Alinea Family Hospice Care LLC

“Based on interview and record review, the hospice failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group for 1 of 3 (Patient #3) patients reviewed. Patient #1 did not receive SN visits 1 time a week according to the POC. This failure placed patients at risk of not receiving the needed services as ordered by the physician/IDG and could have led to needs being unmet. Findings included:Record review of a Certification of Illness for Patient #1 dated 08/06/25 indicated Patient #1 was more withdrawn and forgetful and was sleeping more and spending more time in bed. The certification of illness indicated Patient #1 was oriented to self only, forgetful and confused. (not able to be interviewed) Record review of Patient #1’s POC dated 08/17/25 to 10/15/25 indicated a SOC date of 02/18/25, and indicated she was 98 years old and resided in a nursing facility, and had diagnoses including senile degeneration of the brain (decline in mental abilities severe enough to interfere with daily life), dementia (memory loss), protein-calorie malnutrition (lack of proper nutrition), and chronic obstructive pulmonary disease (lung disease making it hard to breathe). The POC indicated Patient #1 was ordered skilled nursing visits 1 time a week for 9 weeks. Record review of a Patient Schedule/calendar for Patient #1 dated 09/08/25 to 10/06/25 indicated a SN visit for Patient #1 was completed on 09/29/25 by RN E. The frequency indicated SN 1 time a week for 9 weeks. Record review of a Patient Schedule/calendar for Patient #1 dated 10/05/25 to 10/11/25 indicated discharge- no OASIS (assessment) on 10/10/25 with a time of 3:55pm to 3:58pm by RN E. The frequency indicated SN 1 time a week for 9 weeks. Record review of the calendars dated 09/08/25 to 10/11/25 did not indicate Patient #1 had any SN visits between 09/29/25 and 10/11/25 (11 days). Review of the agency’s records and NF J’s notes for Patient #1 gave no indication the agency was notified the patient was sent to the hospital on 10/05/25 and returned to the facility on 10/07/25. Record review of Staff Sign in Log in Patient #1’s binder at NF J indicated RN E signed in on 10/08/25. Record review of a Discharge Summary Report for Patient #1 dated 10/10/25 indicated Patient #1 was discharged due to caregiver revoked hospice services (patient or their legal representative chooses to stop receiving hospice care at any time) to seek skilled therapy at nursing facility. During an interview on 12/08/25 at 1:35 p.m., the COO/Administrator Designee said Patient #1 should have had a visit by a SN the week of 10/05/25. During an interview on 12/08/25 at 1:40 p.m., the DON said RN E probably went to the facility and saw the hospital band on Patient #1 and did not continue the visit (on 10/08/25). She said this meant the agency missed a visit for that week. The DON said RN E should have put a communication note in and there were no communication notes for that week (week of 10/05/25). During an interview on 12/08/25 at 1:42 p.m., RN E said she saw Patient #1 one time a week for SN visits. She said the next visit after she saw Patient #1 on 09/29/25 she found out the weekend facility staff had sent Patient #1 to hospital for a urinary tract infection (common bacterial infection in any part of the urinary system). RN E said when she arrived at the facility (NF J), Patient #1 was sitting on the bed, and RN E saw a hospital bracelet on Patient #1’s arm. RN E said the patient said she was sick. RN E said she left the patient’s room and went and spoke with FN RN K and FN RN K told RN E that Patient #1 was sent to hospital over the weekend. RN E said she did not remember if she documented the encounter/visit. RN E said she did not remember what day of the week it was that she went to the facility. RN E said she contacted the office/agency and the hospice SW. RN E said she didn’t’ remember if she put any notes in. RN E said she couldn’t remember if the visit was the same day as the patient’s discharge. She said she thought the agency was trying to figure out if the patient was going to be discharged or not. RN E said she couldn’t remember if she did an assessment or did vital signs that day. RN E said she only remembered contacting the office and letting them know about the patient going to the hospital. During an interview on 12/08/25 at 2:08 p.m., the DON said she didn’t think RN E went and made a visit for Patient #1’s discharge visit but used the discharge visit (for documentation) as her SN visit that week. She said this meant the agency missed a visit. During an interview on 12/08/25 at 2:18 p.m., the DON said RN E used the 1 time a week visit as her discharge visit. She said clinicians could move visits to any day of the week. The DON said she texted RN E and she did not remember if she went out on the discharge visit. The DON said there were no communication notes documented for that week (week of 10/05/25) for any clinicians. During an interview on 12/08/25 at 2:28 p.m., the DON said RN E text and said she “bet” she just left when the facility said the family no longer wanted Patient #1 to have hospice and she didn’t do the visit. During an interview on 12/08/25 at 2:32 p.m., the DON said depending on the type of visit, the clinicians could code the visit as skilled care