Abundant Hospice, LLC

“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 DEFICIENCY CITED AT IMMEDIATE JEOPARDY. This Condition of participation, which was also cited at Immediate Jeopardy, was not met as evidenced review of clinical records, observation, and interviews with the Administrator, Alternate Administrator, Director of Clinical Services, and Alternate Director of Clinical Services which revealed significant issues with the hospice’s ability to assess and evaluate the patient’s care environment related to patient safety: Failure to ensure the patient’s right to be free from mistreatment and neglect, when the patient’s care environment was not assessed for safety risks (HPFC.2.D/L517). 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 418.52: Patient Rights. 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 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, observation, and interviews with the Administrator, Alternate Administrator, Director of Nursing, and Alternate Director of Nursing which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the Registered Nurse provided coordination of care and ensured continuous assessment of the patient and family needs (HCPC.19.I/L540); Failure to ensure the patient’s primary caregiver received education and training as appropriate to their care responsibilities (HCPC.20.I/L544); Failure to ensure the individualized plan of care included complete treatment orders (HCPC.21.I/L549); and Failure to ensure the plan of care was revised with new/changed problems, interventions, and goals that reflected the changes documented in the assessment (HCPC.22.I/L553). 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 a hospice providing hospice care to residents of a SNF/NF or an ICF/IID follows the standards and requirements defined elsewhere in this manual related to providing care to a hospice patient that resides in a facility. THIS IS A CMS CONDITION LEVEL CITATION. This Condition was not met as evidenced by review of clinical records, document review, observation, and interviews with Administrator, Alternate Administrator, Director of Clinical Services, and Alternate Director of Clinical Services, which revealed significant issues with oversight and coordination of hospice care with facility staff for patients that reside in a Nursing Facility, including: Failure to ensure the hospice Registered Nurse coordinated care and updated the plan of care for the patient that resided in a Nursing Facility (HSRF.4.I/L762); Failure to ensure the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the agreed upon functions (HSRF.6.I/L774); Failure to ensure coordination of medical care for the patient that resides in a Nursing Facility (HSRF.8.I/L780); and Failure to ensure the Nursing Facility was provided with the required hospice information (HSRF.9.I/L781). 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 418.112: Hospices that provide hospice care to residents of a SNF/NF or an ICF/IID. 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 written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient’s right to be free from mistreatment and neglect, when the patient’s care environment was not assessed for safety risks. Agency policy PF.25 “Patient Care Site and Patient Safety Education,” dated 02/01/2026, required in part “...the Interdisciplinary Group/Team (IDG/IDT) will...evaluate each case for ongoing risk and impact for patient...safety to determine if further action is needed. The determined plan of action will be discussed with the patient and/or family. All communication with the patient and/or family regarding safety concerns will be documented in the patient’s medical record. The home environment will be re-evaluated for safety issues and/or hazards on an ongoing basis...” CLINICAL RECORD 2/HOME VISIT 2: During the home visit observation on 06/09/2026 with the Hospice Aide (HA) (Personnel Record 8), a flight of steep steps was ascended to reach the patient in his room above the garage, where the patient was found sitting in the recliner. The patient stood up, and the HA assisted the patient, who appeared unsteady, down the steps to the bathroom on the ground level of the finished garage. The bathroom door handle had a plastic lock protector, similar to a child-proof lock; however, the lock required a key. The Aide located the key underneath the laundry hamper to the right of the door. The key was used to access the bathroom. The Aide unlocked and opened the bathroom door. The Aide then assisted the patient with the step-up into the bathroom to shower the patient. Once the patient was showered and dressed, the Aide assisted the patient to step back down into the garage. The patient was observed to wobble and be unsteady as he held on to the Aide’s shoulder to steady himself in order to slide his feet into his shoes. The patient would not allow the aide to assist in any other manner but to help stabilize him. The patient was observed living in an apartment over the garage and did not have access to a bathroom unless he walked up and down the stairs. There was no bathroom upstairs in or next to the patient’s room, and the patient did not have a bedside commode. A subsequent review of the clinical record revealed the patient resided at the home of his ex-wife and her husband. The hospice benefit election was dated 04/24/2026 with the diagnoses of senile degeneration of the brain and post-concussion syndrome. There was no 24/7 caregiver present with the patient. The family confirmed and was observed not being physically present at all times, and there was