Cardinal Hospice of South Texas

“Based on record review and interview the agency failed to provided volunteer services at a minimum of 5% of the total care hours provided by the agency.This failure caused the agency to not meet the 5% minimum cost savings with volunteer services annually for 2024 and 2025. Findings Include:Record review of Volunteer Hours/Cost Saving Reports for the year 2024 revealed 3.3% volunteer hours were documented. Review of Volunteer Hours/Cost Saving Reports for the year 2025 review 4.87% hours were documented.An interview was conducted on 6.16.26 at 4:15 p.m. with the Administrator and AA. Volunteer cost savings reports for 2024 and 2025 were reviewed. AA stated, “We were aware it was below the minimum. We had a change in staff during that time.”An interview was conducted on 6.19.26 at a.m. with the VC. VC was employed by the agency on 6.3.24. Surveyor asked how the agency recruited, oriented, trained and supervised agency volunteers. VC stated she did the recruiting, training, competencies and supervision. Human Resources did the hiring and orientation. Surveyor asked how often she supervised volunteers. VC stated she attended the first visit with the client and volunteer, met with the volunteer monthly and supervised annually. The agency’s volunteer cost savings reports for 2024 and 2025 were reviewed. VC confirmed 2024 was 4.87% and 2025 was 3.33%. Surveyor asked what caused the inability to meet the minimum cost savings, 5%. VC stated, “I was hired in June 2024 and the numbers were very low. The agency hired four Marketers and there were a lot of new client admissions. At one point we had 200 clients. We worked hard to increase the volunteer hours but we were not able to get to the 5%. In 2025 we had clients in 5 personal care homes that were owned by the same individual. The owner decided to transfer all of our agency clients to a different hospice. That affected the numbers a lot.”Review of the agency’s Policy and Procedure Manual revealed a policy titled “Volunteers- Human Resources.95, Last Reviewed: 09/01/24, which read, “Volunteers will provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid Hospice employees and contract staff.””

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. 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 by review of clinical records and interview with the Chief Nursing Officer/Alternate Supervising Nurse and Director of Nursing which revealed the following issues with coordination of hospice care and the development and implementation of patients’ interdisciplinary plan of care: Failure to ensure the Registered Nurse provided coordination of care and ensured continuous assessment of the patient’s and family’s needs (HCPC.19.I/L540) and Failure to ensure hospice care and services provided to patients and families followed the individualized plan of care that was established by the hospice IDG in collaboration with the attending physician (HCPC.19.I/L543). 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 consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including Conducting ongoing interdisciplinary comprehensive assessments; Developing and evaluating the plan of care; Contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. 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 and interviews with the Director of Nursing, which revealed issues with: Failure to provide nursing care and services under the supervision of a Registered Nurse and per the patient’s plan of care (HCDT.6.I/L591). 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 418.64: Core services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice designates a registered nurse member of the IDG (intradisciplinary group) to provide coordination of care and 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’s and family’s needs. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/12/2025 with diagnoses of Parkinson’s disease and type 2 diabetes mellitus. The clinical record included a physician order dated 04/14/2026 for wound care to five wounds: (Wound 1) Left Heel-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 2) Left lateral ankle-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 3) Left lateral lower shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 4) Left lateral upper shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 5) Right medial shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. Wound care was ordered 3 x week and as needed. Review of nursing documentation revealed that the nurse provided visits once a week, from 04/19/2026 through 05/30/2026. The Licensed Vocational Nurse (LVN) documented one nursing visit for the week of 04/19/2026 with wound care completed. The Registered Nurse (RN) documented wound care completed on 04/30/2026. The LVN documented wound care completed on 05/07/2026. The RN documented wound care on 05/14/2026. The LVN documented wound care on 05/21/2026. There was no documented evidence that the RN ensured continuous assessment of the patient’s needs, when nursing visits were completed once a week for wound care ordered three times a week, and there was no documentation of coordination of care with the patient or caregiver related to the patient’s wound care ordered. During a review of the clinical record and interview on 06/02/2026, the Director of Nursing confirmed there was no documented evidence that wound care was completed as ordered and confirmed that the family was not doing wound care, “It was our nurse. The frequency should have been increased to three times a week when the wound order