Fort Bend Hospice and Palliative Care LLC

“It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared the written home health aide care plan with clear and patient-specific directions {HCDT.15. I/L625/ 418.76(g)(1)}; Failed to ensure that the hospice aide provided visits and services as ordered by the Interdisciplinary Group. {HCDT.16.I/L626/ 418.76(g)(2)(i)}; Failed to ensure that all aides reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities {HCDT.18.I/L628/ 418.76(g)(4)} and Failed to ensure that the Registered Nurse (RN) documented supervision of the hospice aide every 14 days {HSRM.25. I/L629/ 418.76(h)(1)(i)}. 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 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that an initial bereavement assessment was completed as part of the initial comprehensive assessment. AGENCY POLICY: The agency’s policy “Bereavement Services Policy No. 9-023” dated December 2018 included that “...A Bereavement Risk Assessment will be completed by the hospice social worker at the time of admission to hospice...” The agency’s policy “Bereavement Assessment Policy No. 1-021” dated December 2018 included that “...A Bereavement Risk Assessment will be completed by the hospice social worker at the time of admission to hospice...At a minimum, it will include patient and family/caregiver loss issues, survivor needs, social, spiritual, and cultural factors, services to be provided including individual counseling, support groups, and letters and cards, referrals to be made, grief risk factors and potential for pathological grief reactions. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan of intervention based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/19/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) on 03/19/2025 and by the Social Worker and Chaplain on 03/21/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/03/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN)04/03/2025, the Social Worker on 04/04/2025, and the Chaplain on 04/07/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/04/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) 04/03/2025, the Social Worker on 04/08/2025, and the Chaplain on 04/05/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/20/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) 05/20/2025, and by the Social Worker on 05/22/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/02/2024 The initial comprehensive visits were conducted by the Registered Nurse (RN) 10/02/2024, and by the Social Worker on 10/04/2024. There was no documented evidence that an initial bereavement risk assessment completed. After a joint clinical record review and interview with the Director of Nursing (Personnel Record 3) on 10/15/2025, it was determined that the records listed in evidence did not have a documented bereavement risk assessment as part of the initial comprehensive assessment.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the Registered Nurse (RN) did not ensure the implementation of the interdisciplinary plan of care. AGENCY POLICY: The hospice’s policy “Nursing Care Policy No. 9-019) dated December 2018 included that “...The Case Manager will assure that components of the plan of care are established and implemented by the Interdisciplinary Group. The Case Manager will determine the scope and frequency of services of services needed...” CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2024. The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and 09/17/2025 to 11/15/2025 were reviewed and included orders for the Chaplain to visit the patient once a week. Chaplain visits were documented on the following dates: 07/09/2025, 08/15/2025, 09/12/2025, and 10/02/2025, and not weekly as per orders. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 3: The patient elected th hospice benefit on 07/24/2023. The plans of care for the benefit periods from 07/13/2025 to 09/10/2025 and 09/11/2025 to 11/09/2025 were reviewed and included orders for the Chaplain to visit the patient once a month. There were no chaplain visits documented for July, August, or September as per the order. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/03/2025 . The plans of care for the benefit periods 06/03/2025 to 08/31/2025 and 09/01/2025 to 11/29/2025 were reviewed and included orders for the Social Worker to visit the patient once a month. There were no Social Worker visits or missed visits documented for June, July, August, or September. The plans of care included one PRN - as-needed visit for each benefit period. There were documented monthly Chaplain visits dated 06/05/205, 07/04/2025, 08/05/2025, and 09/03/2025, however there were no orders for the chaplain on the plan of care. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/07/2024. The plans of care for the benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the Chaplain and the Social Worker to visit the patient once a month. There were no Chaplain visits or missed visits documented. The Social Worker had visits documented on 07/23/2025 and 09/24/2025. There was no August visit or missed visit documented. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, were reviewed and included orders for the Chaplain to visit the patient once a month. There were no documented Chaplain visits. After a joint clinical record review and interview with the Director of Nursing (DON) (Personnel Record 3) on 10/15/2025 and 10/16/2025 it was determined that the ordered frequency and visits cited in the clinical records in evidence did not match. The DON could provide this site visitor with the verbal frequencies of the psychosocial disciplines but agreed that the plans of care did not accurately reflect that information.