Doctor’s Choice Hospice

“Based on record review and interview, the hospice failed to ensure that the patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights for 1 of 3 patient’s (Patient #1) whose records were reviewed.These failures have the potential to place all patients at risk for substandard quality of care. Based on record review and interview, the hospice must ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator for 1 of 3 client’s (Patient #1) whose records were reviewed, in that; • The hospice failed to report an alleged violation of neglect immediately (means as soon as possible, but not to exceed 24 hours after discovery of the incident) to the State and local bodies having jurisdiction.This failure has the potential to place all clients at risk for further abuse, neglect, and/or exploitation. Refer to L0508. Based on record review and interview, the hospice failed to ensure that the patient has the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness for 1 of 3 patient’s (Patient #1) whose records were reviewed.This failure resulted in a delay of care for Patient #1 and has the potential to place all other patients at risk for substandard quality of care.Refer to L0512. Based on record review and interview, the patient has the right to the following: be free from neglect, for 1 of 3 patient’s (Patient #1) whose records were reviewed, in that; RN A advised FM A to remove/cut Patient #1’s catheter over the phone and without assessment; and Patient #1 had uncontrolled pain without timely intervention.This failure has the potential to place all clients at risk for further abuse, neglect, and/or exploitation. Refer to L0517.”

“Based on record review and interview, the hospice must ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator for 1 of 3 client’s (Patient #1) whose records were reviewed, in that; • The hospice failed to report an alleged violation of neglect immediately (means as soon as possible, but not to exceed 24 hours after discovery of the incident) to the State and local bodies having jurisdiction. This failure has the potential to place all clients at risk for further abuse, neglect, and/or exploitation. Findings Patient #1 Record review of document entitled, “Daily Activity Report” unpaged reads in part, “Chief Complaint: 10/04/2025 at 1704 (5:04PM), [FM A] reports this is FM A’s second call, FM A has not heard back yet about BN-A catheter (flexible, tube-like device inserted into the bladder to drain urine) placement. Assessment: FM A reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. FM A was told a nurse was coming to make a visit. Pt incontinent of urine…” Therefore, the report log revealed that there was documentation of the incident for the date of 10/04/2025. The hospice became aware of the complaint on 10/04/2025 at 17:04 (5:04PM); when the hospice’s on-call staff received multiple calls from FM A and other FMs that Patient#1 was having bladder pain and obstruction of the catheter. Due to the multiple calls from FM A and other FMs; the hospice sent RN B to provide care to Patient #1 due to complaints of bladder pain and obstruction of the catheter. The complaint came to be that care to the patient was delayed for hours (for more than 5 hours and 30 minutes) when FM A initially contacted hospice nurse (RN A) regarding Patinet#1’s initial concerns of bladder pain and obstruction of the catheter. However, the hospice failed to report the complaint immediately to the State and local bodies having jurisdiction upon learning of the incident on 10/04/2025 when FM A initially called RN A on 10/04/2025 at 12:31PM and RN A did not provide said care and/or relay the urgency of Patient#1’s concerns to the hospice. When FM A later on notified the hospice on 10/04/2025 at 5:04PM that Patient #1 had been complaining of bladder pain and obstruction of the catheter for hours; the hospice failed to immediately report that a hospice nurse (RN A) neglected to provide direct in-person care, and/or coordinate to the hospice that Patient #1 needed care from an alternative nurse. • Further review of the report revealed that FM A called the hospice with the complaint three separate times between the dates of 10/04/2025 at 5:04PM to 10/05/2025 at 12:23PM. -The hospice failed to immediately report within 24 hours to the State and local bodies having jurisdiction when the hospice became aware of the incident on 10/04/2025 through RN A, RN B, and the on-call staff and/or on 10/05/2025 from FM A.- • Further review of the report also revealed that the COMP called the agency on 10/05/2025 at 2019 (8:19PM) regarding uncontrolled pain and that the patient did not receive a nurse visit for the entirety of the day of 10/05/2025. -The hospice failed to immediately report the delay of patient’s care within 24 hours to the State and local bodies having jurisdiction when the hospice became aware of the incident from the COMP on 10/05/2025.- Record review of document entitled, “Informed Consent and Election of Benefits” unpaged signed on 09/15/2025 by patient #1 reads in part, “Receipt of Information: I have received a verbal explanation and written notice/policy, in a language I understand, of the following: Abuse, Neglect, and Exploitation… Complaints… Patient Rights and Responsibilities/Rights of the Elderly…” Record review of text message from FM A to RN A on 10/04/2025 at 12:29PM reads in part, “Hello, I hate to bother you. He is in lots of pain while trying to urinate. He says it’s like it won’t come out.” RN A responds back, “Is there urine in the bag? Try repositioning.” -Although, RN A instructed patient #1 to reposition to adjust the BN-A catheter; there was no documentation that RN A notified the hospice and/or the SUP Nurse and/or the physician that patient#1 presented with a new change of condition (pain that was unrelieved from the BN-A catheter) on 10/04/2025.- Record review of text message from FM A to RN B on 10/04/2025 at 4:48PM reads in part, “Is anyone coming to help today?” RN B replied back, “Call the 833 number (on-call hospice number per FM A) on the book so it can officially be documented that you called twice about BN-A replacement… if the pain pill hasn’t decreased the pain give 0.5ML (milliliters) of quick acting morphine…” FM A replied back, “Ok the pain is horrible. I gave it to him. Do you know when the nurse will get here?” - There was no documentation that RN B notified the hospice and/or the SUP Nurse and/or the physician that patient#1’s pain was unrelieved with the use of quick acting morphine on 10/04/2025.-Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:04PM (CDT (Central Standard Time) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1704 (5:04PM in military time) [FM A] reports this is her second call, she has not heard back yet about BN-A catheter placement. Assessment: [FM A] reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. Was told a nurse was coming to make a visit. Pt (patient) incontinent (having no or insufficient voluntary control over urination or defecation (the natural process for expelling solid waste/feces from the digestive tract through the anus) for urine. Response: Advised on call staff would be notified for follow up…” Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:48PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1748 (5:48PM in military time) [FM B], report [FM A] called this afternoon and no one has reached out to her yet regarding replacing BN-A catheter for the patient. Assessment: [FM B] voices frustration, stating this was unacceptable, and state if someone does not call her back within the next 20 mins about a nurse visit she is ‘going to call the department of health.’ Response: Voiced understanding of frustrations. Active listening utilized. Advised on call administrator would be notified…” Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 10:35AM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 10:11 Received a call from [FM A] saying patient went to ER (Emergency Room) last night due to severe pain… Used morphine to try and keep him comfortable through the night. Caller says ER told [FM A] that patient would need nurse visit to follow up and assess in the morning… Response: Advised caller that on call nurse will be notified and will in contact shortly…”Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 12:50PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 at 12:23PM Received a call from [FM A] saying she called almost 2 hours ago requesting nurse visit and hasn’t heard from anyone. Caller is very upset. Requesting visit ASAP (as soon as possible). Assessment: On call nurse [RN C] notified and will be in contact shortly…” Record review of document entitled, “General Details” written by RN G for the date of 10/05/2025 at 07:19PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Time of Event: 08:19PM… Chief Complaint: On 10/05/25 at 2019 (8:19PM military time), COMP called in regards to [patient #1] stating that he returned home from the hospital today and is having uncontrolled pain despite Morphine around the clock. Assessment: … States he did not receive a nurse visit today. Response: On call nurse [RN C]. Education: Nurse will follow up…”Record review on 01/19/2026 during pre-survey preparation of the incident investigation worksheet for intake #1041603 revealed that FM A called in a complaint involving agency’s patient #1 on 10/04/2025 related to BN-A catheter issues and that patient was in pain for hours. During an interview with FM A on 01/22/2026 at 8:14AM. SR inquired from FM A, what the account of the events were for the date of 10/04/2025. FM A stated, “… So, on that day of 10/04/25, it so happened that patient #1 started having a whole lot of pain and a lot of problems with his BN-A catheter tubing. So, I called the nurse [RN A] on 10/04/2025 at 12:31PM and I’m like, hey, I got a problem. He’s in a whole lot of pain, and there’s all this stuff going on (he’s yelling, and he’s moaning in pain). [RN A] said ‘ohh, well, we probably just need to take the catheter out. But I’m on my way to a wedding, so I’m not going to be the one that must be the on-call nurse today but just go ahead, and you can take the tubing out yourself.’ And I’m like, but I’m not a nurse. [RN A] said ‘oh well you can do it. It’s very easy to do.’ I’m like no because again I’m not a nurse. As I refused to do such a thing, she like hung up on me.” During an interview with FM A on 01/22/2026 at 8:18AM. SR inquired from FM A, what happened next. FM A stated, “So, [patient #1] was in all kinds of pain and later I found out there’s some spasming (also known as muscle cramps (when a muscle involuntarily and forcibly contracts uncontrollably and cannot relax)) going on too per an on-call nurse. So, again he is yelling in pain. He’s in so much pain. And I called the on-call nurse to see about getting somebody like a nurse out there. I called [RN B] on 10/04/2025 at 12:34PM explaining to [RN B] that patient #1 was in so much pain and that we needed a nurse to come out to see him. I was just begging for someone to come and help him out. [RN B] kept saying that she was going to be coming all the way from Cypress or Houston or somewhere, which is a gosh awful far away distance from where we lived. At this time I was so desperate, so I called [RN A] back on 10/04/2025 at 12:57PM and told [RN A] look, he’s screaming in pain, and I don’t know what to do. I don’t know when the nurse is going to get here. Just tell me what I need to do, how to take this thing out again. And so, she did. She walked me through the process over the phone, and she told me to cut the catheter, which I did. After that I pulled the tube out myself because he was yelling in so much in pain. So, I’m not sure what I did that day was right or not, since I am not a nurse. But even after that he was still in a whole lot of pain.” During an interview with RN B on 01/22/2026 at 11:38AM. SR inquired from RN B, can you tell me the last day that you provided care to patient #1. RN B stated, “I can’t remember the exact day, but I was home, and she (FM A) told me she’s been calling the on-call number, and she couldn’t get nobody to come out there.” SR inquired further from RN B, why did FM A call you. RN B stated, “Because I’m the one that admitted her initially from some weeks ago, I believe because she had questions, she was just trying to get ahold of somebody (RN A) and she asked me to come out there, but I am not the normal RN case manager. But I told her I would come unless somebody didn’t go out there.” SR inquired further from RN B, who’s the normal RN case manager. RN B stated, “[RN A] is.” -Although, RN B did not remember the exact date; RN B conducted a skilled nurse visit with patient #1 on 10/04/2025 at 07:34PM.