was added but it wasn’t updated.” CLINICAL RECORD 17: The patient elected the hospice benefit on 04/07/2025 with a primary diagnosis of Unspecified diastolic (congestive) heart failure. The patient died on 01/14/2026. Review of the agency’s complaint binder on 06/01/2026 revealed the family member called the agency on 01/02/2026 and reported to the Registered Nurse (RN) concerns regarding possible skin breakdown and was asking about wound care vs preventative measures. The family member reported the patient’s heels were now mushy and reported lack of communication and action resulted in progression of the skin breakdown. A handwritten note attached to the compliant investigation, written by the RNCM (Registered Nurse Case Manager) included the documentation: On Monday evening Dec 29, 2025, I received a message from CNA (Certified Nurse Assistant) that the patient had redness to [his/her] bilateral heels. I contacted the LVN (Licensed Vocational Nurse) (Personnel Record 15) on the morning of Tuesday Dec 30, 2025, and asked him to assess the patient on his visit and call the family with an update. The LVN (Personnel Record 15) saw the patient on Wed Dec 31, and he said he encouraged floating heels and elevation and barrier cream. Then on the morning of Jan 2, 2026, I received a call from family member saying [the patient] has “mushy heels” and I told the family member that the LNV (Personnel Record 15) had seen [the patient] on Wed 12/31/2026 but the family member said he/she did not receive a call. I told the family member what I was told on Wed 12/31/2026 and the LVN (Personnel Record 15) was coming out again to see the patient. The note was signed by RNCM on 01/02/2026. Subsequent review of clinical record 17, associated with the compliant, revealed that the Certified Nurse Assistant (CNA) called the Registered Nurse Case Manager (RNCM) on 12/29/2025 to report that the patient’s heels were reddened. On 12/30/2025 the RNCM instructed the Licensed Vocational Nurse (LVN) to make a visit to the patient and assess the patient. There were no nursing visits documented in the clinical record for 12/29/2025 and 12/30/2025. The LVN provided a nursing visit on 12/31/2025 and documented that the family member was instructed related to heel protectors and elevation of the patient’s feet. There was no documented evidence of an assessment of the patient by the LVN and no documented evidence that the RNCM and the physician were notified of the patient’s condition. The RNCM did not ensure the patient was assessed for the change in condition reported by the CNA on 12/29/2026 at the time the change in condition was reported. The RNCM did not ensure the Registered Nurse provided continuous assessment of the patient’s needs. Per the documentation in the complaint log the family member called the agency on 01/02/2026 to report that the patient’s heels were now mushy. There is no documented evidence that a nursing visit was made on this date. The RN made a visit to the patient on 01/03/2026 and documented bilateral DTI (deep tissue injury) to both heels and pink area to coccyx. “Patient has pink area to coccyx; zine oxide applied to area. No open areas in either location.” The RN documented that wound care was provided to the patient; however, there were no wound care orders in the plan of care for the wound care provided. The Registered Nurse documented a PRN (as needed) nursing visit on 01/03/2026, the documentation as follows: patient has DTI (deep tissue injury) to both heels. Areas cleaned with zinc oxide applied and areas covered with border gauze. Patient has pink coccyx; zinc oxide applied to area. No open areas in either location. The RN did not document notification of the physician related to the patient’s wounds and change in status. The RNCM documented on the nursing visit note dated 01/05/2026, the patient’s pressure injury risk was assessed as minimal. The narrative included, wound was identified and instruction was provided for care management and infection prevention. There was no documented evidence that the physician was notified of the patient’s status. The RNCM documented a PRN nursing visit on 01/06/2026, the patient’s pressure injury risk was assessed as minimal. A wound assessment was documented for 2 wounds, 1st wound assessed with pressure ulcer of right heel unstageable, wound type is acute, non-blanchable 4cm long, 4cm wide. Unstageable pressure area right heel, dressing soak right heel in betadine solution for 30 minutes, change every day. The 2nd wound pressure ulcer of left heel stage 1. 4cm long, 4cm wide unstageable pressure area, left heel, dressing soak left heel in betadine for 30 minutes, change every once a day. The RN documented a PRN visit on 01/07/2026, the patient’s pressure injury risk was assessed as minimal, and the wound care was provided as documented in the 01/06/2026 nursing visit. The clinical record did not include wound care orders from 01/02/2026 to 01/06/2026 and there was no documented evidence of collaboration and coordination with the physician for changes in the patient’s status, related to worsening of wounds. The Nurse Practitioner documented a prn (as needed) wound evaluation visit second opinion on 01/08/2026. The patient was noted to have wounds to her coccyx, right and left buttocks that are being managed with zinc oxide daily and prn soiling. [The patient] was noted with deep tissue injuries to the left heel, left outer ankle, and right heel. [The patient] had multiple red areas over the bony prominences of both feet. She was noted with redness of the left inner ankle and 3 