no way for the patient to call through phone, intercom, or lifeline if immediate assistance was needed. The Registered Nurse (RN) documented in the admission note dated 04/24/2026 that the patient had previously been in an independent living situation but had moved in with his ex-wife because he needed more care. The Social Worker (SW) documented on 04/28/2026 that the patient lacked access to a phone and was unable to make phone calls. The RN documented in the nursing visit note dated 05/28/2026 that, although the patient was able to ambulate, his cognitive deficit affected his judgment and balance. The RN documented in the nursing visit note dated 06/03/2026 that, due to increased “hunching over” while walking, the patient needed to be watched more closely during ambulation, with increased ataxia (poor muscle control and uncoordinated movements) impacting motor skills and balance. The patient required increased monitoring and fall prevention due to the center of gravity shifting forward, increasing his risk of falls “drastically.” The SW documented on 06/08/2026 located the patient in his upstairs room with an unsteady stance and noted he was unbalanced on his feet, although he appeared comfortable and well-cared for. He was able to ambulate on his own “however he has a very unsteady stance when standing and often loses his balance when walking...” The Interdisciplinary Group (IDG) Meetings dated 05/13/2026 and 05/27/2026, the Registered Nurse documented the patient’s Palliative Performance Scale (PPS) of 50% (Ambulation-mainly sit/lie, Activity Level-can’t do any work, Self-Care-considerable assistance needed) and that the patient was a complete assist with 3 out of 6 ADLs (activities of daily living). The patient exhibited increased weakness and confusion. The Social Worker documented in the 05/27/2026 IDG meeting that the patient enjoyed his respite stay and was interested in adult daycare, as he enjoyed the activities during his respite stay. He continued to be supported by his ex-wife, and the SW would continue to support her and her current husband with education and information regarding disease progression but continue the current plan of care and monthly visits. The IDG documentation did not address the patient’s living conditions or assess the safety of the care environment. The clinical record did not include documentation that the patient had been assessed and evaluated to determine if the current care environment was safe for the patient, when the nurse and social worker documented increased unsteadiness with ambulation and assistance needed with activities of daily living. During the home visit observation on 06/08/2026, the patient was observed to be unsteady on his feet, with uncoordinated movements, no assistive devices were available, and the patient had no access to a bathroom without ambulating down a flight of steep stairs. There was no documented evidence that the patient had been assessed for his ability to ambulate the stairs safely or that he had to go downstairs to use the restroom. CLINICIAL RECORD 3/HOME VISIT 3: During the home visit observation on 06/09/2026 with the Licensed Master Social Worker (LMSW) (Personnel Record 6), the patient was bedbound with contractures (shortening and hardening of muscles and tendons, leading to limited joint movement) and unable to move in bed without assistance. The patient was observed to need total care. While talking with the LMSW, the son (primary caregiver) stated he “just couldn’t” move, turn, and change the patient like he has done for years due to his own physical limitations. Respite was offered by the LMSW during the visit, but the patient’s son was reluctant, as he felt his mother would react negatively. Subsequent review of the clinical record revealed that the patient resided at home with the son, who was the primary caregiver. The hospice benefit election was dated 03/11/2026 with a diagnosis of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The plan of care dated 04/13/2026 to 06/11/2026 included the identified problem of a deficit in self-care that included deficits in ambulation, transferring, dressing, toileting and bathing. Interventions included instructing the primary caregiver on safe care of a bed bound patient and the need for Hospice Aide services, which were being provided 5 times a week. The Registered Nurse (RN) documented on the admission assessment date 03/11/2026 the patient was bedbound, PPS 30% (Ambulation-bedbound, Activity Level-can’t do any work, Self-Care-total care); no skin condition or wounds; moderate risk for skin breakdown due to bedfast, potential friction/shear, completely immobile; incontinent bowel/bladder; has pure wick (urine collection system), and history of urinary tract infections; frail and cachectic (wasting syndrome); skin intact; occasional general pain, total assist all activities of daily living. The Registered Nurse documented on 05/06/2026 that the patient appeared clean and well cared for, despite an “unkempt environment (bugs throughout home and trash and dishes everywhere and very strong odor throughout home).” The nurse documented contact and coordination with the Social Worker (SW), who stated she had been “frequently keeping an eye on things.” The Registered Nurse documented the presence of a wound on 05/13/2026. The wound assessment recorded a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with scant serosanguineous drainage and a mild odor. The Social Worker documented a visit on 05/14/2026 and noted the patient appeared comfortable and well cared for, but the son was upset that