provided if vital signs (key measurements of the body’s essential functions, including temperature, pulse rate, respiratory rate, blood pressure, and oxygen) and assessment were done, or no skill care provided. The DON said RN E should have completed the visit and completed documentation regarding the visit and who she called. She said the timeframe for documentation to be turned in was the same day or by 10:00 a.m. the next morning. During a 2nd interview with RN E on 12/08/25 at 4:43 p.m., RN E said she didn’t make a visit the day (10/08/25) she went to see Patient #1 and she didn’t remember seeing Patient #1 anymore that week (week of 10/05/25). She said the day she went to see the patient (10/08/25) she walked out of the patient’s room after she saw the hospital bracelet and did not return to the room. She said Patient #1’s frequency order was 1 time a week for skilled nursing. RN E said she must have changed the visit that week to the discharge visit. RN E said she did not go see Patient #1 for the discharge visit. RN E said the POC frequency was determined by how the patients were doing. She said Patient #1 was stable (unlikely to change). RN E said she didn’t believe she put in any communication notes for Patient #1 that week. She said the time frame for turning in documentation was by 10 p.m. the same night of the visit. RN E said the agency’s protocol for missed visits was the nurse would enter a missed visit, and she would notify the DON. RN E said when the agency did IDG notes they would put in missed visits and the reason. RN E said a patient’s discipline frequency was part of the POC and was considered physician orders. She said when discussing the patients at IDG, the clinicians told the IDG team how many times they were seeing the patients. RN E said the facility (NF J) said the patient’s family didn’t want hospice anymore and she didn’t want to overstep. RN E said she should have documented something. She said she was trying to figure out what was going on that day. RN E said the agency was trying to get ahold of Patient #1’s family and she should have put in a communication note. RN E said the reason she didn’t complete the visit was because she didn’t think Patient #1 was on services anymore and she was trying to figure it out. She said from her understanding the agency was supposed to discharge a patient if they went to the hospital. When asked how a patient could be affected by a missed visit, RN E said she did not have missed visits unless a patient refused. During an interview on 12/09/25 at 8:52 a.m., FN RN K said Patient #1 returned to the facility from the hospital and RN E came that week (week of 10/05/25), but she did not remember the day. She said she did not know if the nurse made a visit that day (date unknown). She said she did not know if anyone from the agency came to the facility that week after she told the nurse Patient #1 had been to the hospital. FN RN K said she saw RN E in the hall and RN E asked her if Patient #1 went to the hospital and FN RN K told her yes, over the weekend. FN RN K said she didn’t know if RN E completed her visit that day. She said RN E had a tablet she brought and had the facility nurse sign after visits, but FN RN K said she could not remember if she signed it that day since it had been a while since it occurred. During an interview on 12/09/25 at 9:36 a.m., RN O said the POC was developed by the RNs. She said the visit frequency was determined by the nurses and discussed in IDT. She said the visit frequency was considered physician’s orders. RN O said for missed visits the clinician would chart it as a missed visit and made a note as to why the visit was missed, and the physician was notified. RN O said if a nurse realized a patient had been in the hospital, the SN would do a complete assessment to figure out why the patient was in the hospital and contacted family members to make sure they were aware. She said there was no reason why a visit wouldn’t be completed at that time. RN O said by not following the POC orders and visit frequency it could affect patients by the patient could start having more decline if the patient was not being monitored if the nurse was not seeing the patient as frequently as they needed to. During an interview on 12/09/25 at 9:48 a.m., RN N said POCs were developed by the IDT, and every 2 weeks the IDT went through the POC with the physician. She said the physician determined the visit frequency and the visit frequency was considered physician’s orders. RN N said the IDT discussed everything and all assessment findings and the physician gave the visit frequency that the clinicians had to abide by (follow). RN N said the SN visit included assessing the patient, checking vital signs, asking about pain and location, reconcile medications (review) to make sure medications were up to date, complete a full head-to-toe assessment, assess for swelling, ask about appetite, and if the caregiver was present ask about any questions/concerns. She said the SN would then contact the doctor if there were any changes. RN N said she never had a missed visit, but she would document it and follow up that week and see the patient. She said if there was a missed visit the SN would notify the doctor because that was something the clinicians were supposed to