red areas on the left arch of her foot. reddish purple area to the right outer and inner ankle, right outer foot, and 2 marks along the right arch. The patient tolerated the wound assessment well but did have discomfort [the patient] was medicated with 1 50 mg tramadol and 1 Tylenol to help with the pain. Eating 50% of 3 child size meals pt “shared that they were experiencing some pain. The patient describes the pain as radiating. The primary location of the patient’s pain is buttocks. During the visit the patient indicated pain in the right and left heels. pain intensity is recorded as 4. The patient indicates the pain is continuous. activity increased the level of pain. a pain intensity goal of 0 has been determined. The clinical record did not include documentation of a nursing visit from 01/09/2026 to 01/14/2026, when the patient expired. There was no documentation in the clinical record of follow-up assessments by the RNCM to assess the patient’s needs and implement the plan of care, after the nursing visit documented on 01/07/2026. During a joint record review and interview on 06/04/2026, the Director of Nursing confirmed there was no documented evidence that Registered Nurse provided coordination of care and ensured continuous assessment of the patient’s and family’s needs. During a joint record review and interview on 06/04/2026, the Chief Nursing Officer/Alternate Supervising Nurse stated, “That case manager at the time was chronically a problem and is no longer here.””

“It is required that hospice care and services provided to patients and families follow an individualized written plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. 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 hospice care and services provided to patients and families followed the individualized plan of care that was established by the hospice IDG in collaboration with the attending physician. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/12/2025 with diagnoses of Parkinson’s disease and type 2 diabetes mellitus. The clinical record included a physician order dated 04/14/2026 for wound care to five wounds: (Wound 1) Left Heel-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 2) Left lateral ankle-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 3) Left lateral lower shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 4) Left lateral upper shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 5) Right medial shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. Wound care was ordered 3 x week and as needed. Review of nursing documentation revealed that the nurse provided visits once a week, from 04/19/2026 through 05/30/2026. The Licensed Vocational Nurse (LVN) documented one nursing visit for the week of 04/19/2026 with wound care completed. The Registered Nurse (RN) documented wound care completed on 04/30/2026. The LVN documented wound care completed on 05/07/2026. The RN documented wound care on 05/14/2026. The LVN documented wound care on 05/21/2026. There was no documented evidence in the clinical record that wound care was provided as ordered by the physician, on the plan of care, when wound care was ordered three times per week and the nurse provided wound care once a week. CLINICAL RECORD 17: The patient elected the hospice benefit on 04/07/2025 with a primary diagnosis of Unspecified diastolic (congestive) heart failure. Review of the agency’s complaint binder on 06/01/2026 revealed the family member called the agency on 01/02/2026 and reported to the Registered Nurse (RN) concerns regarding possible skin breakdown and was asking about wound care vs preventative measures. The family member reported the patient’s heels were now mushy and reported lack of communication and action resulted in progression of the skin breakdown. A handwritten note attached to the compliant investigation, written by the RNCM (Registered Nurse Case Manager) included the documentation: On Monday evening Dec 29, 2025, I received a message from CNA (Certified Nurse Assistant) that the patient had redness to bilateral heels. I contacted the LVN (Personnel Record 15) on the morning of Tuesday Dec 30, 2025, and asked him to assess the patient on his visit and call the family with an update. The LVN (Personnel Record 15) saw the patient on Wed Dec 31, and he said he encouraged floating heels and elevation and barrier cream. Then on the morning of Jan 2, 2026, I received a call from family member saying [the patient] has “mushy heels” and I told the family member that the LNV (Personnel Record 15) had seen [the patient] on Wed 12/31/2026 but the family member said he/she did not receive a call. I told the family member what I was told on Wed 12/31/2026 and the LVN (Personnel Record 15) was coming out again to see the patient. The note was signed by RNCM (Personnel Record 7) on 01/02/2026. Subsequent review of clinical record 17, associated with the compliant, revealed that the Certified Nurse Assistant (CNA) called the Registered Nurse Case Manager (RNCM) on 12/29/2025 to report that the patient’s heels were reddened. On 12/30/2025 the RNCM instructed the Licensed Vocational Nurse (LVN) to make a visit to the patient and assess the patient. There were no nursing visits documented in the clinical record for 12/29/2025 and 12/30/2025. The LVN provided a nursing visit on 12/31/2025 and documented that the family member was instructed related to heel protectors and elevation of the patient’s feet. There was no documented evidence of an assessment of the patient by the LVN and no documented evidence that the RNCM and the physician