a large wound on the patient’s back had reopened due to the “seriousness of it as reported by the assigned nurse.” The Social Worker noted that the patient’s son was aware of the patient’s care needs. The Registered Nurse documented on 05/20/2026 that the son reported that the patient was having a bad day and had made multiple statements of just wanting to die, which he repeated in the nurse’s presence. The patient was noted to be bedbound and contracted. The Interdisciplinary Group (IDG) Meeting dated 06/04/2026 included documentation indicating that the LMSW provided ongoing emotional support and connected the patient to resources, and that the patient remained bedbound with limited communication. “No further SW needs or concerns at this time. The patient will continue the current plan of care and monthly visits.” The RN noted that the patient’s Palliative Performance Score (PPS) was 30%...the patient required complete assistance with 6/6 ADLs. The patient was noted to have a “...stage 3 ulcer getting wound care weekly from RN...” The patient had dark, discolored urine with odor and sediment, and added that an antibiotic had been ordered 2 weeks previously, but the son never began the antibiotic as he decided she did not need it but finally agreed to start giving it at the previous day’s nursing visit. The clinical record did not include documentation of an assessment of the patient’s care needs after the primary caregiver had made multiple statements of just wanting to die in the nurse’s presence. The primary caregiver had also referred to caregiver strain with the Social Worker, with no follow-up assessment documented. During the home visit observation, the patient was found to require total care, unable to turn self in bed or provide own self-care. During interviews with the Administrator (Personnel Record 1), the Alternate Administrator (Personnel Record 2), the Director of Clinical Services (Personnel Record 4), and the Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3) on 06/10/2026 and 06/11/2026, there was no documentation provided that ensured that the patients’ safety had been addressed via assessment, intervention, plan of care updates, orders, or documented discussions with the Interdisciplinary Group (IDG). An interview was conducted with the Medical Director (Personnel Record 12) on 06/10/2026. During the interview, the patient’s living situation and mobility status (Clinical Record 2) were reviewed. The Medical Director did not demonstrate current awareness of the patient’s safety risks within the home environment at the time of the interview. When asked how the interdisciplinary team addressed safety concerns related to the patient’s living environment, the Medical Director stated that concerns were discussed during IDG meetings with participation from all disciplines. He described that the team collaborated to review the situation, identify potential risks, and develop interventions, including determining any additional steps necessary to address ongoing concerns.”

“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, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patients drug profile contained the correct patient prescriptions, over-the-counter drugs, or supplements. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient resided at a Nursing Facility (NF). During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), a medication review was completed by comparing the patient’s hospice medication profile to the NF medication list. The hospice medication profile included Seroquel 100mg at bedtime for behavior/agitation, while the NF medication list included Seroquel 75mg at bedtime. The hospice medication profile included Lorazepam 1mg every 6 hours PRN (as needed) for agitation/behaviors. The NF medication list did not include Lorazepam. The hospice medication profile included Acetaminophen 650mg: 1-2 tablets every 8 hours PRN for pain, while the NF medication list included Acetaminophen 650mg 1 tablet every 8 hours PRN. The NF medication list included Cyanocobalamin 1000mcg daily as a supplement and the hospice medication profile did not include Cyanocobalamin. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The Registered Nurse documented in the nursing visit note dated 05/20/2026, patient with excoriated skin to the patient’s thigh folds and noted that the Hospice Aide applied barrier cream and antifungal powder. The barrier cream and antifungal powder were not listed on the patient’s medication profile and plan of care. During interviews on 06/10/2026 and 06/11/2026 with the Administrator (Personnel Record 1), the Director of Clinical Services (Personnel Record 4), and the Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the leaders could not provide evidence that the medication profiles for Clinical Record 1 and Clinical Record 3 included the current and correct medications and dosages.”

“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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. 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 the initial bereavement assessment was completed as part of the initial comprehensive assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/24/2026 with diagnoses of senile degeneration of the brain, post-concussion syndrome, and depression. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During a review of the record and interview on 06/11/2026, the Alternate Director of Clinical Services (Personnel Record 3) could not provide evidence that the initial bereavement risk assessment had been completed for Clinical Record 2.”