report. She said staff had to let the doctor know if there were any missed visits. She said if a patient went to the hospital, the SN would ask what the patient went to the hospital for and get all the details and contact the doctor. She said the SN would complete the visit and let the doctor know. She said depending on what the patient went to hospital for; they may have to be discharged from services. RN N said the SN would still assess the patient and complete the visit and would make a note of what they did during the visit. She said there was no reason why a SN wouldn’t complete the visit because they would still have to document they were there and why the patient went to the hospital. RN N said a SN wouldn’t leave just because a patient had been in the hospital. She said the SN would still have to have evidence/documentation if a patient went to the hospital. She said the SN would have to have documentation of why the patient was in the hospital and of the SN visit. RN N said a negative potential outcome for not following the visit frequency/POC/physicians orders was it would affect the whole plan of care because the POC was the orders to go by. She said by not following/completing visits it would affect visits and could cause a decline in the patient and would affect their health overall. During an interview on 12/09/25 at 10:45 a.m., the DON said the POC was developed by the IDT members. She said the nurse collected the information during the comprehensive (complete) assessment then the IDT members which included the RN, Social Worker, Chaplain, and Physician reviewed the information and completed the POC within 5 days. She said the frequency of services was determined based on a patient’s needs but was determined by the physician based on the comprehensive visits. She said the visit frequency was considered physician orders. The DON said for a missed visit the clinician would notify the office and the physician. She said this was documented in IDT notes and reviewed in the IDT meetings if there were any missed visits. She said it could affect the patient if the agency was not following the visit frequency because if a nurse didn’t make a visit, the physician would not be aware of what was going on with the patient. She said if a patient wasn’t being seen and the nurse was not following the POC or physician orders a patient could go untreated, and medications could be mismanaged if the agency was not monitoring their medications or how they were responding to medications. She said a patient could decline without appropriate care and it was a patient safety issue if visits were not being made and the POC was not being followed. The DON said RN E should have made a visit that week (week of 10/05/25) on Patient #1. She said in the electronic medical record the SN had the ability to choose the type of assessment, whether it was skill or no skill. The DON said she talked to RN E yesterday (12/08/25) and RN E she said she didn’t know if Patient #1 was still on services and she was scared to provide care and do an assessment if the patient wasn’t on services. The DON said something should have been documented even if no skill was provided. She said the agency told RN E the patient was still on services, and if family chose not to continue services, they had to sign a revocation form. The DON said the SN could go in the electronic medical record and put no skill care provided and document a note of why. She said Patient #1’s discharge should have been an in-person visit, and RN E should have gone and made a visit for discharge. During an interview on 12/09/25 at 11:05 a.m., the Alternate Administrator said the POC was developed by IDT which included the RN, Physician, SW, and Chaplain. She said the visit frequency was determined by the RN case manager and was considered physicians orders. She said for a missed visit the nurse should document that the visit was missed and report it to the supervisor. She said by not following the visit frequency it could affect the patient by not providing continuity of care (consistent healthcare over time ensuring that information flows and care progresses without interruption). During an interview on 12/09/25 at 11:09 a.m., the COO/Administrator Designee said there should have been a visit made for Patient #1 and the agency was trying to determine if the patient was being skilled (receiving a high level of medical or rehabilitative care). He said RN E did not complete the visit, and she should have done the visit and followed the orders. He said the SN should have gone and seen the patient when discharging Patient #1. He said by not completing the visit it could affect the patient and could be considered neglect because the patient was not getting the care the agency signed to provide. Surveyor attempted to call Patient #1’s family/caregiver on 12/09/25 for interview but there was no answer, and no return call was received. Surveyor unable to interview Patient #1 due to cognitive decline/confusion. Record review of a Personnel File for RN E indicated a date of hire of 09/03/24. The file included a signed job description for the RN position dated 09/03/24 and indicated “…Provides Hospice nursing services, treatments and preventive procedures… Develops and re-evaluates the patient/family care plan in conjunction with IDG to meet needs and maintain continuity of care…” Record review of a Plan of Care Process policy dated 09/01/24 indicated “Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy: I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs…” Record review of an Interdisciplinary Group (IDG/IDT)/Core Services policy dated 09/01/24 indicated “…I. The Hospice will designate an interdisciplinary group(s) that in consultation with the patient’s attending physician, will prepare a written plan of care for each patient. The plan of care will specify the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related condition…””