were notified of the patient’s condition. Per the documentation in the complaint log the family member called the agency on 01/02/2026 to report that the patient’s heels were now mushy. There is no documented evidence that a nursing visit was made on this date. The RN made a visit to the patient on 01/03/2026 and documented bilateral DTI (deep tissue injury) to both heels and pink area to coccyx. “Patient has pink area to coccyx; zine oxide applied to area. No open areas in either location.” The RN documented that wound care was provided to the patient; however, there were no wound care orders in the plan of care for the wound care provided. The Registered Nurse documented a PRN (as needed) nursing visit on 01/03/2026, the documentation as follows: patient has DTI (deep tissue injury) to both heels. Areas cleaned with zinc oxide applied and areas covered with border gauze. Patient has pink coccyx; zinc oxide applied to area. No open areas in either location. The RN did not document notification of the physician related to the patient’s wounds and change in status. The RNCM documented on the nursing visit note dated 01/05/2026, the patient’s pressure injury risk was assessed as minimal. The narrative included, wound was identified and instruction was provided for care management and infection prevention. There was no documented evidence that the physician was notified of the patient’s status. The RNCM documented a PRN nursing visit on 01/06/2026, the patient’s pressure injury risk was assessed as minimal. A wound assessment was documented for 2 wounds, 1st wound assessed with pressure ulcer of right heel unstageable, wound type is acute, non-blanchable 4cm long, 4cm wide. Unstageable pressure area right heel, dressing soak right heel in betadine sol for 30 minutes, change every day. The 2nd wound pressure ulcer of left heel stage 1. 4cm long, 4cm wide unstageable pressure area, left heel, dressing soak left heel in betadine for 30 minutes, change every once a day. The RN documented a PRN visit on 01/07/2026, the patient’s pressure injury risk was assessed as minimal, and the wound care was provided as documented in the 01/06/2026 nursing visit. The clinical record and plan of care did not include wound care orders from 01/02/2026 to 01/06/2026 and there was no documented evidence of collaboration and coordination with the physician for changes in the patient’s status, related to worsening of wounds. The Nurse Practitioner documented a prn (as needed) wound evaluation visit second opinion on 01/08/2026. The patient was noted to have wounds to her coccyx, right and left buttocks that are being managed with zinc oxide daily and prn soiling. [The patient] was noted with deep tissue injuries to the left heel, left outer ankle, and right heel. [The patient] had multiple red areas over the bony prominences of both feet. She was noted with redness of the left inner ankle and 3 red areas on the left arch of her foot. reddish purple area to the right outer and inner ankle, right outer foot, and 2 marks along the right arch. The patient tolerated the wound assessment well but did have discomfort [the patient] was medicated with 1 50 mg tramadol and 1 Tylenol to help with the pain. Eating 50% of 3 child size meals pt “shared that they were experiencing some pain. The patient describes the pain as radiating. The primary location of the patient’s pain is buttocks. During the visit the patient indicated pain in the right and left heels. pain intensity is recorded as 4. The patient indicates the pain is continuous. activity increased the level of pain. a pain intensity goal of 0 has been determined. The clinical record did not include documentation of a nursing visit from 01/09/2026 to 01/14/2026, when the patient expired. There was no documentation in the clinical record of follow-up assessments by the RNCM to assess the patient’s needs and coordinate with the physician related to patient needs and the plan of care, after the nursing visit documented on 01/07/2026. During a joint record review and interview on 06/04/2026, the Director of Nursing confirmed there was no documented evidence that hospice care and services were provided in accordance with the patients’ needs, in collaboration with the attending physician.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the hospice did not ensure staff performed hand hygiene as required by agency policy. Agency Policy IC.15 Hand Hygiene, required in part, “Hand Hygiene with soap and water. Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water. Staff will apply the amount of product for at least 15 seconds, covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. Staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet. Hand Hygiene with Alcohol-based Hand Rub. Use an alcohol-based hand rub for routinely decontaminating hands in clinical situations: after contact with wound dressings, before moving from a contaminated body site to a clean body site during patient care, after touching a patient or the patient’s immediate environment, after removing gloves.” HOME VISIT 1: During the home visit observation on 06/03/2026 with the Registered Nurse (RN) (Personnel Record 7), the RN was observed to provide wound care to the patient’s stage 3 right posterior/lateral hallux (big toe) wound. The patient was currently taking antibiotics for a wound infection. The Registered Nurse was observed to don (apply) gloves and removed scissors from the nursing bag. The scissors fell to the floor. The RN removed gloves, obtained and held new gloves in one hand and used a wipe to clean part of scissors