“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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the Registered Nurse provided coordination of care and ensured continuous assessment of the patient and family needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The Registered Nurse (RN) documented on the admission assessment and nursing visits dated through 05/06/2026, no skin issues were identified. The RN documented on the nursing visit note dated 05/13/2026, a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm with a scant amount of serosanguinous drainage with mild odor. A treatment order was documented to cleanse the site with “skin prep,” pack tunneling in the wound with plain packing strips, and cover with a foam dressing every 2 days. Review of the nursing visit notes dated 05/20/2026, 05/27/2026, and 06/03/2026 revealed the wound assessment and documentation did not change the wound size was documented with the same measurements of 1cm x 0cm x 5cm and the same description of the wound drainage. The wound assessments associated with these nursing notes included a wound assessment date of 05/13/2026. There was no documented evidence in the clinical record that the stage 3 pressure ulcer wound was assessed by the RN, except for initial assessment of the wound on 05/13/2026. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/24/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a personal care home. The Registered Nurse documented on the nursing visit note dated 05/18/2026, a stage 2 pressure wound on the patient’s left buttock that measured 1.5cm x 1cm x 0cm. The nursing visits notes dated 05/27/2026 and 06/03/2026, included wound documentation dated 05/18/2026 and included the same wound measurements and staging as the 05/18/2026 nursing visit. The nurse made a visit on 06/10/2026, and the skin assessment included the same wound measurements as documented in the assessment dated 05/18/2026. During the interviews, the Alternate Director of Clinical Services (Personnel Record 3) on 06/10/2026 and the Director of Clinical Services (Personnel Record 4) on 06/11/2026 were unable to provide evidence demonstrating that nursing staff performed ongoing, comprehensive wound assessments or documented updated findings in the clinical record. Both clinical leaders were unable to identify or produce documentation reflecting reassessment of the patient’s wound beyond the initial entry. The only wound documentation in the reviewed clinical records was the original assessment, including the date the wound was first identified and the initial measurement. There was no evidence of subsequent or ongoing wound assessments, specifically, there were no updated measurements of length, width, or depth; no documentation addressing the presence or extent of tunneling or undermining; no description of wound bed characteristics (including granulation, slough, eschar, or hyper-granulation with quantified percentages); no assessment of wound edges or margins (e.g., defined versus undefined, maceration, etc.), and no ongoing evaluation of exudate/drainage (amount, type, color, consistency, or odor).”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. 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 the patient’s primary caregiver received education and training as appropriate to their care responsibilities. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the primary caregiver. On 05/13/2026, the Registered Nurse documented a wound assessment of a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with a scant amount of serosanguineous drainage and a mild odor. A treatment order was documented to cleanse the site with “skin prep,” pack tunneling in the wound with plain packing strips and cover with a foam dressing every 2 days. The plan of care for the benefit period from 04/13/2026 to 06/11/2026 included an order for Skilled Nursing visits once a week and 3 PRN (as needed) visits/unscheduled visits. A problem of the patient being at risk for altered skin integrity due to bowel and bladder incontinence, bedbound status, and previous history of wounds was identified on 04/14/2026. The interventions included education of the primary caregiver on turning the patient every 2 hours, positioning techniques, and the importance of preventing skin breakdown. The documented goals were to minimize the risk of bedsores and to ensure the patient-maintained skin integrity. The wound care order specified dressing changes every 2 days; however, the nursing visit frequency was ordered once a week, leaving the patient’s caregiver to manage the wound in the nurse’s absence. There was no documented evidence in the clinical record that the primary caregiver was educated and demonstrated competency for wound care. During interviews with the Director of Clinical Services (Personnel Record 4) and the Alternate Director of Clinical Services (Personnel Record 3) on 06/10/2026 and 06/11/2026, the leaders were unable to provide evidence that the primary caregiver had been educated and demonstrated competency to provide wound care to the patient on the days the nurse did not provide a visit.”

“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 the following, drugs and treatment necessary to meet the needs of the patient. 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 the individualized plan of care included complete treatment orders. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The Registered Nurse documented on the nursing visit note dated 05/13/2026, a wound assessment for a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with a scant amount of serosanguineous drainage and a mild odor. A treatment order was documented to cleanse the site with “skin prep,” pack tunneling in the wound with plain packing strips and cover with a foam dressing every 2 days. The wound treatment order did not specify the wound site or who was responsible for wound dressing changes when the nurse was not present. There was no indication of what the wound should be cleaned with, as skin prep is not a cleanser but a product to protect skin from irritation caused by medical tape or dressings. The plan of care for the benefit period from 04/13/2026 to 06/11/2026 included orders for Skilled Nursing visits once a week and 3 PRN (as needed) visits/unscheduled visits; however, the plan of care was not updated to include a complete treatment order. During interviews on 06/10/2026 and 06/11/2026, the Director of Clinical Services (Personnel Record 4) and the Alternate Director of Clinical Services (Personnel Record 3) did not produce a clarification order for the wound treatment that included the location of the wound and the type of wound cleanser to be used.”