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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, observation, and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the patient’s individualized plans of care reflected all problems identified in the initial and updated assessments. CLINICAL RECORD 1/HOME VISIT1: The Registered Nurse’s (RN) Recertification visit on 09/08/2025 included in part that the “...Patient is deaf in the left ear and hard of hearing in the right ear. One must get close to the patient’s ear as if about to whisper before the patient could hear. Patient caregiver provides assistance in order to better communicate with the patient...” During the home visit observation with the registered nurse (RN) (Personnel Record 3) on 10/14/2025, the RN repeatedly struggled to communicate with the patient due to the patient’s hearing. The nurse did state that the patient could read lips to some degree. The plan of care for the benefit period from 09/17/2025 to 11/15/2025 did not include an identified problem, intervention, or goal for the assessed communication difficulties secondary to the patient’s hearing difficulty. CLINICAL RECORD 2/HOME VISIT 2: During the Registered Nurse’s (RN)(Personnel Record 5) visit on 08/27/2025, the patient’s pain was rated a 6, and it was noted that her pain occurred daily but not constantly. The nurse documented “...Reviewed pain management plan and instructed caregivers to administer PRN medications if signs of pain occur. SN will continue routine hospice visits to monitor...patient comfort...” The patient’s pain was documented as a four during the RN visit on 09/03/2025. The patient’s medication list included an order dated 05/05/2025 for Hydrocodone-Acetaminophen 10-325mg oral tablet: take one tablet by mouth twice daily for pain (scheduled). The patient’s plan of care for the benefit period from 08/03/2025 to 10/31/2025 did not include the identified problem of pain with any intervention or goal for treatment. The medication list also included an order dated 05/05/2025 for Plavix 75mg: take one tablet orally once daily for anticoagulation. The patient’s plan of care for the benefit period from 08/03/2025 to 10/31/2025 did not include the identified problem of pain with any intervention or goal for treatment. While there was a “Risk for Injury” problem identified on the plan of care, the problem, intervention, and goals did not address the patient’s increased risk for bleeding secondary to Plavix in case of fall or injury. The findings were confirmed after joint record review and interview on 10/15/2025 with the Director of Nurses (Personnel Record 3).”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 9 of 14 (64%) clinical records reviewed revealed the agency did not ensure that the medical supplies necessary for the patient’s needs were documented on the plan of care. AGENCY POLICY: Durable Medical Equipment and Supplies Policy No. 2-037 12/2018 All...supplies...will have an order from the physician ...Those supplies required for optimal comfort, care, and management of the hospice patient will be obtained...” CLINICAL RECORD 1: The patient’s bowel and bladder incontinence was identified in the Registered Nurse’s (RN) Recertification visits documented on 07/07/2025 and 09/08/2025. The Plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and 09/17/2025 to 11/15/2025 did not include incontinence supplies. CLINICAL RECORD 4: In the Hospice Medical Director’s written certifications of terminal illness for the benefit periods 07/17/2025 to 09/14/2025 and 09/15/2025 to 11/15/2025, it was identified that the patient was incontinent of both bowel and bladder. The Plans of care for the same benefit periods did not include incontinence supplies. CLINICAL RECORD 6: The patient’s bowel and bladder incontinence was identified in the Registered Nurse’s (RN) Initial Assessment visit on 06/03/2025. The plans of care for the benefit periods 06/03/2025 to 08/31/2025 and 09/01/2025 to 11/29/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 8: The patient’s bladder incontinence was identified in the Registered Nurse’s (RN) Initial Assessment visit on 08/14/2025. The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 9: The patient’s bowel and bladder incontinence was identified during the Registered Nurse’s (RN) Initial Assessment on 07/18/2025. The plans of care for the benefit periods 07/01/2025 to 08/9/2025 and 08/30/2025 to 10/28/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 11: The patient’s bladder incontinence was identified during the Registered Nurse’s (RN) Initial Assessment visit on 05/20/2025. The plan of care for the benefit period from 05/20/2025 to 05/28/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 12: The patient’s bowel and bladder incontinence was identified in the Registered Nurse’s (RN) Initial Assessment visit on 10/02/2024 and during the Recertification visits documented on 12/17/2024 and 03/25/2025. The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 13: The patient’s bowel and bladder incontinence was identified during the Registered Nurse’s (RN) Initial Assessment visit on 05/21/2025. The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 14: The patient’s bowel and bladder incontinence was identified during the Registered Nurse’s (RN) Initial Assessment on 04/01/2025. The plans of care for the benefit periods 04/01/2025 to 06/29/2025 and 06/30/2025 to 09/09/2025 were reviewed and included no incontinence supplies. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 3) on 10/15/2025, she confirmed that the patient’s medical supplies were not documented in the plan of care for each patient.”