- During an interview with RN B on 01/22/2026 at 11:41AM. SR inquired from RN B, when you got to patient #1’s home, what was your assessment of the patient. RN B stated, “When I got there, he was screaming in pain, his bladder was so distended, and there was blood everywhere.” SR inquired further from RN B, how did you get the BN-A catheter out. RN B stated, “She (FM A) did it wrong, she said she cut it out; In doing so, it caused so much bleeding. I don’t know if he had a partial BN-A still in him or if like if he had particles of the BN-A in there. I attempted to put in another BN-A catheter, but he was still bleeding. I couldn’t do anything with that, with him bleeding and clots coming out like that. So, I called the doctor and I called EMS (emergency medical services); so, I stayed there until the ambulance arrived and they took him to the nearest hospital. But [FM A] should have never cut that catheter. She should have just let that BN-A catheter stay in there and let us (nurses) take care of that. She should have never cut the BN-A catheter.” During an interview with RN B on 01/22/2026 at 11:44AM. SR inquired from RN B, the patient and/or patient’s family members were aware of how to take care of the BN-A catheter and/or how to remove one. RN B stated, “No. I don’t think anyone taught them how to care for it because the BN-A catheter is something that the hospice nurses care for not the patients. I would never tell any of my patients and/or any of their family members to pull a BN-A catheter out and/or cut it. Because doing any of that is too invasive, and there is no one way any of them unless they are nurses would be able to remove the BN-A catheter out right.” During an interview with RN C on 01/22/2026 at 11:49AM. SR inquired from RN C, can you tell me the last day that you provided care to patient #1. RN C stated, “I think I saw that patient on 10/05/2025. It was a Sunday I believe.” SR inquired further from RN C, are you the RN case manager for the patient. RN C stated, “No. It is [RN A].” During an interview with RN C on 01/22/2026 at 11:50 AM. SR inquired from RN C, what was the nature of the nurse’s visit. RN C stated, “[FM A] called, I think it was around one or something around because I remember I came back from church. So, she called, and she told me he came back from the hospital that he’s having pain in his side, and I asked her to give him morphine and to call me back if his pain symptom did not change. She said okay. She called me back saying that the morphine wasn’t working and that he still had pain in his bladder. So, I went home, and it was about a 2-hour drive and/or more to get there. So, when I got there, I let her know that the MD ordered for the BN-A to be discontinued. As soon as I removed the BN-A catheter, fluid continually flowed out that it soaked the bed, and his bladder was not as distended as it was before.” SR inquired further from RN C, did you see any bleeding. RN C stated, “I didn’t see any blood or anything. It was more like suprapubic (located in the lower abdomen just above the pubic bone) pressure that I saw.”During an interview with RN A on 01/22/2026 at 2:13PM. SR inquired from RN A, when was the last time you saw the patient and what was going on around that time frame. RN A stated, “… From what I can recall, um [patient #1] had cancer. He was bed bound by the time that he came to Hospice. He was complaining of having to urinate and he couldn’t urinate they (patient #1 and FM A) both agreed to remove the BN-A. I walked FM A through the steps of how to remove a BN-A over the phone. Everyone always thinks that removing a BN-A is hard, but it is not. She said nothing was coming out and might be obstructed somehow. So, I thought that it might be obstructed because of a blood clot. So, I told FM A to just cut the catheter to clear the clot. I think over the weekend he went to the hospital, he was gone and then he came back and then when I did a follow-up, she was mad at the hospital, she was mad at Hospice, she was mad at the whole world. And I got it because her husband is dying. And she told me, you know that they (patient #1 and FM A) had a bad experience at the hospital. Bad experience she was having with Hospice coming out and I told her, I said, well, I said, I said, I will increase the frequency of the nursing visits. I’ll start coming out more often to provide him a little bit more comfort measures and you know, just trying to actively listen to her and talk to her, so that she can grief appropriately. When I left, I thought everything was good. She seemed to be more at ease. So, when I left, I called the office, I talked to the scheduler and said go ahead and increase the nurse visits. Said he is declining more. She’s, you know, going to need more help. And so, when I called the office, they said never mind that because she’s already called another Hospice, she’s going with another Hospice, and she did. But what’s so crazy was that she never mentioned any of that when I was talking to her so. That’s all I can remember.” During an interview with SUP Nurse on 01/22/2026 at 2:33PM. SR inquired from SUP, what was the account of the events from 10/04/25 to 10/06/25. SUP Nurse stated, “…So the COMP had originally called the concern into our home health side because the patient was originally from our home health side. So, they (patient and FM A) had an established relationship with the home health nurses in the Location A area. They were calling their concerns into [Agency A] rather than the hospice. I got into the mix because they called the Executive Director (ED) on the home health side and the ED called me saying that the [Agency A] had a problem for [Hospice A] and the ED was trying to reach the Hospice ADM but at the time could not get ahold of her. So, the ED called me instead. What I came to know was that the patient had some issues with the BN-A catheter. Having some probable issues with urinary retention. So, I called the ADM and asked the ADM, if we can get a nurse to go out and address those concerns. But in hindsight, [SR] I should have asked the ED to just go and assess the situation, since the ED was bit closer to the patient’s home.” During an interview with SUP Nurse on 01/22/2026 at 2:38PM. SR inquired from SUP Nurse, who was the nurse that was called to go and help the patient with the patient’s concerns on 10/04/2025. SUP Nurse stated, “If I recall correctly, I believe it was [RN B], and the nurse in that area would be [RN A].” SR inquired further from the SUP Nurse, who was the RN case manager for the patient. SUP Nurse stated, “The nurse assigned to the patient would be [RN A].” During an interview with SUP Nurse on 01/22/2026 at 2:40PM. SR inquired from SUP Nurse, when a patient has any change in health condition, such as an increase in pain; what should the hospice do. SUP Nurse stated, “We generally send a nurse right away. But I think that hospice nurses have different modalities and sometimes they can do assessments over the phone.” During an interview with SUP Nurse on 01/22/2026 at 2:45PM. SR inquired from SUP Nurse, Why did it take so long for any nurse to come out and provide care for patient #1. SUP Nurse stated, “I believe it is because we assumed that when we gave the instruction that if he continues to have discomfort, for FM A to give him his pain medication. If the medication doesn’t work and he’s still uncomfortable, for FM A to call us back and then we (myself and the ADM) will send a nurse to get in route. And when we didn’t hear from them, we probably should have made a follow-up phone call. To see right, that it was done but we didn’t do that because when we didn’t hear back from them, we assumed that the patient was resting comfortably…” During an interview with SUP Nurse on 01/22/2026 at 2:48PM. SR inquired from SUP Nurse, who is the individual or the person that supervises the provision of nursing throughout the hospice. SUP Nurse stated, “So I’m on the license as a supervising nurse and [Alt ADM/ Alt SUP Nurse] is the backup supervising nurse.” SR inquired further from the SUP Nurse, who is the individual responsible for the policies and procedures being implemented accordingly throughout the Hospice. SUP Nurse stated, “That would be our compliance department.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:53PM. SR inquired from Alt ADM/ Alt SUP Nurse, what was the account of the events from 10/04/25 to 10/07/25. Alt ADM/ Alt SUP Nurse stated, “I was on leave around that timeframe. When I came back from leave was when I heard in IDG (interdisciplinary group) the issues that the nurses were having with the patient.” SR inquired further from the Alt ADM/ Alt SUP Nurse, what were the issues the nurses were having with the patient. Alt ADM/ Alt SUP Nurse stated, “the issues were with BN-A and the bleeding because [FM A] removed the BN-A catheter solely by herself. But I never saw him, never spoke with him or [FM A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:55PM. SR inquired from Alt ADM/ Alt SUP Nurse, the SUP Nurse stated that you’re the alternate supervising nurse, correct? Alt ADM/ Alt SUP Nurse doesn’t answer but nodded her head yes. SR inquired further from Alt ADM/ Alt SUP Nurse, who is the individual that is to ensure that the policies and procedures of the agency are being implemented accordingly? Alt ADM/ Alt SUP Nurse stated, “that would be [ADM].” SR inquired further from Alt ADM/ Alt SUP Nurse, who was the RN case manager for the patient. Alt ADM/ Alt SUP Nurse stated, “That would have been [RN A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:57PM. SR inquired from Alt ADM/ Alt SUP Nurse, who handles the coordination of care/services when it comes to the supervision of the nurses. Alt ADM/ Alt SUP Nurse stated, “Probably [SUP Nurse].” SR inquired further from Alt ADM/ Alt SUP Nurse, when the nurse has any type of concern, who is the nurse to report to. Alt ADM/ Alt SUP Nurse stated, “A lot of them do come to me because I have a lot of experience. But to say they are actually assigned to report to me, I would say no. But they do come to me a lot. But SUP Nurse is over all the nurses.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:07PM. SR inquired from Alt ADM/ Alt SUP Nurse, who is to ensure that the policies and procedures are implemented throughout the Hospice. Alt ADM/ Alt SUP Nurse stated, “The ADM.” SR inquired further from the Alt ADM/ Alt SUP Nurse, are not an additional ADM. Alt ADM/ Alt SUP Nurse stated, “I am. I have not been given those duties.” During an interview with ADM on 01/22/2026 at 3:31PM. SR inquired from the ADM, what was the account of the events from 10/04/25 to 10/07/25. ADM stated, “The biggest challenge that I think that we had with communication as far as this family goes is they (patient #1 FMs) continued to call the home health nurse side. So, they were originally from our home health service, out of the Location A office. So, they were calling that home health nurse directly instead of calling the 800 number (the hospice’s main number). So, when we finally got a call on 10/05/2025 around 10AM or so from the on-call staff that they needed somebody to come out, that’s when we went out. [RN C] did go out and do a visit on 10/05/2025… I know that previous day on 10/04/2025, they (patient #1’s FMs) had sent him to the ER under the MD’s recommendation and the nurse that was out there was [RN B]… and so, by the time [RN B] got that second call. You know, it was already 7:30PM in the evening, so that’s what made the visit so late on 10/04/2025. But after that visit, I know [RN A] went out to do the visit the next day (on 10/06/2025) and she asked the family, you know, would you like me to increase frequency? Would you like me to know, get some additional support here. And the family was agreeable and the very next day they transferred to another service, which is certainly their right to do… One of the things that I feel like are the reasons I feel like that they ended up transferring was because they wanted somebody local and they felt like maybe they would receive a better response time… We (ADM team) would have gotten that a little bit quicker than getting it (the initial call) from individual nurses. Yeah, so. I hope that wasn’t a delay in care, but that’s my only reasoning for thinking that it might have been so, or that they (FMs of patient #1) might not have felt as supported.” During an interview with ADM on 01/22/2026 at 3:40PM. SR inquired from the ADM, are you aware of any nurses walking a patient over the phone on how to remove BN-A catheter. ADM stated, “I am personally not aware. I don’t know if I would be as I’m not a clinician. So, you know, that’s not really something that would have come to my attention. I would discourage that. 100%. Even as a non-clinician, I would discourage that because count as an invasive procedure.” During an interview with ADM on 01/22/2026 at 3:41PM. SR inquired from the ADM, who is responsible for ensuring that the policies and procedures of the Hospice is implemented accordingly. ADM stated, “Myself with in conjunction with compliance.” SR inquired further from the ADM, what is the roles and responsibilities of the ADM. ADM stated, “… Just the oversight of the entire program… making sure that we’re following the policies and procedures, making sure that on call rotations or cover on call is followed through that. If there are things that need to be. Followed up on complaints, concerns, patient questions, family questions, caregiver questions, things like that…” Record review of the agency’s policy manual included a policy entitled, “Policy: Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect and Exploitation” with an effective date of 03/12/2021 and a revised date of 07/26/2021 reads in part, “Policy. Agency will identify and report possible victims of alleged/suspected abuse, neglect or exploitation. Purpose: To define the processes for identifying and reporting possible victims of alleged/suspected abuse, neglect or exploitation… Procedure: 1. Agency staff will be oriented to signs and symptoms indicating possible abuse, neglect or exploitation.a. Any Agency staff (whether employed directly or under arrangement) in the normal course of providing services to patients, who identifies, notices, witnesses, is notified of, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual and/or physical abuse, including injuries of unknown sources, or misappropriation of patient property, must report these findings immediately to the Agency and other appropriate authorities in accordance with state law… 1. Criteria to identify elder neglect or abuse, physical assault and domestic abuse include:• Injuries to the trunk of the body that could be intentional.• An imprint from a hot object on the back, buttocks or back of hands.• Inadequate supervision with resulting effect on ADL provision, e.g., bathing, toileting, food, etc.• Unexplained injuries, frequent falls or multiple hematomas of various color• Withdrawal and/or crying.• Any patient who reports an abusive incident… 6. Staff will immediately report an assessment of patient’s condition which might indicate exploitation, abuse or neglect to the Director of Clinical Services, who will assign a supervisor to investigate and assess the patient for abuse, neglect and/or exploitation. 7. The Director of Clinical Services will investigate and communicate assessment findings to the physician and the appropriate agency according to state regulations/laws. All findings and communications will be documented in the patient’s medical record. The Agency will report all findings of allegations, investigations, observations and suspected cases of exploitation, abuse and/or neglect to appropriate authorities… Additional [AO] Requirements: The Agency takes appropriate corrective action in accordance with state law if the alleged violation is verified by administration or an outside body having jurisdiction, e.g., [AO], the state survey agency or local law enforcement agency. The Agency ensures that verified violations are reported to [AO], state and local bodies having jurisdiction (including to the State survey and certification agency) within 5 working days of becoming aware of the verified violation, unless state regulations are more stringent.””