“A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the plan of care was revised with new/changed problems, interventions, and goals that reflected the changes documented in the assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. The NF clarification order dated 04/03/2026 included Occupational Therapy (OT) services four (4) times per week for 60 days for self-care, neuro-reeducation, splinting, manual therapy, pain modalities (hot/cold packs and Bio-Freeze), caregiver/patient education, and discharge planning. An additional NF clarification order dated 04/02/2026 prescribed Physical Therapy (PT) services four times per week for 30 days, including therapeutic exercise, therapeutic activity, neuro-reeducation, gait training, and wheelchair management. A further NF recertification order dated 06/02/2026 included Speech-Language Pathology (SLP) services three times per week for 60 days with treatment interventions to maintain and/or improve the patient’s current level of function. Despite the presence of these active therapy orders, the hospice plan of care and IDG (interdisciplinary group) documentation did not reflect incorporation of these services into patient-specific problems, measurable goals, or individualized interventions. The IDG note dated 04/09/2026 did not include documentation of therapy services or evidence of collaboration with the facility regarding therapy interventions, despite active NF therapy orders. There were no corresponding hospice orders for therapy services in the hospice clinical record, and no identified problems, goals, or interventions addressing the patient’s functional status, mobility needs, or therapy-related care. The IDG note dated 04/23/2026 referenced monitoring the patient’s decline and transition to memory care; however, there was no documentation addressing ongoing therapy services or integration of facility-based therapies into the hospice plan of care. The IDG note dated 05/07/2026 contained no reference to therapy services, functional status interventions, or coordination with the NF therapy team. The nursing visit note dated 06/05/2026 included documentation that the patient was “sitting upright in a chair in physical therapy” at the time of arrival, indicating ongoing therapy involvement; however, this was not reflected in the hospice plan of care, including updated problems, measurable goals, or coordinated interventions. The hospice plan of care was not consistently updated to reflect the patient’s current condition, ongoing therapy services, and individualized functional needs. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 04/24/2026 with diagnoses of senile degeneration of the brain, post-concussion syndrome, and depression. Observation of the patient’s home environment during the home visit observation revealed the patient resided in an upstairs room with access via flight of steep stairs above the garage. The Registered Nurse (RN) documented on the admission assessment dated 04/24/2026 the patient had experienced a recent decline that required a transition from independent living. The Social Worker (SW) documented an assessment on 04/28/2026 that the patient had a lack of phone access, an absence of an MPOA (medical power of attorney) due to impaired capacity, and an upstairs living arrangement with potential need for relocation. Subsequent nursing and social work documentation reflected the patient’s progressive decline and increasing safety concerns. On 05/28/2026, the RN noted impaired judgment and balance despite continued ambulation and on 06/03/2026, increased ataxia (uncoordinated movements), forward posturing, and elevated fall risk were documented. The SW described in a note dated 06/08/2026 an unsteady gait with frequent loss of balance in the upstairs environment. During the home visit observation on 06/09/2026 with the Hospice Aide (HA) (Personnel Record 8), a flight of steep steps was ascended to reach the patient in his room above the garage where the patient was found sitting in the recliner. The patient stood up and the HA proceeded to assist the patient who appeared to be unsteady down the steps to the bathroom that was located on the ground level of the finished garage. The door handle to the bathroom had a plastic lock protector, similar to a child-proof door lock; however, the lock required a key. The Aide located the key underneath the laundry hamper to the right of the door. The key was used to access the bathroom. The patient was observed to exhibit marked unsteadiness requiring hands-on support. The plan of care was not revised to include the patient’s increased risk of falls, unsteadiness of gait, and specific environmental hazards related to the steep stairs and lack of bathroom access without ambulating up and down stairs. The hospice plan of care did not reflect the patient’s progressive decline and hazardous environment through updated, individualized problems, goals and interventions. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The RN documented on the admission assessment dated 03/11/2026 the patient had transferred from another hospice provider. The patient was described as bedbound with a PPS of 30% (Ambulation-bedbound, Activity Level-can’t do any work, Self-Care-total care), completely dependent for activities of daily living, incontinent of bowel and bladder, and utilizing a Pure Wick (urinary collection system) with a history of urinary tract infections. The patient was noted to be frail and cachectic (wasting syndrome), with intact skin; however, the assessment identified moderate risk for skin breakdown related to immobility, incontinence, and potential for friction and shear. The patient also experienced occasional generalized pain. The hospice plan of care did not include patient-specific problems, measurable goals, and individualized interventions to address pressure injury prevention, incontinence management, infection risk, or pain management strategies consistent with the patient’s condition and level of dependence. During review of clinical records and interviews conducted on 06/09/2026, 06/10/2026, and 06/11/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the organization’s leadership was unable to provide evidence that the patient’s plans of care were consistently updated to reflect current needs, services, and care coordination.