“It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CMS CONDITION LEVEL DEFIENCY This CONDITION was not met as evidenced by a review of clinical records, interviews, document review which revealed the hospice: Failed to ensure that the patient was free from mistreatment, neglect, or mental, sexual and physical abuse, injuries unknown source, misappropriate of property HPFC.2.D/L517/ 418.52(c)(6)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, interviews, and review of findings with the Director of Clinical Services and Director of Nursing which revealed the following issues with the development and implementation of the patients’ interdisciplinary care plans: Failed to ensure that the plan of care reflected the patient and family goals {HCPC.21.I/L545/ 418.56(c)}; Failed to ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments {HCPC.21. I/L546/ 418.56(c)(1)}; and Failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings {HCPC.23.D/L557/ 418.56(e)(4)}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, observation, personnel record reviews, clinical record reviews, and interviews which revealed issues with the organization’s compliance with local, state, and federal law and regulation related to the health and safety of patient in the following areas: Failed to ensure that nursing services were provided in a manner consistent with accepted standards of practice {HCDT.1.I/L652/ 418.100(c)(1)}; and Failed to ensure responsibility for the organization’ ongoing performance improvement and patient safety (HSLG.12. I/L574/ 418.58(e)(1)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.100: Organization and administration of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. It includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. In review of the agency emergency preparedness plan, there was no evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The Administrator appointee for emergency preparedness was interviewed and confirmed there was not a documented “all hazards” hospice-based and community-based risk assessment. In review of the agency emergency preparedness plan, there was no evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The Administrator appointee for emergency preparedness was interviewed and confirmed there was not a documented “all hazards” hospice-based and community-based risk assessment.”

“It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical record reviews, the agency did not ensure that the patient’s right to be free from neglect was protected. DOCUMENT 4: Agency policy Abuse, Neglect and Exploitation Policy PC.15, stated, in part: “Patients have the right to be free from mistreatment, neglect or verbal, mental, sexual and physical abuse....”. CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer’s Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice; and documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. The RN notes on 08/05/2024 and 09/10/2024 identified and documented a left medial proximal inner buttocks coccyx wound stage II and the wound was cleansed with soap and water and covered with a hydrocolloid gauze. On 09/22/2024, there was a call from the family stating that the son was requesting assistance with wound care on the patient’s legs. Following the call, the RN made a visit and documented wounds on the left medial distal inner leg knee and right medial distal inner leg knee. The RN contacted the physician and provided wound care as well as received new medication for pain. On 09/25/2024, the patient was transferred to a skilled nursing facility (SNF) for respite. At that time, the receiving RN at the facility notified the on-call Administrator that the patient had several open areas which were not reported to the receiving RN at the facility. During a visit by the agency on-call nurse on 09/25/2024 to oversee the admission of a patient for respite care, the nurse noted open areas on the patient. She contacted the Director of Nursing and reported that the patient had open areas that had not been identified or reported to the receiving RN at the facility. In review of the clinical record for the date of 09/10/2024, the interdisciplinary notes documented there were no active wounds. In review of the IDT notes from 09/12/2024-09/22/2024, there was no documentation of the care of the patient’s wounds. The RN documentation for 09/25/2024 included the wounds and treatment orders and a consultation was performed by a wound care physician on 09/26/2024. In review of the documentation by the wound care physician, it included the following open areas: 1. Stage 4 pressure wound sacrum full thickness duration greater