“Based on record review and interview, the hospice failed to ensure that the patient has the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness for 1 of 3 patient’s (Patient #1) whose records were reviewed.This failure resulted in a delay of care for Patient #1 and has the potential to place all other patients at risk for substandard quality of care. Findings Record review of document entitled, “Daily Activity Report” unpaged reads in part, “Chief Complaint: 10/04/2025 at 1704 (5:04PM), [FM A] reports this is FM A’s second call, FM A has not heard back yet about BN-A catheter placement. Assessment: FM A reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. FM A was told a nurse was coming to make a visit. Pt incontinent of urine…” Therefore, the report log revealed that there was documentation of the incident for the date of 10/04/2025. • Further review of the report revealed that FM A called the agency with the complaint three separate times between the dates of 10/04/2025 at 5:04PM to 10/05/2025 at 12:23PM. • Further review of the report also revealed that the COMP called the agency on 10/05/2025 at 2019 (8:19PM) regarding uncontrolled pain and that the patient did not receive a nurse visit for the entirety of the day of 10/05/2025. Patient #1Record review of discharged patient #1’s CR revealed a POC titled, “Plan of Care Effective 9/15/25.” The POC showed a SOC date of 09/15/2025 with the benefit period of 09/15/2025 to 10/06/2025 and primary diagnosis of Malignant (disease that is very virulent (extremely severe) or infectious) neoplasm (abnormal excessive or uncoordinated growth of tissue, commonly known as a tumor, resulting from cells that divide more than they should or do not die when they should) of unspecified kidney, except renal pelvis (the area at the center of the kidney (urine collects here and is funneled into the ureter (the tube that connects the kidney to the bladder)). The POC reads in part, “Assignments: Discipline… Skilled nurse: Name: [RN A], Primary?: Yes, Visits: 2 visit(s) Weekly, PRN Visits: 8 PRN visit(s) every 30 days… • Problem: Deficit related to skin/membrane integrity. Goal: Maintain and/or improve skin integrity. Interventions: Assess skin integrity and effectiveness of skin care each visit. Collaborate with primary physician prn… • Problem: Physical comfort alternation due to pain. Goal: Effective pain regimen. Interventions: Assess pain control @ (at) each weekly visit and prn (as needed) with 24-hour availability. Assess pt’s anxiety/stress level. Notify MD, if necessary. Assess pt’s on a level of 0-10 if appropriate, note effectiveness of pain control q (every) visit. Collaborate with primary MD prn. Titrate (gradually adjust the medication over to, find the lowest effective amount to achieve comfort) pain medicine to control pain prn. Adjust per MD’s orders… If pt is unable to verbalize pain - assess for physical signs of discomfort, i.e (in other words/ in essence), facial grimacing, moaning, etc (etcetera)… • Problem: Deficit related to infection. Goal: Decrease infection risk. Interventions: Assess TPR (temperature, pulse and respiration), BP (blood pressure), neuro, and comfort status every visit… Problem: Deficit related to dying process. Goal: Acceptance. Interventions: … Assess patient’s physical status… Inform physician of patient status as warranted… Notify appropriate team members/ volunteers… Provide family with additional support and resources, as needed… • Problem: Initial Plan of Care prior to Service Provision. Goal: POC. Interventions: … Assess for Immediate Global Needs… Assess Pain/symptoms and intervene as necessary to bring to level of patient comfort… Assign RN Case Manager to assess Scope of Service and oversee ongoing patient care needs… IDG team to assess and review of patient/ legal representative’s level of understanding, involvement, and agreement with the plan of care, in accordance with hospice’s policies… The Registered Nurse initiates the Plan of Care and makes necessary revisions based upon patient current assessments…• Medicationso Morphine Sulfate (Concentrate), 0.5 ML (milliliters) sublingual (applied under the tongue) every 2 hours as needed for pain/SOB (shortness of breath) (20 MG/ML (milligram/ milliliter)…o Lorazepam, 1 tablet oral every 2 hours as needed for anxiety/agitation and dyspnea (difficult/ uncomfortable breathing)… o Acetaminophen 1 Suppository rectal every 4 hours as needed for pain/temp (650 MG Suppository)… o Morphine Sulfate ER (extended release), oral every 12 hours (30 MG tablet ER)…o Lidocaine Pain Relief, 1 patch topical 1 times a day (4 % (percent) Patch)… • Physician Orders… o Administer and/ or teach Prescribed Medications to patient/family. o Meds (medications) may be administered by: Nurse/ caregiver to monitor and control pain level and coordinate with MD prn… o Insert and provide BN-A catheter care PRN… o Per Orders contact hospice for any changes in condition… o May consult Hospice Medical Director or Hospice physician for future orders…” Record review of document entitled, “Informed Consent and Election of Benefits” unpaged signed on 09/15/2025 by patient #1 reads in part, “Receipt of Information: I have received a verbal explanation and written notice/policy, in a language I understand, of the following: Abuse, Neglect, and Exploitation… Complaints… Patient Rights and Responsibilities/Rights of the Elderly…” Record review of text message from FM A to RN A on 10/04/2025 at 12:29PM reads in part, “Hello, I hate to bother you. He is in lots of pain while trying to urinate. He says it’s like it won’t come out.” RN A responds back, “Is there urine in the bag? Try repositioning.” -Although, RN A instructed patient #1 to reposition to adjust the BN-A catheter; there was no documentation that RN A notified the hospice and/or the SUP Nurse and/or the physician that patient#1 presented with a new change of condition (pain that was unrelieved from the BN-A catheter) on 10/04/2025.-Further review of text messages from FM A to RN A from the dates of 10/04/2025 to 10/06/2025 revealed that RN A did not address Patient#1’s complaints of bladder pain, and RN A did not provide instruction for FM A to administer any form of pain medications to relieve Patient#1’s pain. Record review of text message from FM A to RN B on 10/04/2025 at 4:48PM reads in part, “Is anyone coming to help today?” RN B replied back, “Call the 833 number on the book so it can officially be documented that you called twice about BN-A replacement… if the pain pill hasn’t decreased the pain give 0.5ML (milliliters) of quick acting morphine…” FM A replied back, “Ok the pain is horrible. I gave it to him. Do you know when the nurse will get here?” -Although, RN B instructed FM A to give quick acting morphine to help decrease the pain. There was no documentation that RN B notified the agency and/or the SUP Nurse and/or the physician that patient#1’s pain was unrelieved with the use of quick acting morphine on 10/04/2025.-Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:04PM (CDT (Central Standard Time) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1704 (5:04PM in military time) [FM A] reports this is her second call, she has not heard back yet about BN-A catheter placement. Assessment: [FM A] reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. Was told a nurse was coming to make a visit. Pt (patient) incontinent (having no or insufficient voluntary control over urination or defecation (the natural process for expelling solid waste/feces from the digestive tract through the anus) for urine. Response: Advised on call staff would be notified for follow up…” Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:48PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1748 (5:48PM in military time) [FM B], report [FM A] called this afternoon and no one has reached out to her yet regarding replacing BN-A catheter for the patient. Assessment: [FM B] voices frustration, stating this was unacceptable, and state if someone does not call her back within the next 20 mins about a nurse visit she is ‘going to call the department of health.’ Response: Voiced understanding of frustrations. Active listening utilized. Advised on call administrator would be notified…” Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 10:35AM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 10:11 Received a call from [FM A] saying patient went to ER (Emergency Room) last night due to severe pain… Used morphine to try and keep him comfortable through the night. Caller says ER told [FM A] that patient would need nurse visit to follow up and assess in the morning… Response: Advised caller that on call nurse will be notified and will in contact shortly…”Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 12:50PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 at 12:23PM Received a call from [FM A] saying she called almost 2 hours ago requesting nurse visit and hasn’t heard from anyone. Caller is very upset. Requesting visit ASAP (as soon as possible). Assessment: On call nurse [RN C] notified and will be in contact shortly…” Record review of document entitled, “General Details” written by RN G for the date of 10/05/2025 at 07:19PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Time of Event: 08:19PM… Chief Complaint: On 10/05/25 at 2019 (8:19PM military time), COMP called in regards to [patient #1] stating that he returned home from the hospital today and is having uncontrolled pain despite Morphine around the clock. Assessment: … States he did not receive a nurse visit today. Response: On call nurse [RN C]. Education: Nurse will follow up…” Record review on 01/19/2026 during pre-survey preparation of the incident investigation worksheet for intake #1041603 revealed that FM A called in a complaint involving agency’s patient #1 on 10/04/2025 related to BN-A catheter issues and that patient was in pain for hours. Record review of document entitled, “Routine- RN Nursing Visit (No Aide)” signed by RN B and dated 10/04/2025 at 07:34PM (CDT) reads in part, “… Mileage: 174 miles… Blood pressure: 165/84, Oxygen Saturation: 93, Respiration: 22, Radial Pulse: 108, Tachycardia: Yes… Catheter: Yes, Catheter Type: BN-A- 14 Fr (French), Catheter last Changed: 10/04/2025… Received phone call prior to visit concerning BN-A catheter output. Upon arrival patient awoke… Patient was moaning and grimacing. During assessment the previous BN-A was removed by the FM A, she removed the BN-A incorrectly, minimal urine and blood clot noted coming out of penile. Patient bladder was distended and firm. Pain scale: 10/10; prn pain med administered New BN-A 14fr inserted using aseptic technique. Urine output at minimal and small blood clot passed. Bladder remains distended. Begin saline flushes of catheter blood clot noted coming out catheter but could not pass with numerous saline flushes. Through several attempts blood clot or urine would not pass. Bladder remains distended and patient unrelieved with pain med. Hospice physician called, order to send patient out to ED. EMS called. EMS arrived shortly. Patient was taken to ED…” During an interview with FM A on 01/22/2026 at 8:14AM. SR inquired from FM A, what the account of the events were for the date of 10/04/2025. FM A stated, “.... So, on that day of 10/04/25, it so happened that Patient #1 started having a whole lot of pain and a lot of problems with his BN-A catheter tubing. So, I called the nurse [RN A] on 10/04/2025 at 12:31PM and I’m like, hey, I got a problem. He’s in a whole lot of pain, and there’s all this stuff going on (he’s yelling, and he’s moaning in pain). [RN A] said ‘ohh, well, we probably just need to take the catheter out. But I’m on my way to a wedding, so I’m not going to be the one that must be the on-call nurse today but just go ahead, and you can take the tubing out yourself.’ And I’m like, but I’m not a nurse. [RN A] said ‘oh well you can do it. It’s very easy to do.’ I’m like no because again I’m not a nurse. As I refused to do such a thing, she like hung up on me.” During an interview with FM A on 01/22/2026 at 8:18AM. SR inquired from FM A, what happened next. FM A stated, “So, [patient #1] was in all kinds of pain and later I found out there’s some spasming going on too per an on-call nurse. So, again he is yelling in pain. He’s in so much pain. And I called the on-call nurse to see about getting somebody like a nurse out there. I called [RN B] on 10/04/2025 at 12:34PM explaining to [RN B] that patient #1 was in so much pain and that we needed a nurse to come out to see him. I was just begging for someone to come and help him out. [RN B] kept saying that she was going to be coming all the way from Cypress or Houston or somewhere, which is a gosh awful far away distance from where we lived. At this time I was so desperate, so I called [RN A] back on 10/04/2025 at 12:57PM and told [RN A] look, he’s screaming in pain, and I don’t know what to do. I don’t know when the nurse is going to get here. Just tell me what I need to do, how to take this thing out again. And so, she did. She walked me through the process over the phone, and she told me to cut the catheter, which I did. After that I pulled the tube out myself because he was yelling in so much in pain. So, I’m not sure what I did that day was right or not, since I am not a nurse. But even after that he was still in a whole lot of pain.” During an interview with RN B on 01/22/2026 at 11:38AM. SR inquired from RN B, can you tell me the last day that you provided care to patient #1. RN B stated, “I can’t remember the exact day, but I was home, and she (FM A) told me she’s been calling the on-call number, and she couldn’t get nobody to come out there.” SR inquired further from RN B, why did FM A call you. RN B stated, “Because I’m the one that admitted her initially from some weeks ago, I believe because she had questions, she was just trying to get ahold of somebody (RN A) and she asked me to come out there, but I am not the normal RN case manager. But I told her I would come unless somebody didn’t go out there.” SR inquired further from RN B, who’s the normal RN case manager. RN B stated, “[RN A] is.” -Although, RN B did not remember the exact date; RN B conducted a skilled nurse visit with patient #1 on 10/04/2025 at 07:34PM.