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) 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 2 of 15 (13%) clinical records reviewed with aide services provided, the agency did not ensure the aide plan of care included patient specific care instructions for the hospice aide. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The plan of care for the benefit period dated 04/13/2026 to 06/11/2026 included an order for Hospice Aide services at a frequency of five times per week. The current aide care plan dated 05/04/2026 assigned the aide routine personal care tasks to be completed during each visit, including incontinence care for bowel and bladder, perineal care, bed bath, shampooing and brushing hair, shaving using a safety razor, oral care, and nail care. The Registered Nurse documented on the 05/13/2026 nursing visit note, the patient was incontinent of bowel and bladder and identified a Stage 3 pressure ulcer located on the sacrum, measuring 1 cm x 0 cm x 5 cm with tunneling. The treatment order dated 05/13/2026 directed staff to cleanse the wound with skin prep, pack the tunneled area with plain packing strips, and cover with a foam dressing, with dressing changes every two days. The aide care plan did not include instructions for the aide related to the patient’s wound, wound dressing, and incontinence. There were no instructions provided to the aide regarding appropriate actions to take if the wound dressing became wet, loose, or soiled and how to care for the wound dressing while providing care to the patient. CLINICAL RECORD 17: The patient elected the hospice benefit on 07/29/2025 with a diagnosis of interstitial pulmonary disease. Review of the clinical record and plan of care for the benefit period from 10/27/2025 to 01/24/2026 revealed an order dated 12/02/2025 for the Hospice Aide to provide services twice a week. The current aide care plan dated 12/23/2025 assigned the aide to provide a shower at each visit. The Registered Nurse documented on the nursing visit note dated 12/30/2025, the patient was unable to stand and required maximum assistance with bathing, toileting, and dressing, and indicated this was a significant change in condition and care needs for the patient. There was no documented evidence that the aide care plan was updated after the Registered Nurse documented the patient’s decline in mobility and need for maximum assist with bathing, toileting, and dressing. During a review of records and interview on 06/11/2026, the Director of Clinical Services (Personnel Record 4) or the Alternate Director of Clinical Services (Personnel Record 3) did not provide evidence to show that aide care plans included directions to the aide for protection and observation of the patient’s wound during care, or a change in assigned bathing as the patient’s function deteriorated.”

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes: the volunteer’s duties and responsibilities; the person to whom they report; the person to contact if they need assistance and instruction; hospice goals, services, and philosophy; confidentiality and protection of the patient’s and family’s rights; family dynamics and psychological issues surrounding terminal illness, death, and bereavement; procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) volunteer personnel file reviewed, the hospice did not ensure hospice volunteer orientation and training include required elements. PERSONNEL RECORD 11: Volunteer date of hire 01/14/2026. There was no documented evidence in the personnel record that the volunteer was oriented and trained to the role of volunteer. During an interview with the Alternate Administrator (Personnel Record 2) on 06/11/2026, it was confirmed that a complete orientation record could not be produced for the volunteer. The only form located included the volunteer acknowledgment of drug testing, confidentiality, harassment, non-solicitation/illegal remuneration, non-discrimination, and abuse, neglect, and prevention policies.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure documentation of efforts to recruit and retain volunteers. During a review of the Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 06/11/2026, the discussion revealed a lack of an established, consistently implemented process for documenting volunteer recruitment and retention efforts. The VC was unable to describe a formal process for tracking or maintaining records related to volunteer retention, and no supporting documentation was provided upon request. While the VC described general recruitment strategies including social media postings, outreach to facilities to participate in group activities, and collaboration with hospice marketing staff. The efforts were not supported by systematic or ongoing documentation. The evidence produced consisted of three printed social media posts. No documentation or process was provided to demonstrate active monitoring, evaluation, or sustained efforts related to volunteer retention. A review of the Volunteer Program documentation, along with an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 06/11/2026, revealed that the agency lacks an established, consistently implemented process for documenting volunteer recruitment and retention efforts. The VC was unable to describe a formal process for tracking or maintaining records related to volunteer retention, and no supporting documentation was provided upon request. While the VC described general recruitment strategies—including social media postings, outreach to facilities to participate in group activities, and collaboration with hospice marketing staff—these efforts were not supported by systematic or ongoing documentation. The only evidence produced consisted of three printed social media posts. No documentation or process was provided to demonstrate active monitoring, evaluation, or sustained efforts related to volunteer retention. In addition, the VC demonstrated a lack of knowledge about integrating volunteer services into the patient’s overall plan of care. During the interview, the VC was unable to describe the process for developing or implementing volunteer-specific plans of care, including determining visit frequency, assigning volunteer activities, or aligning with patient needs and interdisciplinary care planning. The absence of both a structured recruitment and retention documentation process and a clear understanding of volunteer care planning requirements indicates potential for ineffective utilization and oversight of the hospice volunteer program.”