than 140 days. 2. Unstageable (due to necrosis) of the left heel full thickness greater than 56 days. 3. Unstageable (due to necrosis) of the right heel full thickness greater than 14 days. 4. Unstageable right lateral foot. 5. End stage skin failure of the right shoulder partial thickness greater than 7 days. 6. End stage skin failure of the left knee full thickness greater than 7 days. 7. Wound of the right knee full thickness greater than 7 days. The physician provided documentation that the patient was at end of life and recommended treatment was palliative. There was no documented evidence that the agency ensured that the patient’s right to be free from neglect was protected. During an interview with the Director of Clinical Services on 03/04/2025, it was reported the agency self-reported to the Dept. of HHS and the (State) Board of Nursing on 09/26/2024 and filled out Form 3613 which was sent by certified mail. The Director of Clinical Services stated the Department of Health and Human Services conducted an investigation 09/30/2024-10/2/2024 and submitted preliminary findings, but the agency had not received formal required actions at the time of this site visit. In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2026, it was confirmed that a performance improvement plan was written 09/26/2024 and executed for “Wounds are not consistently assessed and measured at a minimum of 1XW” The audits for measurement of wounds in 4th quarter 2024 was 50%. In an interview conducted with the Administrator on 03/06/2025, it was confirmed that the documentation provided did not ensure that the patient’s right to be free from neglect was protected”

“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, and 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, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile was updated as per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication was added, or changes were made to the existing medication. DOCUMENT 2: : Agency policy Medication Administration, PC. 80, stated in part: “III. The Hospice staff will transcribe written medications orders as soon as possible after they are received and update the POC.” CLINICAL RECORD 11: This patient elected the hospice benefit 03/01/2025 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater. In review of the Registered Nurse (RN) comprehensive assessment dated 03/01/2025, the RN documented that the patient used nitroglycerine tabs for chest pain. The drug profile was reviewed for the dates of 03/01/2025-03/07/2025. Nitroglycerine was not listed on the drug profile. There was no documented evidence that the medication profile was updated during the comprehensive assessment. In an interview conducted 03/07/2025 with the Director of Clinical Services, it was confirmed that the drug profile was not updated as per hospice policy.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care reflected the patient and family goals. CLINICAL RECORD 6: This patient elected the hospice benefit on 02/05/2025 with a diagnosis of Alzheimer’s and Down’s Syndrome. In review of the Registered Nurse (RN) comprehensive assessment dated 02/05/2025, it was documented that the patient was unable to make wishes known, but family stated the patient cried out and they would give Tylenol which seems to help with the pain. The goal for pain was “pt will be pain free or verbalize an acceptable pain level with the current pain management regimen”. In review of the clinical record for dates of 02/05/2025-03/06/2025, there was no documentation that the plan of care reflected the patient and family goal for pain management as the patient was not able to verbalize what was acceptable pain level. In an interview conducted on 03/06/2025, the Director of Clinical Services confirmed that the plan of care did not reflect patient and family goals.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 9: This patient elected the hospice benefit 10/02/2024 with a terminal diagnosis of end stage renal disease. The medication profile reviewed 03/06/2025 documented that Eliquis was started on 02/26/2025. In review of the plan of care for the dates of 02/26/2025-03/06/2025, there were no identified planned interventions for education and care of the patient while on Eliquis. CLINICAL RECORD 11: This patient elected the hospice benefit 03/01/2025 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater. The Registered Nurse (RN) comprehensive assessment dated 03/01/2025 documented the patient was experiencing dyspnea upon admission and morphine and oxygen were ordered. In review of the plan of care for dates of 03/02/3035-03/07/2025, there were no identified planned interventions for dyspnea. CLINICAL RECORD 12: This patient elected the hospice benefit 01/13/2025 with a terminal diagnosis of cirrhosis of the liver. The Registered Nurse (RN) comprehensive assessment documented that the patient experienced pain with movement. In review of the plan of care for the dates of 01/13.2025-03/07/2025, there were no identified planned interventions for pain. In an interview conducted with the Director of Clinical Services on 03/07/2025, it was confirmed that the plans of care did not include planned interventions based on problems identified in the initial and updated comprehensive assessments.”