- During an interview with RN B on 01/22/2026 at 11:41AM. SR inquired from RN B, when you got to patient #1’s home, what was your assessment of the patient. RN B stated, “When I got there, he was screaming in pain, his bladder was so distended, and there was blood everywhere.” SR inquired further from RN B, how did you get the BN-A catheter out. RN B stated, “She (FM A) did it wrong, she said she cut it out; In doing so, it caused so much bleeding. I don’t know if he had a partial BN-A still in him or if like if he had particles of the BN-A in there. I attempted to put in another BN-A catheter, but he was still bleeding. I couldn’t do anything with that, with him bleeding and clots coming out like that. So, I called the doctor and I called EMS (emergency medical services); so, I stayed there until the ambulance arrived and they took him to the nearest hospital. But [FM A] should have never cut that catheter. She should have just let that BN-A catheter stay in there and let us (nurses) take care of that. She should have never cut the BN-A catheter.” During an interview with RN B on 01/22/2026 at 11:44AM. SR inquired from RN B, the patient and/or patient’s family members were aware of how to take care of the BN-A catheter and/or how to remove one. RN B stated, “No. I don’t think anyone taught them how to care for it because the BN-A catheter is something that the hospice nurses care for not the patients. I would never tell any of my patients and/or any of their family members to pull a BN-A catheter out and/or cut it. Because doing any of that is too invasive, and there is no one way any of them unless they are nurses would be able to remove the BN-A catheter out right.” During an interview with RN C on 01/22/2026 at 11:49AM. SR inquired from RN C, can you tell me the last day that you provided care to patient #1. RN C stated, “I think I saw that patient on 10/05/2025. It was a Sunday I believe.” SR inquired further from RN C, are you the RN case manager for the patient. RN C stated, “No. It is [RN A].” During an interview with RN C on 01/22/2026 at 11:50 AM. SR inquired from RN C, what was the nature of the nurse’s visit. RN C stated, “[FM A] called, I think it was around one or something around because I remember I came back from church. So, she called, and she told me he came back from the hospital that he’s having pain in his side, and I asked her to give him morphine and to call me back if his pain symptom did not change. She said okay. She called me back saying that the morphine wasn’t working and that he still had pain in his bladder. So, I went home, and it was about a 2-hour drive and/or more to get there. So, when I got there, I let her know that the MD ordered for the BN-A to be discontinued. As soon as I removed the BN-A catheter, fluid continually flowed out that it soaked the bed, and his bladder was not as distended as it was before.” SR inquired further from RN C, did you see any bleeding. RN C stated, “I didn’t see any blood or anything. It was more like suprapubic (located in the lower abdomen just above the pubic bone) pressure that I saw.”During an interview with RN A on 01/22/2026 at 2:13PM. SR inquired from RN A, when was the last time you saw the patient and what was going on around that time frame. RN A stated, “… From what I can recall, um [patient #1] had cancer. He was bed bound by the time that he came to Hospice. He was complaining of having to urinate and he couldn’t urinate they (patient #1 and FM A) both agreed to do remove the BN-A. I walked FM A through the steps of how to remove a BN-A over the phone. Everyone always thinks that removing a BN-A is hard, but it is not. She said nothing was coming out and might be obstructed somehow. So, I thought that it might be obstructed because of a blood clot. So, I told FM A to just cut the catheter to clear the clot. I think over the weekend he went to the hospital, he was gone and then he came back and then when I did a follow-up, she was mad at the hospital, she was mad at Hospice, she was mad at the whole world. And I got it because her husband is dying. And she told me, you know what bad experience she had at the hospital. Bad experience she was having with Hospice coming out and. I told her, I said, well, I said, I will increase the frequency of the nursing visits. I’ll start coming out more often. To provide him a little bit more comfort measures and you know, just trying to actively listen to her and talk to her, so that she can grief appropriately. When I left, I thought everything was good. She seemed to be more at ease. So, when I left, I called the office, I talked to the scheduler and said go ahead and increase the nurse visits. Said he is declining more. She’s, you know, going to need more help. And so, when I called the office when they said we’ll never mind, she’s already called another Hospice, she’s going with another Hospice, and she did. But what’s so crazy was that she never mentioned any of that when I was talking to her so. That’s all I can remember.” During an interview with SUP Nurse on 01/22/2026 at 2:33PM. SR inquired from SUP, what was the account of the events from 10/04/25 to 10/06/25. SUP Nurse stated, “…So the COMP had originally called the concern into our home health side because the patient was originally from our home health side. So, they (patient and FM A) had an established relationship with the home health nurses in the Location A area. They were calling their concerns into [Agency A] rather than the hospice. I got into the mix because they called the Executive Director (ED) on the home health side and the ED called me saying that the [Agency A] had a problem for [Hospice A] and the ED was trying to reach the Hospice ADM but at the time could not get ahold of her. So, the ED called me instead. What I came to know was that the patient had some issues with the BN-A catheter. Having some probable issues with urinary retention. So, I called the ADM and asked the ADM, if we can get a nurse to go out and address those concerns. But in hindsight, [SR] I should have asked the ED to just go and assess the situation, since the ED was bit closer to the patient’s home.” During an interview with SUP Nurse on 01/22/2026 at 2:38PM. SR inquired from SUP Nurse, who was the nurse that was called to go and help the patient with the patient’s concerns on 10/04/2025. SUP Nurse stated, “If I recall correctly, I believe it was [RN B], and the nurse in that area would be [RN A].” SR inquired further from the SUP Nurse, who was the RN case manager for the patient. SUP Nurse stated, “The nurse assigned to the patient would be [RN A].” During an interview with SUP Nurse on 01/22/2026 at 2:40PM. SR inquired from SUP Nurse, when a patient has any change in health condition, such as an increase in pain; what should the hospice do. SUP Nurse stated, “We generally send a nurse right away. But I think that hospice nurses have different modalities and sometimes they can do assessments over the phone.” During an interview with SUP Nurse on 01/22/2026 at 2:45PM. SR inquired from SUP Nurse, Why did it take so long for any nurse to come out and provide care for patient #1. SUP Nurse stated, “I believe it is because we assumed that when we gave the instruction that if he continues to have discomfort, for FM A to give him his pain medication. If the medication doesn’t work and he’s still uncomfortable, for FM A to call us back and then we (myself and the ADM) will send a nurse to get in route. And when we didn’t hear from them, we probably should have made a follow-up phone call. To see right, that it was done but we didn’t do that because when we didn’t hear back from them, we assumed that the patient was resting comfortably…” During an interview with SUP Nurse on 01/22/2026 at 2:48PM. SR inquired from SUP Nurse, who is the individual or the person that supervises the provision of nursing throughout the hospice. SUP Nurse stated, “So I’m on the license as a supervising nurse and [Alt ADM/ Alt SUP Nurse] is the backup supervising nurse.” SR inquired further from the SUP Nurse, who is the individual responsible for the policies and procedures being implemented accordingly throughout the Hospice. SUP Nurse stated, “That would be our compliance department.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:53PM. SR inquired from Alt ADM/ Alt SUP Nurse, what was the account of the events from 10/04/25 to 10/07/25. Alt ADM/ Alt SUP Nurse stated, “I was on leave around that timeframe. When I came back from leave was when I heard in IDG (interdisciplinary group) the issues that the nurses were having with the patient.” SR inquired further from the Alt ADM/ Alt SUP Nurse, what were the issues the nurses were having with the patient. Alt ADM/ Alt SUP Nurse stated, “the issues were with BN-A and the bleeding because [FM A] removed the BN-A catheter solely by herself. But I never saw him, never spoke with him or [FM A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:55PM. SR inquired from Alt ADM/ Alt SUP Nurse, the SUP Nurse stated that you’re the alternate supervising nurse, correct? Alt ADM/ Alt SUP Nurse doesn’t answer but nodded her head yes. SR inquired further from Alt ADM/ Alt SUP Nurse, who is the individual that is to ensure that the policies and procedures of the agency are being implemented accordingly? Alt ADM/ Alt SUP Nurse stated, “that would be [ADM].” SR inquired further from Alt ADM/ Alt SUP Nurse, who was the RN case manager for the patient. Alt ADM/ Alt SUP Nurse stated, “That would have been [RN A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:57PM. SR inquired from Alt ADM/ Alt SUP Nurse, who handles the coordination of care/services when it comes to the supervision of the nurses. Alt ADM/ Alt SUP Nurse stated, “Probably [SUP Nurse].” SR inquired further from Alt ADM/ Alt SUP Nurse, when the nurse has any type of concern, who is the nurse to report to. Alt ADM/ Alt SUP Nurse stated, “A lot of them do come to me because I have a lot of experience. But to say they are actually assigned to report to me, I would say no. But they do come to me a lot. But SUP Nurse is over all the nurses.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:07PM. SR inquired from Alt ADM/ Alt SUP Nurse, who is to ensure that the policies and procedures are implemented throughout the Hospice. Alt ADM/ Alt SUP Nurse stated, “The ADM.” SR inquired further from the Alt ADM/ Alt SUP Nurse, are not an additional ADM. Alt ADM/ Alt SUP Nurse stated, “I am. I have not been given those duties.” During an interview with ADM on 01/22/2026 at 3:31PM. SR inquired from the ADM, what was the account of the events from 10/04/25 to 10/07/25. ADM stated, “The biggest challenge that I think that we had with communication as far as this family goes is they (patient #1 FMs) continued to call the home health nurse side. So, they were originally from our home health service, out of the Location A office. So, they were calling that home health nurse directly instead of calling the 800 number (the hospice’s main number). So, when we finally got a call on 10/05/2025 around 10AM or so from the on-call staff that they needed somebody to come out, that’s when we went out. [RN C] did go out and do a visit on 10/05/2025… I know that previous day on 10/04/2025, they (patient #1’s FMs) had sent him to the ER under the MD’s recommendation and the nurse that was out there was [RN B]… and so, by the time [RN B] got that second call. You know, it was already 7:30PM in the evening, so that’s what made the visit so late on 10/04/2025. But after that visit, I know [RN A] went out to do the visit the next day (on 10/06/2025) and she asked the family, you know, would you like me to increase frequency? Would you like me to know, get some additional support here. And the family was agreeable and the very next day they transferred to another service, which is certainly their right to do… One of the things that I feel like are the reasons I feel like that they ended up transferring was because they wanted somebody local and they felt like maybe they would receive a better response time… We (ADM team) would have gotten that a little bit quicker than getting it (the initial call) from individual nurses. Yeah, so. I hope that