“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. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure that the patient’s plan of care was updated at least every 15 days. AGENCY POLICY: The hospice’s policy, “Interdisciplinary Group Meeting Policy No. 1-036” dated December 2018, included “...An interdisciplinary group meeting plan of care update form will be used for update of the patient...It will note changes, response to treatment, and progress toward targeted outcomes...” CLINICAL RECORD 3: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 06/06/2025 (28 days) 07/04/2025 (28 days) 08/01/2024(28 days) 08/15/2025, 09/12/2025 (28 days), 09/26/2025, and 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 6: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 06/03/2025, 07/04/2025 (31 days), 07/18/2025, 08/01/2025, 08/15/2025, 08/29/2025, 09/12/2025, 09/26/2025, 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 10: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 04/16/2024,06/03/2025 (31 days) 07/04/2025931 days), 07/18/2025, 08/01/2025, 08/15/2025, 08/29/2025, 09/12/2025, 09/26/2025, 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/01/2025. There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 04/01/2025, 05/23/2025(52 days, 06/30/2025 (38 days) and post-death on 07/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. A joint clinical record review and interview were conducted with the Director of Nursing (DON) (Personnel Record 3) on 10/16/2025, confirming the absence of documented updates in the clinical records every 15 days.”

“It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel records reviewed revealed that the agency did not ensure that the Administrator and the Alternate Administrator had documentation of the annual twelve hours of state-required Administrator continuing education completed. STATE REGULATION: State Administrative Code: Title 26, Part 1, Chapter 558, Subchapter C, Division 3, Rule §558.260 - Continuing Education in Administration of Agencies included in part that “...an administrator and alternate administrator must complete 12 clock hours of continuing education within each 12-month period beginning with the date of designation...” The provisions of this §558.260 adopted to be effective May 1, 2008, 33 (State)Reg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 (State)Reg 1893; amended to be effective April 25, 2021, 46 (State)Reg 2427. PERSONNEL RECORD 1: The Medical Director/Administrator hired on 04/01/2018 had twelve hours of the annual state-required continuing administrative education documented on 09/24/2025, but none documented for years 2023 or 2024. PERSONNEL RECORD 2: The Alternate Administrator hired 04/01/2018 had twelve hours of the annual state-required continuing administrative education documented on 08/11/2025, but none documented for years 2023 or 2024. After a joint personnel record review and interview with the Office Administrator (Personnel Record 7) on 10/16/2025, the absence of the continuing Administrator hours required by the state for the Administrator and Alternate Administrator was confirmed.”