“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. The policies and procedures ensure that sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure ongoing sharing of information between all disciplines providing care and services in all settings. DOCUMENT 3: In complaint statement dated 09/25/2024, the document stated, in part: “Multiple wounds were found on the patient by _______ RN on 09/24/24.” “No active wounds were documented by the previous nurse.” CLINICAL RECORD 19: This patient elected the hospice benefit 07/18/2024 with a terminal diagnosis of Alzheimer’s Disease. In review of the clinical record, the Registered Nurse (RN) visit notes on 08/05/2024 and 09/10/2024 documented a left medial proximal inner buttocks coccyx wound stage II and the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of the interdisciplinary team notes for the dates of 07/18/2024-09/24/2024, there was no documentation of coordination of care for the wounds documented in the RN notes. In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2025, it was confirmed that the interdisciplinary team (IDT) did not ensure that the sharing of information occurred between the members of the team, and did not discuss that wound care orders were missing from the clinical record.”

“It is required that the hospice’s governing body assumes legal authority and responsibility or the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review, clinical record review, observation and interview. A review of the clinical records, observation, and interviews with the Administrator, Director of Clinical Services, and Director of Nursing revealed that the governing body did not assume responsibility for the organization’ ongoing performance improvement and patient safety as evidenced by: 1 of 19 (5%) clinical record reviews, the agency did not ensure that the patient’s right to be free from neglect was protected. {HPDC.2.D} L571. 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. {HCPC.21. I} L 546. 1 of 19 (5%) clinical records reviewed, the agency did not ensure ongoing sharing of information between all disciplines providing care and services in all settings. { HCPC.23. D} 557. 2 of 5 (40%) clinical records reviewed, of patients receiving wound care, the agency did not ensure that the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. {HCDT.6.I} 591. 1 of 19 (5%) clinical records reviewed, the agency did not ensure that nursing services were provided in a manner consistent with accepted standards of practice. {HCDT.1.I} L652. In an interview conducted with the Administrator (Personnel Record 9) on 03/06/2025, it was confirmed that the documentation provided did not ensure that the patient’s right to be free from neglect was protected In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2025, it was confirmed that the interdisciplinary team (IDT) did not ensure that the sharing of information occurred between the members of the team, and did not discuss that wound care orders were missing from the clinical record. In an interview conducted on 03/07/2025 with the Director of Clinical Services, it was confirmed that the nursing needs of the patient were not met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes the education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that the infection control program included the education of employees. PERSONNEL RECORD 10: The volunteer was hired 08/16/2022. There was no documentation of infection control education for 2024 in the personnel record. In an interview conducted with the Director of Clinical Services on 03/05/2025, she stated that the agency provided annual education which included infection control, and this education was missing from the personnel record.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 2 of 5 (40%) clinical records reviewed, of patients receiving wound care, the agency did not ensure that the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. DOCUMENT 1: The agency policy “Skin Assessment/Wound Care Policy stated in part: “The Registered Nurse/Case Manager will complete and document a skin assessment at least once a week on every patient. Upon the discovery of a wound the Registered Nurse/Case Manager will document a complete assessment and institute care/treatment measures until such time as the wound is resolved.” “Procedure: A. Upon the discovery of a wound, the Registered Nurse/Case Manager will add a “wound” in the patient chart in _____ noting the following: 4. Measurements-to include length, width, depth; updated weekly. CLINICAL RECORD 1/HOME VISIT 1: CLINICAL RECORD 1: This patient elected the hospice benefit 01/12/2024 with a terminal diagnosis of COPD. In review of the Registered Nurse (RN) comprehensive assessment dated 12/18/2024, it was documented that an open area was discovered on the patient’s right heel. In review of the RN visits for 01/22/2024, 01/30/2024, 02/05/2024, 02/11/2024, 02/18/2024 and 03/04,2024, there was no update to the assessment of the wound measurements of the open area. During the home visit (Clinical Record 1) on 03/05/2025 to observe the Registered Nurse (Personnel Record 1), it was confirmed that the patient was receiving wound care for an open area on the right heel. The clinical record was reviewed, and no documented evidence was present for the measurements of the open area on the right heal. The clinical record lacked evidence that the nursing needs were not met. CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer’s Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice. The RN documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. On 08/05/2024 and 09/10/2024, the RN documented a left medial proximal inner buttocks coccyx wound stage II and documented that the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of physician orders from dates of 08/05/2024-09/25/2024, there was no documented evidence that physician orders were received for care of the wounds. The clinical record lacked evidence that the nursing needs were not met. In an interview conducted on 03/07/2025 with the Director of Clinical Services, it was confirmed that the nursing needs of the patient were not met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.”

