewed. The Initial Competency Assessment - CNA, Home/Hospice Care Aide form was signed and dated by both the hospice aide and the registered nurse (RN) on 05/16/2024. The RN marked that the hospice aide was competent on all the tasks included on the agency’s form. There was no documentation of the method of evaluation utilized. There was a Supervisory Visit documented in a clinical record on 05/20/2024 by the RN indicating that the hospice aide was present during the visit. The hospice aide plan of care dated 04/23/2024 for this patient included the tasks: bed bath, comb hair, foot care, peri care, shampoo hair (bed), skin care, oral hygiene, skin check for pressure areas, assist in ambulation, transfer, position/range of motion, and incontinent care/bedside commode. There was no documented evidence of a competency assessment of the aide was for shower or shampoo (shower) for 2024. The 2025 Competency Assessment - CNA, Home/Hospice Care Aide form was signed and dated by both the hospice aide and the RN on 05/20/2025. The RN marked that the hospice aide was competent on all the tasks included on the agency’s form. There was no documentation of the method of evaluation utilized. There was no documented evidence for a joint supervisory visit for 2025. A joint personnel record review and interview with the Administrator (Personnel Record 2), the Quality Nurse (Personnel Record 3) and the Business Operations Manager/Human Relations on 09/12/2025 confirmed that there was no joint Supervisory Visit by the Registered Nurse since 05/20/2024.”

“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 document review, interview, and personnel record review. In 1 of 1 (100%) hospice aide personnel files reviewed revealed the agency did not ensure that an initial or subsequent annual on-site visit by the Registered Nurse. AGENCY POLICY: The agency’s policy entitled “Hospice Aide Supervisory Visits,” dated 1Q2022 included in part that “...an annual supervisory visit must be made by an RN to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care...The supervising nurse must assess and document the aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include...Demonstrating competency with assigned tasks PERSONNEL RECORD 7: The personnel record for the hospice aide hired on 05/16/2024 was reviewed and revealed there was no documentation of an On-Site Supervisory visit of the hospice aide by the Registered Nurse for 2025. A joint personnel record review and interview with the Administrator (Personnel Record 2), the Quality Nurse (Personnel Record 3) and the Business Operations Manager/Human Relations on 09/12/2025 confirmed that there was no supervisory visit by the Registered Nurse for 05/20/2025.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 9 of 14 (64%) clinical records reviewed revealed the agency did not ensure that there was documentation that volunteer services were offered and accepted or declined in the patients’ plans of care. AGENCY POLICY: The hospice’s policy, “Volunteer Services” dated 3Q2023 included in part that “...Appropriate referral for volunteer services will be made based on patient/family/caregiver need or request for the services. Recommended volunteer services will be indicated on the patient’s plan of care. Refusal of recommended services may be documented on the plan of care...” CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2025. After a review of the plan of care for the benefit period 06/21/2025 to 09/18/2025 and the Interdisciplinary Group Meetings documented on 07/03/2025, 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/04/2025. After a review of the plan of care for the benefit period 06/04/2025 to 09/01/2025 and the Interdisciplinary Group Meetings documented on 06/06/2025, 06/20/2025, 07/03/2025, 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/20/2025. After a review of the plans of care for the benefit periods 03/20/2025 to 06/17/2025 and 06/18/2025 to 09/15/2025 along with the Interdisciplinary Group Meetings documented on 03/28/2025, 04/11/2025, 04/25/2025, 05/09/2025, 05/23/2025, 06/06/2025, 06/20/2025, 07/03/2025, 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/09/2025. After a review of the plans of care for the benefit periods 05/09/2025 to 08/06/2025 and 08/07/2025 to 11/04/2025 along with the Interdisciplinary Group Meetings documented on 05/09/2025, 05/23/2025, 06/06/2025, 06/20/2025, 07/03/2025, 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/15/2025. After a review of the plan of care for the benefit period 07/15/2025 to 10/12/2025 and the Interdisciplinary Group Meetings documented on 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/08/2025. After a review of the plan of care for the benefit period 07/08/2025 to 10/05/2025 and the Interdisciplinary Group Meetings documented on 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/05/2025. After a review of the plans of care for the benefit periods 06/05/2025 to 09/02/2025 and 09/03/2025 to 12/01/2025 along with the Interdisciplinary Group Meetings documented on 06/06/2025, 06/20/2025, 07/03/2025, 07/18/2025, 08/15/2025, and 08/29/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/17/2025. After a review of the plan of care for the benefit period 02/17/2025 to 04/04/2025 and the Interdisciplinary Group Meetings documented on 02/28/2025, 03/14/2025, and 03/28/2025, there was no documentation that volunteer needs and services were addressed. CLINICAL RECORD 13: The patient elected the hospice benefit on 01/20/2025. After a review of the plans of care for the benefit periods 03/21/2025 to 05/19/2025 and 05/20/2025 to 06/21/2025 and the Interdisciplinary Group Meetings documented on 02/28/2025, 03/14/2025, and 03/28/2025, there was no documentation that volunteer needs and services were addressed. After a joint clinical record review with the Administrator/Alternate Director of Nursing (Personnel Record 2) and the Quality Nurse (Personnel Record 3) on 09/11/2025, they confirmed that volunteer needs/declination of services were not documented in the clinical records.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency’s policy, “Volunteer Services” dated 3Q2023 included in part that “...Documentation and demonstration of recruiting and retention activities will be conducted on an on-going basis in order to maintain an adequate and diverse staff of volunteers...” After a review of the volunteer program materials for 2024 and 2025 and a joint interview with the Administrator/Alternate Director of Nursing/Volunteer Coordinator (Personnel Record 2) and the Quality Nurse (Personnel Record 3) on 09/12/2025, there was no evidence that volunteer recruitment or retention activities were documented for 2024 and no retention activities noted for 2025 in the program documentation. After a review of the volunteer program materials for 2024 and 2025 and a joint interview with the Administrator/Alternate Director of Nursing/Volunteer Coordinator (Personnel Record 2) and the Quality Nurse (Personnel Record 2) on 09/12/2025, there was no evidence that volunteer recruitment or retention activities were documented for 2024 and no retention activities noted for 2025 in the program documentation. The agency’s policy, “Volunteer Services” dated 3Q2023 included in part that “...Documentation and demonstration of recruiting and retention activities will be conducted on an on-going basis in order to maintain an adequate and diverse staff of volunteers...””