“It is required that counseling services include an organized program for providing 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%) clinical records reviewed revealed the agency did not ensure that a bereavement plan of care was documented. The agency’s policy, “Bereavement Assessment Policy No. 1-021” dated December 2018, included “...After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan of interventions based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions...” CLINICAL RECORD 13: The patient elected the hospice benefit on 05/21/2025 and died on hospice services on 06/13/2025. The Chaplain completed a post-death Bereavement Risk Assessment on the day of death, 06/13/2025, with a finding of low risk and noted that the patient’s son would be followed by Bereavement. There was no Bereavement Plan of Care documented to indicate the scope and frequency of Bereavement Services/interventions. The finding was confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025. The Bereavement Coordinator (Personnel Record 6) was interviewed on 10/15/2025 and was surprised to learn of the missing bereavement plan of care. She stated she thought that the patient’s son had refused bereavement services. The note of the post-death assessment indicating that indicated that the patient’s son would be followed by bereavement was reviewed. The chart was reviewed and was confirmed that the patient’s son declined bereavement services, and this was updated in the record.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (10%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure patient-specific instructions were provided to the hospice aide. CLINICAL RECORD 2: The plans of care for the benefit periods 05/05/2025 to 08/02/2025 and 08/03/2025 to 10/31/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. During the Registered Nurse’s (RN) visit on 08/27/2025, she noted the patient had bilateral wounds on each hip that were approximately the size of a quarter. A physician’s order dated 09/02/2025 included wound care orders for a stage 2 pressure ulcer on both the patient’s right and left hip. Cleanse both wounds with normal saline and betadine solution. Apply calcium alginate to the wound bed and cover with a hydrocolloid dressing twice weekly until healed. The active hospice aide plan of care at the time of record review was dated 08/03/2025. It included interventions to be performed at each visit: complete bed bath, perineal care, and incontinent care during each hospice aide visit, but there were no instructions provided to the hospice aide regarding the patient’s wounds and what to do should the dressing become loose or soiled due to the patient’s incontinence. The findings were confirmed following a joint clinical record review and an interview with the Director of Nursing (Personnel Record 3) on October 15, 2025.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 8 of 11 (73%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide provided visits and services as ordered by the Interdisciplinary Group. CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plans of care dated 07/19/2025 and 09/17/2025 included the following interventions to be performed during every hospice aide visit: complete shower, incontinent care, perineal care, skin care, foot care, nail care, oral hygiene/denture care, shave, check pressure areas on the patient’s skin, document the date of the patient’s last bowel movement, assist the patient to transfer, turn/position patient, change linen, and make the patient’s bed. The following task were not marked as completed by the hospice aide during the visits documented on 8/18/2025, 09/01/2025, 09/17/2025, and 09/29/2025: incontinent care, nail care, shaving, checking the patient’s skin for pressure areas, and noting the date of the patient’s last bowel movement. CLINICAL RECORD 3: The plans of care for the benefit periods 07/13/2025 to 09/10/2025 and 09/11/2025 to 11/09/2025 were reviewed and included orders for the hospice aide) to visit the patient three times a week. There were no hospice aide visits documented, and no discontinuation order for hospice aide services documented. CLINICAL RECORD 8: The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed. Both included orders for the hospice aide to provide visits to the patient three times a week. The hospice aide plan of care dated 08/14/2025 included the following task to be performed every visit: complete shower, incontinent care, perineal care, shampoo hair, foot care, skin care, back rub/massage, oral hygiene/denture care, nail care, check pressure areas, comb hair, dress patient. During the hospice aide visits on 09/17/2025 and 09/26/2025, the hospice aide did not mark that incontinent care, nail care, checking pressure areas, and back rub/massage were completed. CLINICAL RECORD 9: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 08/30/2025 included the following task to be performed every visit: complete shower, shampoo hair, foot care, nail care, perineal care, incontinent care, skin care, check pressure areas, comb hair, oral hygiene/denture care, and dress patient. During the hospice aide visits on 09/01/2025 and 09/24/2025, the hospice aide did not document that foot care, nail care, incontinence care, or checking pressure areas were performed. On 10/06/2025, the interventions for perineal care, incontinence care, nail care, and checking pressure areas were not documented as having been completed. CLINICAL RECORD 10: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to provide visits to the patient three times a week. The hospice aide plan of care dated 07/01/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. During the hospice aide visit on 08/04/2025, the hospice aide did not mark shaving, incontinence care, nail care, and checking pressure areas as completed. On 08/22/2025, back rub/massage and incontinence care were not documented as having been performed. On both 09/08/2025 and 09/15/2025, the hospice aide did not document that the task of back rub/massage, checking pressure areas, incontinent care, or nail care were performed. Then, on 10/01/2025, foot care, perineal care, incontinent care, back rub/massage, check pressure areas, and nail care were not documented as completed. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, included orders for the hospice aide to provide visits to the patient three times a week. The first hospice aide visit was on 10/04/2024, and the last aide visit on 03/19/2025. There were no further hospice aide visits documented after 03/19/2025 until the patient’s discharge from hospice care on 04/16/2025 and no order to discontinue hospice aide services. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to provide visits to the patient three times a week. The Patient died on hospice services on 06/13/2025. The hospice aide plan of care dated 05/21/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. The following task perineal care, incontinent care, and nail care were not marked as completed by the hospice aide during the visits documented on 05/26/2025, 06/02/2025, 06/06/2025, and 06/11/2025. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 04/01/2025 included the following interventions to be performed by the hospice aide every visit: complete bed bath, perineal care, foot care, shampooing hair, incontinent care, skin care, checking pressure areas, oral hygiene/denture care, nail care, shaving, and dressing the patient. On 04/23/2025, the hospice aide did not document that shaving, incontinent care, skin care, or checking of pressure areas were completed. On 06/03/2025 and 06/18/2025, perineal care, incontinence care, and checking pressure areas were not documented as completed. The last documented hospice aide visit was 06/30/2025. The patient died on hospice services on 07/09/2025. There was no order discontinuing hospice aide services, no missed visits documented, and no hospice aide visits were documented from 07/01/2025 to 07/09/2025. The findings were confirmed following a joint clinical record review and an interview with the Director of Nursing (Personnel Record 3) on October 15, 2025.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 6 of 11 (55%) clinical records reviewed for patients receiving aide services revealed that the agency did not ensure that the hospice aide reported to the Registered Nurse (RN) when the hospice aide plan of care was not followed as directed by the RN. CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plans of care dated 07/19/2025 and 09/17/2025 included the following task to be performed during every hospice aide visit: complete shower, incontinent care, perineal care, skin care, foot care, nail care, oral hygiene/denture care, shave, check pressure areas on the patient’s skin, document the date of the patient’s last bowel movement, assist the patient to transfer, turn/position patient, change linen, and make the patient’s bed. The following task were not marked as completed by the hospice aide during the visits documented on 8/18/2025, 09/01/2025, 09/17/2025, and 09/29/2025: incontinent care, nail care, shaving, checking the patient’s skin for pressure areas, and noting the date of the patient’s last bowel movement. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 8: The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed. Both included orders for the hospice aide to visit the patient three times a week. hospice aide plan of care dated 08/14/2025 included the following interventions to be performed every visit: complete shower, incontinent care, perineal care, shampoo hair, foot care, skin care, back rub/massage, oral hygiene/denture care, nail care, check pressure areas, comb hair, dress patient. During the hospice aide visits on 09/17/2025 and 09/26/2025, the hospice aide did not mark that incontinent care, nail care, checking pressure areas, and back rub/massage were completed. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 9: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 08/30/2025 included the following tasks to be performed every visit: complete shower, shampoo hair, foot care, nail care, perineal care, incontinent care, skin care, check pressure areas, comb hair, oral hygiene/denture care, and dress patient. During the hospice aide visits on 09/01/2025 and 09/24/2025, the hospice aide did not document that foot care, nail care, incontinence care, or checking pressure areas were performed. On 10/06/2025, the interventions for perineal care, incontinence care, nail care, and checking pressure areas were not documented as having been completed. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 10: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 07/01/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. During the hospice aide visit on 08/04/2025, the hospice aide did not mark shaving, incontinence care, nail care, and checking pressure areas as completed. On 08/22/2025, back rub/massage and incontinence care were not documented as having been performed. On both 09/08/2025 and 09/15/2025, the hospice aide did not document that the interventions of back rub/massage, checking pressure areas, incontinent care, or nail care were performed. Then, on 10/01/2025, foot care, perineal care, incontinent care, back rub/massage, check pressure areas, and nail care were not documented as completed. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The Patient died on hospice services on 06/13/2025. The hospice aide plan of care dated 05/21/2025 included the following tasks to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. The following interventions were not marked as completed by the hospice aide during the visits documented on 05/26/2025, 06/02/2025, 06/06/2025, and 06/11/2025: perineal care, incontinent care, and nail care. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 04/01/2025 included the following tasks to be performed by the hospice aide every visit: complete bed bath, perineal care, foot care, shampoo hair, incontinent care, skin care, checking pressure areas, oral hygiene/denture care, nail care, shaving, and dressing the patient. On 04/23/2025, the hospice aide did not mark that shaving, incontinent care, skin care, or checking pressure areas were done. On 06/03/2025 and 06/18/2025, perineal care, incontinence care, and checking pressure areas were not documented as performed. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. The findings were confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 11 of 11 (100%) clinical records reviewed for patients receiving home health services revealed the agency did not ensure that the Registered Nurse (RN) documented supervision of the hospice aide every 14 days. CLINICAL RECORD 1: The plans of care for benefit periods 05/20/2025 to 07/18/2025, 07/19/2025 to 09/16/2025, and 09/17/2025 to 11/15/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/28/2025, 06/27/2025 (30 days), 07/28/2025 (31 days), and 08/27/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 2: The plans of care for the benefit periods 05/05/2025 to 08/02/2025 and 08/03/2025 to 10/31/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. The first aide visit was on 05/06/2025. Documented hospice aide supervision by the Registered Nurse (RN) occurred: 06/05/2025 (30 days), 08/07/2025 (63 days), 09/05/2025(29 days), and 10/06/2025 (31 days). CLINICAL RECORD 4: The plans of care for the benefit periods 05/18/2025 to 07/16/2025, 07/17/2025 - 09/14/2025, and 09/15/2025 - 11/13/2025 included orders for the hospice aide to visit the patient three to five times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/20/2025, 06/13/2025 (27 days), 07/14/2025 (28 days), 08/13/2025(30 days), and 09/12/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 5: The plans of care for benefit periods 04/03/2025 to 07/01/2025 and 07/02/2025 to 09/29/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/07/2025, 06/06/2025 (30 days), 08/06/2025(61 days),8/27/2025 (21 days) and 09/05/2025. The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 7: The plans of care for benefit periods 06/15/2025 to 08/13/2025 and 08/13/2025 to 10/12/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 06/23/205, 07/28/2025 (35 days) 08/27/2025 (30 days), and 09/26/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 8: The plan of care for the benefit period 08/14/2025 to 10/12/2025 was reviewed and included orders for the Hospice Aide (HA) to visit the patient three times a week. The first aide visit was on 08/15/2025. The only documented HA supervision by the Registered Nurse (RN) occurred on 09/15/2025 (31days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 9: The plans of care for benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 07/30/2025, 08/29/2025 (30 days), and 09/29/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 10: The plans of care for benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 07/28/2025, 08/27/2025 (30 days), and 09/26/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, included orders for the hospice aide to visit the patient three times a week. The first aide visit was on 10/04/2024. Documented aide supervision by the Registered Nurse (RN) occurred: 11/04/2024(31 days), 12/04/2024(30 days), 01/01/2025 (28 days), 01/31/2025(30 days), and 03/03/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The first aide visit was 05/21/2025, and there was no documented aide supervision by the Registered Nurse (RN). The Patient died on hospice services on 06/13/2025. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 04/30/2025, 05/29/2025 (29 days). The nurse did not supervise the hospice aide every fourteen days. The finding was confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025. She stated that she misunderstood the requirement to mean that supervision was required after fourteen aide visits, not every fourteen days.”

“It is required that 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 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure the plan of care accurately reflected he scope and frequency of volunteer services. AGENCY POLICY: The hospice’s policy “Volunteer Services Policy No. 9-024” dated December 2018 included that “...The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care...” CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a month. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. CLINICAL RECORD 3: The plans of care for the benefit periods from 07/13/2025 to 09/10/2025 and from 09/11/2025 to 11/09/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a week. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. CLINICAL RECORD 4: The plans of care for the benefit periods from 07/17/2025 to 09/14/2025 and from 09/15/2025 to 11/13/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a month. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. During a joint clinical record review and interview with the Director of Nursing (DON) (Personnel Record 3) on 10/16/2025, the documented findings were confirmed, and the issue was revealed to be a documentation issue versus Volunteer visit orders with no visits made. The DON observed the evidence and agreed that the ordered frequency appeared to reflect that visits should be made; however, with her knowledge of the patients, she stated that this was not correct, and the documentation would be brought into compliance to reflect the services to be provided accurately.”