for 3 seconds and wipe part of hands, then donned new glove and placed betadine on table. The nurse cut off gauze dressing to wound, picked up wound cleanser bottle and sprayed on right foot wound and wiped with gauze. Then the RN used a Q-Tip to paint Medi honey on wound, placed calcium alginate fiber, and dressing. The nurse then removed gloves and washed hands. The Registered Nurse was observed to touch contaminated surfaces and items while performing wound care and did not wash hands between glove changes. The Registered Nurse did not wash hands after cleaning the wound and before applying Medi-honey and calcium alginate to the wound. HOME VISIT 2: During the home visit observation with the hospice aide (HA) (Personnel Record 10) on 06/03/2026, the hospice aide was observed to turn on the faucet and use water only to wash hands. The hospice aide was not observed to use soap or paper towels. The hospice aide turned the faucet off with her hand. The hospice aide walked down the hall to the linen room and dried her hands on a towel in the linen room and gathered linens for the patient. The hospice aide confirmed that there were no soap or paper towels in the bathroom. During a review of the home visits and agency policy on 06/03/2026, the Director of Nursing agreed that the staff did not adhere to the agency’s hand hygiene policy.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard is not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure nursing care and services were provided by or under the supervision of a Registered Nurse and per the patient plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/12/2025 with diagnoses of Parkinson’s disease and type 2 diabetes mellitus. The clinical record included a physician order dated 04/14/2026 for wound care to five wounds: (Wound 1) Left Heel-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 2) Left lateral ankle-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 3) Left lateral lower shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 4) Left lateral upper shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. (Wound 5) Right medial shin-Cleanse with wound cleanser, pat dry, apply Medi honey; calcium alginate; cover with dry dressing/gauze. Wound care was ordered 3 x week and as needed. Review of nursing documentation revealed that the nurse provided visits once a week, from 04/19/2026 through 05/30/2026. The Licensed Vocational Nurse (LVN) documented one nursing visit for the week of 04/19/2026 with wound care completed. The Registered Nurse (RN) documented wound care completed on 04/30/2026. The LVN documented wound care completed on 05/07/2026. The RN documented wound care on 05/14/2026. The LVN documented wound care on 05/21/2026. There was no documented evidence that the RN ensured continuous assessment of the patient’s needs, when nursing visits were completed once a week for wound care ordered three times a week, and there was no documentation of coordination of care with the patient or caregiver related to the patient’s wound care ordered. During a review of the clinical record and interview on 06/02/2026, the Director of Nursing confirmed there was no documented evidence that wound care was completed as ordered and confirmed that the family was not doing wound care, “It was our nurse. The frequency should have been increased to three times a week when the wound order was added but it wasn’t updated.” CLINICAL RECORD 17: The patient elected the hospice benefit on 04/07/2025 with a primary diagnosis of unspecified diastolic (congestive) heart failure. Review of the agency’s complaint binder on 06/01/2026 revealed the family member called the agency on 01/02/2026 and reported to the Registered Nurse (RN) concerns regarding possible skin breakdown and was asking about wound care vs preventative measures. The family member reported the patient’s heels were now mushy and reported lack of communication and action resulted in progression of the skin breakdown. A handwritten note attached to the compliant investigation, written by the RNCM (Registered Nurse Case Manager) included the documentation: On Monday evening Dec 29, 2025, I received a message from CNA (Certified Nurse Assistant) that the patient had redness to [his/her] bilateral heels. I contacted the LVN (Licensed Vocational Nurse) (Personnel Record 15) on the morning of Tuesday Dec 30, 2025, and asked him to assess the patient on his visit and call the family with an update. The LVN (Personnel Record 15) saw the patient on Wed Dec 31, and he said he encouraged floating heels and elevation and barrier cream. Then on the morning of Jan 2, 2026, I received a call from family member saying [the patient] has “mushy heels” and I told the family member that the LNV (Personnel Record 15) had seen [the patient] on Wed 12/31/2026 but the family member said he/she did not receive a call. I told the family member what I was told on Wed 12/31/2026 and the LVN (Personnel Record 15) was coming out again to see the patient. The note was signed by RNCM on 01/02/2026. Subsequent review of clinical record 17, associated with the compliant, revealed that the Certified Nurse Assistant (CNA) called the Registered Nurse Case Manager (RNCM) on 12/29/2025 to report that the patient’s heels were reddened. On 12/30/2025 the RNCM instructed the Licensed Vocational Nurse (LVN) to make a visit to the patient and assess the patient. There were no nursing visits documented in the clinical record for 12/29/2025 and 12/30/2025. The RNCM did not ensure the patient was assessed by an RN when it was reported that the