wasn’t a delay in care, but that’s my only reasoning for thinking that it might have been so, or that they (FMs of patient #1) might not have felt as supported.” During an interview with ADM on 01/22/2026 at 3:40PM. SR inquired from the ADM, are you aware of any nurses walking a patient over the phone on how to remove BN-A catheter. ADM stated, “I am personally not aware. I don’t know if I would be as I’m not a clinician. So, you know, that’s not really something that would have come to my attention. I would discourage that. 100%. Even as a non-clinician, I would discourage that because count as an invasive procedure.” During an interview with ADM on 01/22/2026 at 3:41PM. SR inquired from the ADM, who is responsible for ensuring that the policies and procedures of the Hospice is implemented accordingly. ADM stated, “Myself with in conjunction with compliance.” SR inquired further from the ADM, what is the roles and responsibilities of the ADM. ADM stated, “… Just the oversight of the entire program… making sure that we’re following the policies and procedures, making sure that on call rotations or cover on call is followed through that. If there are things that need to be. Followed up on complaints, concerns, patient questions, family questions, caregiver questions, things like that…”Record review of the agency’s policy manual included a policy entitled, “Policy: Patient Bill of Rights” with an effective date of 03/12/2021 and a unrevised date reads in part, “… Purpose: The Agency protects and promotes the rights of each individual in its care… Procedure: • The Agency protects and promotes the rights of each individual. In advance of furnishing care to the patient, during the initial evaluation visit before the initiation of treatment, the patient is informed both verbally and in writing of all rights… • Patients have the right:o To be advised of the telephone number and hours of operation of the state’s Home Health Agency hotline, that receives complaints or questions about local home care agencies.o The hours are 24 hours a day, seven (7) days a week.o To be informed of rights under state law to make decisions concerning medical care, including the right to accept or refuse treatment… o To effective pain management.o Voice concerns related to care, treatment or services and patient safety issues: Please call Agency Director of Nursing.o Be informed of his/her rights.o Exercise rights at any time.o Have his/her property and person treated with respect.o Be free from neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the Agency.o Make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the Agency.o Voice and report grievances or complaints regarding treatment or care that are (or fail to be) delivered, the lack of respect for property and/or person, or the violation of any rights to the Agency… applicable) and state of local agencies.o Receive all services in the plan of care… o Be free from any discrimination or reprisal for exercising his/her rights or for voicing grievances to the Agency or an outside entity…o Participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to: Completion of all assessments. The care to be furnished based on the comprehensive assessment. Establishing and revising the plan of care. The disciplines that will furnish the care. The frequency of visits. Expected outcomes of care, including patient-identified goals and anticipated risks and benefits. Any factors that could impact treatment effectiveness. Any changes in the care to be furnished.o To have complaints investigated. The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family, including, but not limited to,o the following topics: Treatment or care that is (or fails to be) furnished inconsistently or is furnished inappropriately. Mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source and/or misappropriation of patient’s property by anyone furnishing services on behalf of the Agency. Document both the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations, including retaliation, while the complaint is being investigated.o To know that any Agency staff (whether employed directly or under arrangement) in the course of providing services to patient, who identifies, notices or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual and/or physical abuse, including injuries of unknown source or misappropriation of patient property, must report these findings immediately to the Agencyo and other appropriate authorities in accordance with state law…””

“Based on record review and interview, the patient has the right to the following: be free from neglect, for 1 of 3 patient’s (Patient #1) whose records were reviewed, in that; RN A advised FM A to remove/cut Patient #1’s catheter over the phone and without assessment; and Patient #1 had uncontrolled pain without timely intervention.This failure has the potential to place all clients at risk for further abuse, neglect, and/or exploitation. Findings Record review of document entitled, “Daily Activity Report” unpaged reads in part, “Chief Complaint: 10/04/2025 at 1704 (5:04PM), [FM A] reports this is FM A’s second call, FM A has not heard back yet about BN-A catheter placement. Assessment: FM A reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. FM A was told a nurse was coming to make a visit. Pt incontinent of urine…” Therefore, the report log revealed that there was documentation of the incident for the date of 10/04/2025. The agency became aware of the complaint on 10/04/2025 at 17:04 (5:04PM); however, the agency failed to report the complaint within 24 hours to HHSC upon learning of the incident on 10/04/2025 when FM A called the agency. • Further review of the report revealed that FM A called the agency with the complaint three separate times between the dates of 10/04/2025 at 5:04PM to 10/05/2025 at 12:23PM. • Further review of the report also revealed that the COMP called the agency on 10/05/2025 at 2019 (8:19PM) regarding uncontrolled pain and that the patient did not receive a nurse visit for the entirety of the day of 10/05/2025. Patient #1Record review of discharged patient #1’s CR revealed a POC titled, “Plan of Care Effective 9/15/25.” The POC showed a SOC date of 09/15/2025 with the benefit period of 09/15/2025 to 10/06/2025 and primary diagnosis of malignant neoplasm of unspecified kidney, except renal pelvis. The POC reads in part, “Assignments: Discipline… Skilled nurse: Name: [RN A], Primary?: Yes, Visits: 2 visit(s) Weekly, PRN Visits: 8 PRN visit(s) every 30 days… • Problem: Deficit related to skin/membrane integrity. Goal: Maintain and/or improve skin integrity. Interventions: Assess skin integrity and effectiveness of skin care each visit. Collaborate with primary physician prn… • Problem: Physical comfort alternation due to pain. Goal: Effective pain regimen. Interventions: Assess pain control @ (at) each weekly visit and prn (as needed) with 24-hour availability. Assess pt’s anxiety/stress level. Notify MD, if necessary. Assess pt’s on a level of 0-10 if appropriate, note effectiveness of pain control q (every) visit. Collaborate with primary MD prn. Titrate pain medicine to control pain prn. Adjust per MD’s orders… If pt is unable to verbalize pain - assess for physical signs of discomfort, i.e (in other words/ in essence) ., facial grimacing, moaning, etc (etcetera)… • Problem: Deficit related to infection. Goal: Decrease infection risk. Interventions: Assess TPR (temperature, pulse and respiration), BP (blood pressure), neuro, and comfort status every visit.. Problem: Deficit related to dying process. Goal: Acceptance. Interventions: … Assess patient’s physical status… Inform physician of patient status as warranted… Notify appropriate team members/ volunteers… Provide family with additional support and resources, as needed… • Problem: Initial Plan of Care prior to Service Provision. Goal: POC. Interventions: … Assess for Immediate Global Needs… Assess Pain/symptoms and intervene as necessary to bring to level of patient comfort… Assign RN Case Manager to assess Scope of Service and oversee ongoing patient care needs… IDG team to assess and review of patient/ legal representative’s level of understanding, involvement, and agreement with the plan of care, in accordance with hospice’s policies… The Registered Nurse initiates the Plan of Care and makes necessary revisions based upon patient current assessments…• Medicationso Morphine Sulfate (Concentrate), 0.5 ML (milliliters) sublingual (applied under the tongue) every 2 hours as needed for pain/SOB (shortness of breath) (20 MG/ML (milligram/ milliliter)…o Lorazepam, 1 tablet oral every 2 hours as needed for anxiety/agitation and dyspnea (difficult/ uncomfortable breathing)… o Acetaminophen 1 Suppository rectal every 4 hours as needed for pain/temp (650 MG Suppository)… o Morphine Sulfate ER (extended release), oral every 12 hours (30 MG tablet ER)…o Lidocaine Pain Relief, 1 patch topical 1 times a day (4 % (percent) Patch)… • Physician Orders… o Administer and/ or teach Prescribed Medications to patient/family. o Meds (medications) may be administered by: Nurse/ caregiver to monitor and control pain level and coordinate with MD prn… o Insert and provide BN-A catheter care PRN… o Per Orders contact hospice for any changes in condition… o May consult Hospice Medical Director or Hospice physician for future orders…” Further review of the POC did not reveal documentation details of the urinary catheter such as duration and insertion method (i.e. indwelling (BN-A), etc), the size of the catheter, and whether the balloon needed to be inflated (with sterile saline or sterile water). Record review of document entitled, “Informed Consent and Election of Benefits” unpaged signed on 09/15/2025 by patient #1 reads in part, “Receipt of Information: I have received a verbal explanation and written notice/policy, in a language I understand, of the following: Abuse, Neglect, and Exploitation… Complaints… Patient Rights and Responsibilities/Rights of the Elderly…” Record review of text message from FM A to RN A on 10/04/2025 at 12:29PM reads in part, “Hello, I hate to bother you. He is in lots of pain while trying to urinate. He says it’s like it won’t come out.” RN A responds back, “Is there urine in the bag? Try repositioning.” -Although, RN A instructed patient #1 to reposition to adjust the BN-A catheter; there was no documentation that RN A notified the hospice and/or the SUP Nurse and/or the physician that patient#1 presented with a new change of condition (pain that was unrelieved from the BN-A catheter) on 10/04/2025.- Further review of text messages from FM A to RN A from the dates of 10/04/2025 to 10/06/2025 revealed that RN A did not address Patient#1’s complaints of bladder pain, and RN A did not provide instruction for FM A to administer any form of pain medications to relieve Patient#1’s pain. Record review of text message from FM A to RN B on 10/04/2025 at 4:48PM reads in part, “Is anyone coming to help today?” RN B replied back, “Call the 833 number on the book so it can officially be documented that you called twice about BN-A replacement… if the pain pill hasn’t decreased the pain give 0.5ML (milliliters) of quick acting morphine…” FM A replied back, “Ok the pain is horrible. I gave it to him. Do you know when the nurse will get here?” -Although, RN B instructed FM A to give quick acting morphine to help decrease the pain. There was no documentation that RN B notified the agency and/or the SUP Nurse and/or the physician that patient#1’s pain was unrelieved with the use of quick acting morphine on 10/04/2025.-Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:04PM (CDT (Central Standard Time) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1704 (5:04PM in military time) [FM A] reports this is her second call, she has not heard back yet about BN-A catheter placement. Assessment: [FM A] reports patient was having bladder pain and BN-A catheter was clogged. A nurse had walked her through removing the BN-A catheter earlier. Was told a nurse was coming to make a visit. Pt (patient) incontinent (having no or insufficient voluntary control over urination or defecation (the natural process for expelling solid waste/feces from the digestive tract through the anus) for urine. Response: Advised on call staff would be notified for follow up…” Record review of document entitled, “General Details” written by RN E for the date of 10/04/2025 at 07:48PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/4/2025 1748 (5:48PM in military time) [FM B], report [FM A] called this afternoon and no one has reached out to her yet regarding replacing BN-A catheter for the patient. Assessment: [FM B] voices frustration, stating this was unacceptable, and state if someone does not call her back within the next 20 mins about a nurse visit she is ‘going to call the department of health.’ Response: Voiced understanding of frustrations. Active listening utilized. Advised on call administrator would be notified…” Record review of document entitled, “Routine- RN Nursing Visit (No Aide)” signed by RN B and dated 10/04/2025 at 07:34PM (CDT) reads in part, “… Mileage: 174 miles… Blood pressure: 165/84, Oxygen Saturation: 93, Respiration: 22, Radial Pulse: 108, Tachycardia: Yes… Catheter: Yes, Catheter Type: BN-A- 14 Fr (French), Catheter last Changed: 10/04/2025… Received phone call prior to visit concerning BN-A catheter output. Upon arrival patient awoke… Patient was moaning and grimacing. During assessment the previous BN-A was removed by the FM A, she removed the BN-A incorrectly, minimal urine and blood clot noted coming out of penile. Patient bladder was distended and firm. Pain scale: 10/10; prn pain med administered New BN-A 14fr inserted using aseptic technique. Urine output at minimal and small blood clot passed. Bladder remains distended. Begin saline flushes of catheter blood clot noted coming out catheter but could not pass with numerous saline flushes. Through several attempts blood clot or urine would not pass. Bladder remains distended and patient unrelieved with pain med. Hospice physician called, order to send patient out to ED. EMS called. EMS arrived shortly. Patient was taken to ED…” Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 10:35AM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 10:11 Received a call from [FM A] saying patient went to ER (Emergency Room) last night due to severe pain… Used morphine to try and keep him comfortable through the night. Caller says ER told [FM A] that patient would need nurse visit to follow up and assess in the morning… Response: Advised caller that on call nurse will be notified and will in contact shortly…”Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 12:50PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 at 12:23PM Received a call from [FM A] saying she called almost 2 hours ago requesting nurse visit and hasn’t heard from anyone. Caller is very upset. Requesting visit ASAP (as soon as possible). Assessment: On call nurse [RN C] notified and will be in contact shortly…” Record review of document entitled, “General Details” written by RN G for the date of 10/05/2025 at 07:19PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Time of Event: 08:19PM… Chief Complaint: On 10/05/25 at 2019 (8:19PM military time), COMP called in regards to [patient #1] stating that he returned home from the hospital today and is having uncontrolled pain despite Morphine around the clock. Assessment: … States he did not receive a nurse visit today. Response: On call nurse [RN C]. Education: Nurse will follow up…” Record review on 01/19/2026 during pre-survey preparation of the incident investigation worksheet for intake #1041603 revealed that FM A called in a complaint involving agency’s patient #1 on 10/04/2025 related to BN-A catheter issues and that patient was in pain for hours. RN ARecord review on 01/22/2026 of RN A’s PR revealed DOH (date of hire) of 06/19/2025 with a signed Job Description of Registered Nurse- PRN Hospice for same date of 06/19/2025. • Document entitled, “Job Description” signed for the date of 06/19/2025 reads in part, “… The Registered Nurse will deliver quality compassionate care to patients during the final stages of the patients’ lives established by the plan of care... The skilled professional staff member whether direct employee of the agency or under arrangement are expected to contribute to all phases of the QAPI (Quality Assurance Performance Improvement) program and participates in ongoing interdisciplinary assessments of patients… Duties and Responsibilities: 1. Effectively case manages all patients assigned which include: review of chart and documentation from all disciplines, coordination of care of all disciplines, effective communication between all disciplines, ensuring quality outcomes and verifying that all necessary follow-up by all disciplines have been completed. 2. Consistently establishes an individualized plan of care based on the evaluation, patient’s skilled needs and physician orders... 4. Consistently completes comprehensive assessments within forty-eight (48) hours. 5. Effectively re-evaluates plan of care upon changes in orders or condition of patient. 8. Effectively prepares plan of care to meet or exceed national standards by determining appropriate number of visits and type of care required for patient to effectively meet goals. 9. Demonstrates proper reporting and documents any patient incidents, variances, complaints, infections or any other deemed reportable insistences to ensure patient care is maintained. 10. Participates in ongoing interdisciplinary assessments of patients. 11. Adheres to standard nursing practices as defined by state regulatory guidelines and Board of Nursing… 12. Effectively coordinates and properly documents care with all disciplines involved and informed physician of patient needs or changes in care. 16. Demonstrates competent performance of technical skills established according to established procedures. 18. Ensures patient safety needs are assessed and implemented in plan of care. Reviews patient safety goals to ensure best practices are followed in home setting. 21. Makes clinical notes that are written, timed and dated, and which describes signs, and symptoms, treatments, drug administered and the patient’s reaction or response, and any changes in physical or emotional condition during a given period of time…” • Further review of the PR revealed that RN A; signed a Competency Assessment on 06/20/2025 that was observed by Alt ADM/Alt SUP Nurse on same date of 06/20/2025. The document entitled, “Registered Nurse: Competency Assessment” with date of 06/20/2025 reads in part, “[RN A], Initial… Registered Nurse Self Rating: A= (equals) I can perform well… Preceptor/Clinical Manger Competency Assessment Method: DOS= Direct On-Site Observation… Insert Urethral (refers to the urethra, the tube-like structure that carries urine from the bladder out of the body) Catheter… Male… RN A= A (RN A selected I can perform well)… Alt ADM/Alt SUP Nurse= DOS…” During an interview with FM A on 01/22/2026 at 8:14AM. SR inquired from FM A, what the account of the events were for the date of 10/04/2025. FM A stated, “I had called [Hospice A] multiple times because of pervious issues with his wound care, where the nurse [RN A] didn’t seem to be bothered by it. [RN A] at one point told me that the wound care wasn’t part of her job, even though before he was discharged from the hospital to come here; the hospital was doing wound care daily for him, and [Agency A] where we transferred from was doing it daily as well. So, at this point, I’m feeling like I’m bothering these people whenever I call them regarding anything to do with his care, especially if anything is wrong. So, on that day of 10/04/25, it so happened that patient #1 started having a whole lot of pain and a lot of problems with his BN-A catheter tubing. So, I called the nurse [RN A] on 10/04/2025 at 12:31PM and I’m like, hey, I got a problem. He’s in a whole lot of pain, and there’s all this stuff going on (he’s yelling, and he’s moaning in pain). [RN A] said ‘ohh, well, we probably just need to take the catheter out. But I’m on my way to a wedding, so I’m not going to be the one that must be the on-call nurse today but just go ahead, and you can take the tubing out yourself.’ And I’m like, but I’m not a nurse. [RN A] said ‘oh well you can do it. It’s very easy to do.’ I’m like no because again I’m not a nurse. As I refused to do such a thing, she like hung up on me.” During an interview with FM A on 01/22/2026 at 8:18AM. SR inquired from FM A, what happened next. FM A stated, “So, [patient #1] was in all kinds of pain and later I found out there’s some spasming going on too per an on-call nurse. So, again he is yelling in pain. He’s in so much pain. And I called the on-call nurse to see about getting somebody like a nurse out there. I called [RN B] on 10/04/2025 at 12:34PM explaining to [RN B] that patient #1 was in so much pain and that we needed a nurse to come out to see him. I was just begging for someone to come and help him out. [RN B] kept saying that she was going to be coming all the way from Cypress or Houston or somewhere, which is a gosh awful far away distance from where we lived. At this time I was so desperate, so I called [RN A] back on 10/04/2025 at 12:57PM and told [RN A] look, he’s screaming in pain, and I don’t know what to do. I don’t know when the nurse is going to get here. Just tell me what I need to do, how to take this thing out again. And so, she did. She walked me through the process over the phone, and she told me to cut the catheter, which I did. After that I pulled the tube out myself because he was yelling in so much pain. So, I’m not sure what I did that day was right or not, since I am not a nurse. But even after that he’s was still in a whole lot of pain.” During an interview with RN B on 01/22/2026 at 11:38AM. SR inquired from RN B, can you tell me the last day that you provided care to patient #1. RN B stated, “I can’t remember the exact day, but I was home, and she (FM A) told me she’s been calling the on-call number, and she couldn’t get nobody to come out there.” SR inquired further from RN B, why did FM A call you. RN B stated, “Because I’m the one that admitted her initially from some weeks ago, I believe because she had questions, she was just trying to get ahold of somebody (RN A) and she asked me to come out there, but I am not the normal RN case manager. But I told her I would come unless somebody didn’t go out there.” SR inquired further from RN B, who’s the normal RN case manager. RN B stated, “[RN A] is.” -Although, RN B did not remember the exact date; RN B conducted a skilled nurse visit with patient #1 on 10/04/2025 at 07:34PM.- During an interview with RN B on 01/22/2026 at 11:41AM. SR inquired from RN B, when you got to patient #1’s home, what was your assessment of the patient. RN B stated, “When I got there, he was screaming in pain, his bladder was so distended, and there was blood everywhere.” SR inquired further from RN B, how did you get the BN-A catheter out. RN B stated, “She (FM A) did it wrong, she said she cut it out; In doing so, it caused so much bleeding. I don’t know if he had a partial BN-A still in him or if like if he had particles of the BN-A in there. I attempted to put in another BN-A catheter, but he was still bleeding. I couldn’t do anything with that, with him bleeding and clots coming out like that. So, I called the doctor and I called EMS (emergency medical services); so, I stayed there until the ambulance arrived and they took him to the nearest hospital. But [FM A] should have never cut that catheter. She should have just let that BN-A catheter stay in there and let us (nurses) take care of that. She should have never cut the BN-A catheter.” During an interview with RN B on 01/22/2026 at 11:44AM. SR inquired from RN B, the patient and/or patient’s family members were aware of how to take care of the BN-A catheter and/or how to remove one. RN B stated, “No. I don’t think anyone taught them how to care for it because the BN-A catheter is something that the hospice nurses care for not the patients. I would never tell any of my patients and/or any of their family members to pull a BN-A catheter out and/or cut it. Because doing any of that is too invasive, and there is no one way any of them unless they are nurses would be able to remove the BN-A catheter out right.” During an interview with RN C on 01/22/2026 at 11:49AM. SR inquired from RN C, can you tell me the last day that you provided care to patient #1. RN C stated, “I think I saw that patient on 10/05/2025. It was a Sunday I believe.” SR inquired further from RN C, are you the RN case manager for the patient. RN C stated, “No. It is [RN A].” During an interview with RN C on 01/22/2026 at 11:50 AM. SR inquired from RN C, what was the nature of the nurse’s visit. RN C stated, “[FM A] called, I think it was around one or something around because I remember I came back from church. So, she called, and she told me he came back from the hospital that he’s having pain in his side, and I asked her to give him morphine and to call me back if his pain symptom did not change. She said okay. She called me back saying that the morphine wasn’t working and that he still had pain in his bladder. So, I went home, and it was about a 2-hour drive and/or more to get there. So, when I got there, I let her know that the MD ordered for the BN-A to be discontinued. As soon as I removed the BN-A catheter, fluid continually flowed out that it soaked the bed, and his bladder was not as distended as it was before.” SR inquired further from RN C, did you see any bleeding. RN C stated, “I didn’t see any blood or anything. It was more like suprapubic (located in the lower abdomen just above the pubic bone) pressure that I saw.”During an interview with RN A on 01/22/2026 at 2:13PM. SR inquired from RN A, when was the last time you saw the patient and what was going on around that time frame. RN A stated, “… From what I can recall, um [patient #1] had cancer. He was bed bound by the time that he came to Hospice. He was complaining of having to urinate and he couldn’t urinate they (patient #1 and FM A) both agreed to do remove the BN-A. I walked FM A through the steps of how to remove a BN-A over the phone. Everyone always thinks that removing a BN-A is hard, but it is not. She said nothing was coming out and might be obstructed somehow. So, I thought