“It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG); consultation about the patient’s/resident’s care with the facility staff; and coordination by the hospice Registered Nurse (RN) for the implementation of the plan of care for the patient/resident. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 1 of 1 (100%) clinical records reviewed for patients that reside in a nursing facility (NF), the hospice did not ensure the hospice RN coordinated care and updated the plan of care for the patient that resided in a Nursing Facility. Agency policy PC.125 “Hospice Care in a SNF/NF or ICF/IID,” dated 11/12/2024, required in part, “...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC (plan of care) will be developed based on the patient/family’s needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family...Change to the POC will be discussed with patient or representative and the facility representatives and approved by the Hospice prior to implementation...The Hospice will authorize services to be provided in the facility...Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to provide overall coordination of the Hospice care of the patient with the facility representatives, communicating with the facility representatives...maintain professional management responsibility and coordination of services furnished...according to the POC...” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the patient was observed in the therapy room actively receiving Occupational Therapy services. The current hospice plan of care and active physician orders were compared to the NF plan of care and active physician orders. The NF plan of care and active orders indicated that the patient had ongoing restorative therapy services, including Physical Therapy four times per week for 30 days (order dated 04/02/2026), Occupational Therapy four times per week for 60 days (order dated 04/03/2026), and Speech Therapy services, with a recertification/clarification order dated 06/02/2026 and an original evaluation and treatment order dated 04/03/2026. These services remained active and were being delivered by the NF staff concurrently with hospice care. Clinical record review revealed the Registered Nurse was aware the patient received therapy services at the NF. The Registered Nurse documented on the nursing visit note dated 06/05/2026, “…Upon arrival patient sitting upright in chair in physical therapy….” The hospice clinical record did not include documentation of coordinated oversight, evaluation of appropriateness, or integration of these therapy services into the hospice plan of care. There was no documented evidence of interdisciplinary discussion, physician involvement, or consideration of how these therapies aligned with the patient’s hospice diagnosis, goals of care, or prognosis. During review of clinical records and interviews conducted on 06/10/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services (Personnel Record 3), the organization’s leadership lacked knowledge of the Nursing Facility’s plan of care and the services that were provided to the hospice patient that resided in a NF. Home Visit Observation (HVO) 2 was conducted on 06/09/2026, including a review of the nursing facility (NF) plan of care and active physician orders, the hospice plan of care and active orders, interviews with the Director of Clinical Services (DCS) (Personnel Record 4) and the Administrator (Personnel Record 1), and review of the agency’s policies. This comprehensive review identified a lack of coordination and oversight of non-hospice services being provided to the patient (Clinical Record 1). Specifically, the NF plan of care and active orders indicated that the patient had ongoing restorative therapy services, including Physical Therapy (PT) four times per week for 30 days (order dated 04/02/2026), Occupational Therapy (OT) four times per week for 60 days (order dated 04/03/2026), and Speech Therapy (ST) services, with a recertification/clarification order dated 06/02/2026 and an original evaluation and treatment order dated 04/03/2026. These services remained active and were being delivered concurrently with hospice care. During the HVO conducted with the Chaplain (Personnel Record 7) on 06/09/2026, the patient was observed in the therapy room actively receiving Occupational Therapy services. In addition, documentation by the Registered Nurse (RN) on 06/05/2026 noted, “…Upon arrival patient sitting upright in chair in physical therapy…,” confirming the patient’s ongoing participation in therapy services. Despite clear evidence that the patient was receiving routine, restorative therapies, the hospice clinical record did not reflect coordinated oversight, evaluation of appropriateness, or integration of these services into the hospice plan of care. There was no documentation demonstrating interdisciplinary discussion, physician involvement, or consideration of how these therapies aligned with the patient’s hospice diagnosis, goals of care, or prognosis. Interviews with leadership (Personnel Records 1, 2, 3, and 4) demonstrated lack of knowledge regarding the NF’s plan of care and of services being provided to the hospice patient while at the NF. The lack of coordination and oversight of ongoing therapy services reflects a breakdown in the hospice agency’s responsibility to manage and direct all aspects of the patient’s care. The agency’s policy “Hospice Care in a SNF/NF or ICF/IID (PC.125)” dated 11/12/2024, read in part that “...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC will be developed based on the patient/family’s needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family...Change to the POC will be discussed with patient or representative and the facility representatives and approved by the Hospice prior to implementation...The Hospice will authorize services to be provided in the facility...Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to provide overall coordination of the Hospice care of the patient with the facility representatives, communicating with the facility representatives...maintain professional management responsibility and coordination of services furnished...according to the POC...””