patient had significant changes in assessment related to worsening heel wounds. The LVN provided a nursing visit on 12/31/2025 and documented that the family member was instructed related to heel protectors and elevation of the patient’s feet. There was no documented evidence of an assessment of the patient by the LVN and no documented evidence that the RNCM and the physician were notified of the patient’s condition. Per the documentation in the complaint log the family member called the agency on 01/02/2026 to report that the patient’s heels were now mushy. There is no documented evidence that a nursing visit was made on this date. The RN made a visit to the patient on 01/03/2026 and documented bilateral DTI (deep tissue injury) to both heels and pink area to coccyx. “Patient has pink area to coccyx; zine oxide applied to area. No open areas in either location.” The RN documented that wound care was provided to the patient; however, there were no wound care orders in the clinical record and there was no documented evidence that the physician was notified of the patient’s condition and need for wound care treatment. The Registered Nurse documented a PRN (as needed) nursing visit on 01/03/2026, the documentation as follows: patient has DTI (deep tissue injury) to both heels. Areas cleaned with zinc oxide applied and areas covered with border gauze. Patient has pink coccyx; zinc oxide applied to area. No open areas in either location. The RN did not document notification of the physician related to the patient’s wounds and change in status. The RNCM documented on the nursing visit note dated 01/05/2026, the patient’s pressure injury risk was assessed as minimal. The narrative included, wound was identified and instruction was provided for care management and infection prevention. There was no documented evidence that the physician was notified of the patient’s status. The RNCM documented a PRN nursing visit on 01/06/2026, the patient’s pressure injury risk was assessed as minimal. A wound assessment was documented for 2 wounds, 1st wound assessed with pressure ulcer of right heel unstageable, wound type is acute, non-blanchable 4cm long, 4cm wide. Unstageable pressure area right heel, dressing soak right heel in betadine solution for 30 minutes, change every day. The 2nd wound pressure ulcer of left heel stage 1. 4cm long, 4cm wide unstageable pressure area, left heel, dressing soak left heel in betadine for 30 minutes, change every once a day. The RN documented a PRN visit on 01/07/2026, the patient’s pressure injury risk was assessed as minimal, and the wound care was provided as documented in the 01/06/2026 nursing visit. The clinical record did not include wound care orders from 01/02/2026 to 01/06/2026. The Registered Nurse provided wound care to the patient without a physician order. The Nurse Practitioner documented a prn (as needed) wound evaluation visit second opinion on 01/08/2026. The patient was noted to have wounds to her coccyx, right and left buttocks that are being managed with zinc oxide daily and prn soiling. [The patient] was noted with deep tissue injuries to the left heel, left outer ankle, and right heel. [The patient] had multiple red areas over the bony prominences of both feet. She was noted with redness of the left inner ankle and 3 red areas on the left arch of her foot. reddish purple area to the right outer and inner ankle, right outer foot, and 2 marks along the right arch. The patient tolerated the wound assessment well but did have discomfort [the patient] was medicated with 1 50 mg tramadol and 1 Tylenol to help with the pain. Eating 50% of 3 child size meals pt “shared that they were experiencing some pain. The patient describes the pain as radiating. The primary location of the patient’s pain is buttocks. During the visit the patient indicated pain in the right and left heels. pain intensity is recorded as 4. The patient indicates the pain is continuous. activity increased the level of pain. a pain intensity goal of 0 has been determined. The clinical record did not include documentation of a nursing visit from 01/09/2026 to 01/14/2026, when the patient expired. There was no documentation in the clinical record of follow-up assessments by the RNCM, after the nursing visit documented on 01/07/2026. During a joint record review and interview on 06/04/2026, the Chief Nursing Officer/Alternate Supervising Nurse stated, “That case manager at the time was chronically a problem and is no longer here.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice did not ensure volunteers provided day-to-day administrative or direct patient care services at an amount that equaled at least 5% of the total patient care hours. Review of the Volunteer Requirement/Cost Savings Report for 06/01/2025 to 05/31/2026 revealed volunteer hours at 3.21% of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Requirement/Cost Savings Report from 01/01/2025- to 12/31/2025 revealed volunteer hours at 3.33% of the total patient care hours of all paid hospice employees and contract staff. During a joint review of the documentation and interview on 06/04/2026, the Volunteer Coordinator agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. The Volunteer Coordinator stated, “It has been hard to get the number of volunteer hours up with growth of the company.” A review of the Volunteer Requirement/Cost Savings Reports revealed that the agency did not ensure volunteers provided administrative or direct patient care services at least 5% of the total patient care hours of all paid hospice employees and contracted staff.”