that it might be obstructed because of a blood clot. So, I told FM A to just cut the catheter to clear the clot. I think over the weekend he went to the hospital, he was gone and then he came back and then when I did a follow-up, she was mad at the hospital, she was mad at Hospice, she was mad at the whole world. And I got it because her husband is dying. And she told me, you know what bad experience she had at the hospital. Bad experience she was having with Hospice coming out and. I told her, I said, well, I said, I will increase the frequency of the nursing visits. I’ll start coming out more often. To provide him a little bit more comfort measures and you know, just trying to actively listen to her and talk to her, so that she can grief appropriately. When I left, I thought everything was good. She seemed to be more at ease. So, when I left, I called the office, I talked to the scheduler and said go ahead and increase the nurse visits. Said he is declining more. She’s, you know, going to need more help. And so, when I called the office when they said we’ll never mind, she’s already called another Hospice, she’s going with another Hospice, and she did. But what’s so crazy was that she never mentioned any of that when I was talking to her so. That’s all I can remember.” During an interview with SUP Nurse on 01/22/2026 at 2:33PM. SR inquired from SUP, what was the account of the events from 10/04/25 to 10/06/25. SUP Nurse stated, “…So the COMP had originally called the concern into our home health side because the patient was originally from our home health side. So, they (patient and FM A) had an established relationship with the home health nurses in the Location A area. They were calling their concerns into [Agency A] rather than the hospice. I got into the mix because they called the Executive Director (ED) on the home health side and the ED called me saying that the [Agency A] had a problem for [Hospice A] and the ED was trying to reach the Hospice ADM but at the time could not get ahold of her. So, the ED called me instead. What I came to know was that the patient had some issues with the BN-A catheter. Having some probable issues with urinary retention. So, I called the ADM and asked the ADM, if we can get a nurse to go out and address those concerns. But in hindsight, [SR] I should have asked the ED to just go and assess the situation, since the ED was bit closer to the patient’s home.” During an interview with SUP Nurse on 01/22/2026 at 2:38PM. SR inquired from SUP Nurse, who was the nurse that was called to go and help the patient with the patient’s concerns on 10/04/2025. SUP Nurse stated, “If I recall correctly, I believe it was [RN B], and the nurse in that area would be [RN A].” SR inquired further from the SUP Nurse, who was the RN case manager for the patient. SUP Nurse stated, “The nurse assigned to the patient would be [RN A].” During an interview with SUP Nurse on 01/22/2026 at 2:40PM. SR inquired from SUP Nurse, when a patient has any change in health condition, such as an increase in pain; what should the hospice do. SUP Nurse stated, “We generally send a nurse right away. But I think that hospice nurses have different modalities and sometimes they can do assessments over the phone.” During an interview with SUP Nurse on 01/22/2026 at 2:45PM. SR inquired from SUP Nurse, Why did it take so long for any nurse to come out and provide care for patient #1. SUP Nurse stated, “I believe it is because we assumed that when we gave the instruction that if he continues to have discomfort, for FM A to give him his pain medication. If the medication doesn’t work and he’s still uncomfortable, for FM A to call us back and then we (myself and the ADM) will send a nurse to get in route. And when we didn’t hear from them, we probably should have made a follow-up phone call. To see right, that it was done but we didn’t do that because when we didn’t hear back from them, we assumed that the patient was resting comfortably…” During an interview with SUP Nurse on 01/22/2026 at 2:48PM. SR inquired from SUP Nurse, who is the individual or the person that supervises the provision of nursing throughout the hospice. SUP Nurse stated, “So I’m on the license as a supervising nurse and [Alt ADM/ Alt SUP Nurse] is the backup supervising nurse.” SR inquired further from the SUP Nurse, who is the individual responsible for the policies and procedures being implemented accordingly throughout the Hospice. SUP Nurse stated, “That would be our compliance department.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:53PM. SR inquired from Alt ADM/ Alt SUP Nurse, what was the account of the events from 10/04/25 to 10/07/25. Alt ADM/ Alt SUP Nurse stated, “I was on leave around that timeframe. When I came back from leave was when I heard in IDG (interdisciplinary group) the issues that the nurses were having with the patient.” SR inquired further from the Alt ADM/ Alt SUP Nurse, what were the issues the nurses were having with the patient. Alt ADM/ Alt SUP Nurse stated, “the issues were with BN-A and the bleeding because [FM A] removed the BN-A catheter solely by herself. But I never saw him, never spoke with him or [FM A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:55PM. SR inquired from Alt ADM/ Alt SUP Nurse, the SUP Nurse stated that you’re the alternate supervising nurse, correct? Alt ADM/ Alt SUP Nurse doesn’t answer but nodded her head yes. SR inquired further from Alt ADM/ Alt SUP Nurse, who is the individual that is to ensure that the policies and procedures of the agency are being implemented accordingly? Alt ADM/ Alt SUP Nurse stated, “that would be [ADM].” SR inquired further from Alt ADM/ Alt SUP Nurse, who was the RN case manager for the patient. Alt ADM/ Alt SUP Nurse stated, “That would have been [RN A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:57PM. SR inquired from Alt ADM/ Alt SUP Nurse, who handles the coordination of care/services when it comes to the supervision of the nurses. Alt ADM/ Alt SUP Nurse stated, “Probably [SUP Nurse].” SR inquired further from Alt ADM/ Alt SUP Nurse, when the nurse has any type of concern, who is the nurse to report to. Alt ADM/ Alt SUP Nurse stated, “A lot of them do come to me because I have a lot of experience. But to say they are actually assigned to report to me, I would say no. But they do come to me a lot. But SUP Nurse is over all the nurses.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:07PM. SR inquired from Alt ADM/ Alt SUP Nurse, who is to ensure that the policies and procedures are implemented throughout the Hospice. Alt ADM/ Alt SUP Nurse stated, “The ADM.” SR inquired further from the Alt ADM/ Alt SUP Nurse, are not an additional ADM. Alt ADM/ Alt SUP Nurse stated, “I am. I have not been given those duties.” During an interview with ADM on 01/22/2026 at 3:31PM. SR inquired from the ADM, what was the account of the events from 10/04/25 to 10/07/25. ADM stated, “The biggest challenge that I think that we had with communication as far as this family goes is they (patient #1 FMs) continued to call the home health nurse side. So, they were originally from our home health service, out of the Location A office. So, they were calling that home health nurse directly instead of calling the 800 number (the hospice’s main number). So, when we finally got a call on 10/05/2025 around 10AM or so from the on-call staff that they needed somebody to come out, that’s when we went out. [RN C] did go out and do a visit on 10/05/2025… I know that previous day on 10/04/2025, they (patient #1’s FMs) had sent him to the ER under the MD’s recommendation and the nurse that was out there was [RN B]… and so, by the time [RN B] got that second call. You know, it was already 7:30PM in the evening, so that’s what made the visit so late on 10/04/2025. But after that visit, I know [RN A] went out to do the visit the next day (on 10/06/2025) and she asked the family, you know, would you like me to increase frequency? Would you like me to know, get some additional support here. And the family was agreeable and the very next day they transferred to another service, which is certainly their right to do… One of the things that I feel like are the reasons I feel like that they ended up transferring was because they wanted somebody local and they felt like maybe they would receive a better response time… We (ADM team) would have gotten that a little bit quicker than getting it (the initial call) from individual nurses. Yeah, so. I hope that wasn’t a delay in care, but that’s my only reasoning for thinking that it might have been so, or that they (FMs of patient #1) might not have felt as supported.” During an interview with ADM on 01/22/2026 at 3:40PM. SR inquired from the ADM, are you aware of any nurses walking a patient over the phone on how to remove BN-A catheter. ADM stated, “I am personally not aware. I don’t know if I would be as I’m not a clinician. So, you know, that’s not really something that would have come to my attention. I would discourage that. 100%. Even as a non-clinician, I would discourage that because count as an invasive procedure.” During an interview with ADM on 01/22/2026 at 3:41PM. SR inquired from the ADM, who is responsible for ensuring that the policies and procedures of the Hospice is implemented accordingly. ADM stated, “Myself with in conjunction with compliance.” SR inquired further from the ADM, what is the roles and responsibilities of the ADM. ADM stated, “… Just the oversight of the entire program… making sure that we’re following the policies and procedures, making sure that on call rotations or cover on call is followed through that. If there are things that need to be. Followed up on complaints, concerns, patient questions, family questions, caregiver questions, things like that…” Record review of the agency’s policy manual included a policy entitled, “Policy: Patient Bill of Rights” with an effective date of 03/12/2021 and a unrevised date reads in part, “… Purpose: The Agency protects and promotes the rights of each individual in its care… • Patients have the right:o … To be informed of rights under state law t o make decisions concerning medical care, including the right to accept or refuse treatment… o … Exercise rights at any time.o Have his/her property and person treated with respect.o Be free from neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the Agency.o Make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the Agency.o Voice and report grievances or complaints regarding treatment or care that are (or fail to be) delivered, the lack of respect for property and/or person, or the violation of any rights to the Agency… applicable) and state of local agencies.o Receive all services in the plan of care… o Be free from any discrimination or reprisal for exercising his/her rights or for voicing grievances to the Agency or an outside entity…o Participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to: Completion of all assessments. The care to be furnished based on the comprehensive assessment. Establishing and revising the plan of care. The disciplines that will furnish the care. The frequency of visits. Expected outcomes of care, including patient-identified goals and anticipated risks and benefits. Any factors that could impact treatment effectiveness. Any changes in the care to be furnished.o To have complaints investigated. The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family, including, but not limited to,o the following topics: Treatment or care that is (or fails to be) furnished inconsistently or is furnished inappropriately. Mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source and/or misappropriation of patient’s property by anyone furnishing services on behalf of the Agency. Document both the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations, including retaliation, while the complaint is being investigated.o To know that any Agency staff (whether employed directly or under arrangement) in the course of providing services to patient, who identifies, notices or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual and/or physical abuse, including injuries of unknown source or misappropriation of patient property, must report these findings immediately to the Agency and other appropriate authorities in accordance with state law…””