“It is required that 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 document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed for patients that reside in a Nursing Facility (NF), the hospice did not ensure the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the agreed upon functions. Agency policy PC.125 “Hospice Care in a SNF/NF or ICF/IID,” dated 11/12/2024, required in part, “...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC (plan of care) will be developed based on the patient/family’s needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family.” CLINICAL RECORD 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. The Interdisciplinary Group (IDG) Plan of Care dated 06/04/2026, described a 79-year-old [patient] with a primary diagnosis of senile degeneration of the brain, exhibiting moderate cognitive impairment (FAST 6E), wandering behaviors within a locked unit, insomnia, increased somnolence, impaired mobility, fall risk, edema, incontinence, nutritional decline, and pain symptoms. Interventions outlined in the hospice plan of care focused on monitoring, medication education, and skilled nursing assessments across a range of clinical conditions, including cardiac status, respiratory status, depression, pain, urinary elimination, and nutritional intake. However, despite the patient residing in a nursing facility with 24-hour staff supervision, the plan of care did not specify how facility staff would participate in, support, or carry out these interventions. There was no documentation that specified communication pathways, delegation, or coordination strategies to ensure that interventions such as fall prevention, incontinence care, monitoring of wandering behaviors, medication administration, and response to changes in condition were implemented in the facility setting. Additionally, despite noted behavioral concerns (wandering, nighttime agitation, pulling at clothing/briefs) and safety risks. The plan of care did not include individualized, setting-specific interventions tailored to the locked NF unit environment. During an interview conducted on 06/10/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the leadership team was unable to demonstrate that the hospice plan of care was developed and implemented in coordination with the Nursing Facility.”

“It is required that the Interdisciplinary Group member ensure that the IDG communicates with the SNF/NF or ICF/IID medical director, the patient’s attending physician, and other physicians participating in the patient’s/resident’s care to coordinate the hospice care with the medical care provided by other physicians. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) clinical records reviewed for patients that resided in a Nursing Facility (NF), the hospice did not ensure coordination of medical care. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the current hospice plan of care and active physician orders were compared to the NF plan of care and active physician orders. The hospice plan of care listed the Associate Hospice Medical Director as the patient’s attending physician, while the NF plan of care identified a different attending physician. The discrepancy was not addressed or reconciled within the clinical record, and there was no documentation that demonstrated coordination between the hospice and facility to clarify responsibility for medical oversight and order management. During an interview on 06/10/2026, the Administrator (Personnel Record 1) was unaware of the discrepancy in attending physician designation between the hospice plan of care and the nursing facility plan of care. The Director of Clinical Services (Personnel Record 4) reported that he visited the facility on 06/10/2026 but did not discover or report the discrepancy in the patient’s listed attending physicians.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information, and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observation for a patient that resided in a Nursing Facility (NF), the hospice did not ensure the facility was provided with the required hospice information. HOME VISIT 1: During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the hospice facility binder was reviewed. The binder included the patient’s hospice election form, out-of-hospital DNR (do not resuscitate), medication list, and a hospice plan of care dated 06/04/2026. However, at the time of review, the binder did not contain the physician’s certification of terminal illness and did not include the names and contact information of hospice staff involved in the patient’s care. During the home visit at the NF an interview was conducted with the NF Director of Nursing (DON). The NF DON provided printed copies of the nursing facility’s medication list and plan of care for the patient and did not indicate that additional hospice documentation existed within the facility’s system that would be necessary or available for review during the survey.”