“It is required that a written agreement with another organization or individual to furnish hospice care or services includes: the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice, care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice, care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) contract reviewed for therapy services, the agency did not ensure the contract included the requirement that care be provided in accordance with the patient’s plan of care. The Therapy contract between the hospice and Therapy agency, with an effective date of 02/11/2026 did not include the requirement that care will be delivered in accordance with the patient’s plan of care. The contract was reviewed with the Alternate Administrator on 06/01/2026 and confirmed that the contract did not include the requirement that care be provided in accordance with the patient’s plan of care. During an interview on 06/02/2026, the Alternate Administrator stated in reference to the therapy contract, “I don’t know what happened, we have an updated one now.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed for patients with wounds, the agency did not ensure to obtain a physician order for wound care provided. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/12/2025 with diagnoses of Parkinson’s disease and type 2 diabetes mellitus. The Registered Nurse (RN) documented on the nursing visit note dated 04/02/2026 wound care to right lower extremity, “I cleansed the open areas with wound cleanser and applied calcium alginate to the affected area. I covered the wound with a sterile 4x4 dressing.” The clinical record did not include a wound care order for the wound care provided by the RN. CLINICAL RECORD 17: The patient elected the hospice benefit on 04/07/2025 with a primary diagnosis of unspecified diastolic (congestive) heart failure. The RN documented on the nursing visit note dated 01/03/2026 bilateral DTI (deep tissue injury) to both heels and pink area to coccyx. “Patient has pink area to coccyx; zinc oxide applied to area. No open areas in either location.” The clinical record did not include a wound care order for the wound care provided by the RN. The Registered Nurse Case Manager (RNCM) documented on the nursing visit note for the PRN (as needed) visit dated 01/06/2026, a wound assessment for 2 wounds, an unstageable pressure ulcer to the right heel and a stage 1 pressure ulcer to the left heel. The RNCM documented wound care was provided to both wounds, right heel and left heel, dressing soak in betadine for 30 minutes, change every once a day. The clinical record did not include wound care orders for the wound care provided by the RNCM. During a joint record review and interview on 06/04/2026, the Director of Nursing agreed there was no documented evidence of physician orders for the wound care provided.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients with live discharge, the agency did not ensure the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 15: The patient elected the hospice benefit on 04/15/2026. The patient was discharged as no longer terminally ill on 05/12/2026. There was no documented evidence that the discharge summary was provided to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit on 03/28/2023 and discharged. The patient revoked hospice care on 06/08/2025. There was no documented evidence that the discharge summary was provided to the patient’s attending physician. During a review of records and interview on 06/04/2026, the Director of Nursing confirmed there was no evidence that the discharge summaries were provided to the attending physicians. The Director of Nursing stated, “I do not see anything.””

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 5 (20%) hospice contracts reviewed, the agency did not ensure the contract required that contracted employees who have direct patient contact or access to patient records obtain criminal background checks. CONTRACT 2: The pharmacy contract effective date 03/23/2023 did not include the requirement that contracted employees with direct patient contact or access to patient records obtain criminal background checks. The contract was reviewed with the Alternate Administrator on 06/01/2026 and confirmed that the contract did not require background checks to be obtained. The Alternate Administrator stated, “It is not there but we will reach out to the pharmacy and get it updated.””