“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. A review of the documentation of the volunteer hours that were provided for 2024 did not equal five (5%) percent of the total patient care hours of all paid hospice employees and contract staff. The agency documented for 2024 1.95% volunteer hours. In an interview conducted with the Volunteer Coordinator on 03/06/2025, it was confirmed that the volunteer hours did not equal, at a minimum, 5% percent of the total patient care hours of all paid hospice employees and contract staff. (1.95%) A review of the documentation of the volunteer hours that were provided for 2024 did not equal five percent of the total patient care hours of all paid hospice employees and contract staff. In an interview conducted with the Volunteer Coordinator on 03/06/2025, it was confirmed that the volunteer hours did not equal, at a minimum, 5 percent of the total patient care hours of all paid hospice employees and contract staff. (1.95%)”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: nursing services. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that nursing services were provided in a manner consistent with accepted standards of practice. CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer’s Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice. The RN documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. On 08/05/2024 and 09/10/2024, the RN documented a left medial proximal inner buttocks coccyx wound stage II and documented that the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of physician orders from dates of 08/05/2024-09/25/2024, there was no documented evidence that physician orders were received for care of the wounds. In an interview conducted 03/07/2025 with the Director of Clinical Services, it was confirmed that the Registered Nurse was preforming wound care without a physician order.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that each’s patient’s record included documentation of an updated comprehensive assessments. The agency policy “Skin Assessment/Wound Care Policy stated in part: “The Registered Nurse/Case Manager will complete and document a skin assessment at least once a week on every patient. Upon the discovery of a wound the Registered Nurse/Case Manager will document a complete assessment and institute care/treatment measures until such time as the wound is resolved.” “Procedure: A. Upon the discovery of a wound, the Registered Nurse/Case Manager will add a “wound” in the patient chart in (_____) noting the following: 4. Measurements-to include length, width, depth; updated weekly. CLINICAL RECORD 1: This patient elected the hospice benefit 01/12/2024 with a terminal diagnosis of COPD. The Registered Nurse (RN) comprehensive assessment dated12/18/2024 included documentation that an open area was discovered on the patient’s right heel. In review of the RN visits for 01/22/2024, 01/30/2024, 02/05/2024, 02/11/2024, 02/18/2024 and 03/04,2024, there was no documentation of the measurements of this open area on the right heel in accordance with the agency Skin Assessment/Wound Care Policy. In an interview conducted on 03/05/2025 with the Director of Clinical Services, it was confirmed that the agency did not ensure that each’s patient’s record included documentation of updated comprehensive assessments of wounds as per the hospice policy.”

“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. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged from hospice, the agency did not ensure that a hospice discharge summary was forwarded to the attending physician. CLINICAL RECORD 16: This patient elected the hospice benefit 01/13/2025 with a terminal diagnosis of gastrointestinal stromal tumor. The patient revocated services on 02/04/2025 to seek aggressive treatment. In review of the clinical record, there was no documentation that a discharge summary was forwarded to the attending physician. In an interview conducted on 03/06/2025 with the Director of Clinical Services, it was confirmed that there was no documentation that a hospice discharge summary was forwarded to the attending physician.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 2 (50%) clinical records reviewed where home visits were conducted in the SNF, the agency did not ensure that the delineation of duties form to identify the care and services that were needed and to specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care was present in the hospice binder. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 07/22/2024 with a terminal diagnosis of congestive obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). The hospice plan of care did not include documentation to specify which provider was responsible to perform the functions included in the patient’s plan of care. During Home Visit 4 (Clinical Record 4) on 03/05/2025 to observe the Chaplain (Personnel Record 4) in the skilled nursing facility (SNF), the hospice binder was reviewed for the delineation of duties form to identify the care and services that were needed and to specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. This form was not present in the hospice binder. In an interview conducted on 03/05/2025 with the Director of Clinical Services, it was confirmed that the agency utilized a delineation of duties form for skilled nursing facilities and confirmed that this form should have been present in the hospice binder.”