“Based on record review and interview, the hospice failed to implement interventions to manage the pain and symptoms for 1 of 3 patients (patient #1) whose records were reviewed, in that; When [FM A] reported patient #1’s unrelieved acute bladder pain to hospice employee [RN A] on 10/04/2025; RN A did not implement any quality interventions to help reduce Patient #1’s pain. This failure has the potential to place all patients at risk for ineffective pain control and substandard quality of care. Findings Patient #1Record review of discharged patient #1’s CR revealed a POC titled, “Plan of Care Effective 9/15/25.” The POC showed a SOC date of 09/15/2025 with the benefit period of 09/15/2025 to 10/06/2025 and primary diagnosis of malignant neoplasm of unspecified kidney, except renal pelvis. The POC reads in part, “Assignments: Discipline… Skilled nurse: Name: [RN A], Primary?: Yes, Visits: 2 visit(s) Weekly, PRN Visits: 8 PRN visit(s) every 30 days… • Problem: Physical comfort alternation due to pain. Goal: Effective pain regimen. Interventions: Assess pain control @ (at) each weekly visit and prn (as needed) with 24-hour availability. Assess pt’s anxiety/stress level. Notify MD, if necessary. Assess pt’s on a level of 0-10 if appropriate, note effectiveness of pain control q (every) visit. Collaborate with primary MD prn. Titrate pain medicine to control pain prn. Adjust per MD’s orders… If pt is unable to verbalize pain - assess for physical signs of discomfort, i.e (in other words/ in essence) ., facial grimacing, moaning, etc (etcetera)… • Problem: Deficit related to infection. Goal: Decrease infection risk. Interventions: Assess TPR (temperature, pulse and respiration), BP (blood pressure), neuro, and comfort status every visit.. Problem: Deficit related to dying process. Goal: Acceptance. Interventions: … Assess patient’s physical status… Inform physician of patient status as warranted… Notify appropriate team members/ volunteers… Provide family with additional support and resources, as needed… • Problem: Initial Plan of Care prior to Service Provision. Goal: POC. Interventions: … Assess for Immediate Global Needs… Assess Pain/symptoms and intervene as necessary to bring to level of patient comfort… Assign RN Case Manager to assess Scope of Service and oversee ongoing patient care needs… IDG team to assess and review of patient/ legal representative’s level of understanding, involvement, and agreement with the plan of care, in accordance with hospice’s policies… The Registered Nurse initiates the Plan of Care and makes necessary revisions based upon patient current assessments…• Medicationso Morphine Sulfate (Concentrate), 0.5 ML (milliliters) sublingual (applied under the tongue) every 2 hours as needed for pain/SOB (shortness of breath) (20 MG/ML (milligram/ milliliter)…o Lorazepam, 1 tablet oral every 2 hours as needed for anxiety/agitation and dyspnea (difficult/ uncomfortable breathing)… o Acetaminophen 1 Suppository rectal every 4 hours as needed for pain/temp (650 MG Suppository)… o Morphine Sulfate ER (extended release), oral every 12 hours (30 MG tablet ER)…o Lidocaine Pain Relief, 1 patch topical 1 times a day (4 % (percent) Patch)… • Physician Orders… o Administer and/ or teach Prescribed Medications to patient/family. o Meds (medications) may be administered by: Nurse/ caregiver to monitor and control pain level and coordinate with MD prn… o Insert and provide BN-A catheter care PRN… o Per Orders contact hospice for any changes in condition… o May consult Hospice Medical Director or Hospice physician for future orders…” Record review of text message from FM A to RN A on 10/04/2025 at 12:29PM reads in part, “Hello, I hate to bother you. He is in lots of pain while trying to urinate. He says it’s like it won’t come out...” - Further review revealed that there was no documentation that RN A implemented any quality interventions to help reduce Patient #1’s pain when [FM A] initially reported patient #1’s unrelieved acute bladder pain to hospice employee [RN A] on 10/04/2025.- Record review of document entitled, “Routine- RN Nursing Visit (No Aide)” signed by RN B and dated 10/04/2025 at 07:34PM (CDT) reads in part, “… Mileage: 174 miles… Blood pressure: 165/84, Oxygen Saturation: 93, Respiration: 22, Radial Pulse: 108, Tachycardia: Yes… Catheter: Yes, Catheter Type: BN-A- 14 Fr (French), Catheter last Changed: 10/04/2025… Received phone call prior to visit concerning BN-A catheter output. Upon arrival patient awoke… Patient was moaning and grimacing. During assessment the previous BN-A was removed by the FM A, she removed the BN-A incorrectly, minimal urine and blood clot noted coming out of penile. Patient bladder was distended and firm. Pain scale: 10/10; prn pain med administered New BN-A 14fr inserted using aseptic technique. Urine output at minimal and small blood clot passed. Bladder remains distended. Begin saline flushes of catheter blood clot noted coming out catheter but could not pass with numerous saline flushes. Through several attempts blood clot or urine would not pass. Bladder remains distended and patient unrelieved with pain med. Hospice physician called, order to send patient out to ED. EMS called. EMS arrived shortly. Patient was taken to ED…” Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 10:35AM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 10:11 Received a call from [FM A] saying patient went to ER (Emergency Room) last night due to severe pain… Used morphine to try and keep him comfortable through the night. Caller says ER told [FM A] that patient would need nurse visit to follow up and assess in the morning… Response: Advised caller that on call nurse will be notified and will in contact shortly…”Record review of document entitled, “General Details” written by RN F for the date of 10/05/2025 at 12:50PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Chief Complaint: 10/05/2025 at 12:23PM Received a call from [FM A] saying she called almost 2 hours ago requesting nurse visit and hasn’t heard from anyone. Caller is very upset. Requesting visit ASAP (as soon as possible). Assessment: On call nurse [RN C] notified and will be in contact shortly…” Record review of document entitled, “General Details” written by RN G for the date of 10/05/2025 at 07:19PM (CDT) unpaged reads in part, “Encounter Type: Phone Call… Time of Event: 08:19PM… Chief Complaint: On 10/05/25 at 2019 (8:19PM military time), COMP called in regards to [patient #1] stating that he returned home from the hospital today and is having uncontrolled pain despite Morphine around the clock. Assessment: … Response: On call nurse [RN C]. Education: Nurse will follow up…”Record review of document entitled, “WS HOPE Symptom Follow UP” signed by RN C and dated 10/05/2025 at 10:54PM (CDT) reads in part, “… Note: PRN visit completed: During today’s visit, patient was alert and able to communicate verbally. Vital signs were as follows: BP 145/62, HR 96, O2 saturation 94% on 3 LPM via nasal cannula. No fever was reported or observed. Patients reported pain level of 7/10, primarily in the lower extremity. Pain was managed with Morphine sulfate every 2 hours as directed, with noted relief following urination and repositioning. Patient reported difficulty sleeping due to pain an: spasms but was cooperative with nurse-assisted turning and repositioning and expressed satisfaction with current comfort level… BN-A catheter had been placed the previous evening due to urinary retention. Patient was transported to the ER (on 10/04/2025) for evaluation of possible blood clot. Bladder was flushed and no clots or obstructions were found. Patient reported increased pain and spasms associated with the BN-A’ MD was notified and ordered catheter removal. Following removal, patient reported relief and spontaneous urination was observed…” Record review of document entitled, “RN Aide Supervisory Visit” signed by RN A and dated 10/06/2025 at 03:00PM (CDT) reads in part, “… Mileage: 30… Blood pressure: 105/55, Oxygen Saturation: 90, Oxygen: 5L (liters), Respiration: 22, Radial Pulse: 112, pulse quality: irregular, Tachycardia: Yes, Temperature: 95.0F (Fahrenheit). Skin color: pallor (pale)… Nursing Summary: Pt is lethargic, confused. Unable to make needs known. Appears to be transitioning… Nurse notified hospice office re daily visits… discussed visit frequency: daily nurse visits d/t change in condition…” Record review on 01/19/2026 during pre-survey preparation of the incident investigation worksheet for intake #1041603 revealed that FM A called in a complaint involving agency’s patient #1 on 10/04/2025 related to BN-A catheter issues and that patient was in pain for hours. During an interview with FM A on 01/22/2026 at 8:18AM. SR inquired from FM A, what happened next. FM A stated, “So, [patient #1] was in all kinds of pain and later I found out there’s some spasming going on too per an on-call nurse. So, again he is yelling in pain. He’s in so much pain. And I called the on-call nurse to see about getting somebody like a nurse out there. I called [RN B] on 10/04/2025 at 12:34PM explaining to [RN B] that patient #1 was in so much pain and that we needed a nurse to come out to see him. I was just begging for someone to come and help him out. [RN B] kept saying that she was going to be coming all the way from Cypress or Houston or somewhere, which is a gosh awful far away distance from where we lived. At this time I was so desperate, so I called [RN A] back on 10/04/2025 at 12:57PM and told [RN A] look, he’s screaming in pain, and I don’t know what to do. I don’t know when the nurse is going to get here. Just tell me what I need to do, how to take this thing out again. And so, she did. She walked me through the process over the phone, and she told me to cut the catheter, which I did. After that I pulled the tube out myself because he was yelling in so much in pain. So, I’m not sure what I did that day was right or not, since I am not a nurse. But even after that he’s was still in a whole lot of pain.” During an interview with FM A on 01/22/2026 at 8:25AM. SR inquired from FM A, when did a nurse arrive for a visit with the patient. FM A stated, “It 8 hours for somebody to come to my house!!! I was calling all the nurses on his care, and I was calling the hospice from 10/04/2025 to 10/06/2025. COMP called and FM B called; no one came! It took hours for any nurses, it was like 7:00PM at night when a nurse finally showed up. My husband had been screaming in pain all day, even with the use of the pain meds at home. Oh my God! It took hours for anyone to show up to take care of him. He went for hours without any care. Finally [RN B] came and put another BN-A catheter in; immediately after placing the new one that BN-A catheter started having problems right away. Even with the placement of the new catheter, there was no urine draining from it. [RN B] thought there was a blood clot or something blocking the flow. So, we went to the hospital under the instruction of [RN B]. [RN B] I have no qualms with her but [RN A] is another story.” During an interview with FM A on 01/22/2026 at 8:28AM. SR inquired from FM A, what was done in the hospital. FM A stated, “He stayed at the hospital; they (hospital) didn’t find anything but they kept pumping water in that BN-A and he’s was just all in these different kinds of pain and they sent him home and apparently they said that someone (a nurse) was supposed to be at our house when they sent him home at 1:00AM in the morning of 10/05/2025 and nobody came.”During an interview with FM A on 01/22/2026 at 8:29AM. FM A stated, “Of course, none of the nurses came on time. Again, it took hours, it was like 8 hours!!! It was 9:00PM at night when a nurse finally showed up that day (10/05/2025). It was a big hot mess. That’s all I know is I know I kept calling and no one would come and I had to get ugly one time and said look, I know you’re not going to send a nurse, but can y’all send somebody anybody to fix the bed because the bed rails were down; I didn’t know how to fix that and I don’t want him to fall out of the bed. Someone came to fix that issue, which blew my mind. Because somehow none of the nurses could come on time or at all. But this time, it became like a pattern, where it took more than one phone call and hours for someone to come to attend to him. So, I finally called another [Hospice B] and we fired that one [Hospice A]. And [Hospice A] took their good old sweet time releasing his medical information. She said it’d be done by 10:00AM that morning on 10/06/2025. It was 3:00PM in the afternoon on 10/08/2025 before they released that information to [Hospice B]. [Hospice B] showed up at my house that same day of 10/08/2025. My husband went 24 hours with no one at our house to help me. He went more than 24 hours with no care being provided to him by [Hospice A], and he started having strokes. He eventually died the wee hours of the morning of 10/08/2025 before [Hospice B] could truly provide any care for him. [Hospice B] provided exceptional care, but [Hospice A] was disastrous; I will never recommend anyone to ever place their loved ones at this hospice ever!” During an interview with FM A on 01/22/2026 at 8:35AM. SR inquired from FM A, when did patient #1 die. FM A stated, “I was the only with him till the end. As I said before starting having strokes; I called [Hospice B] and they (nurse and a aide) came promptly about 3:30AM on 10/08/2025. Patient #1 died at 4:00AM in the morning. [Hospice B] staff did an amazing job; they treated him with respect, gave him a bath, and provided him with the care that he deserved. I really wished that we had gone with [Hospice B] instead of [Hospice A] but I was misled by [Agency A] saying that they provided great care to their hospice patients. If I only knew, maybe patient #1 would still be here. If they [Hospice A] didn’t have any staff near us and all of them were like 2 hours or more away, why would they admit patient #1? I don’t understand that. Why?? This is crazy. I know he was going to die of his diagnosis, but [Hospice A] did not give him the care he deserved and I think that is beyond ridiculous. They did not care about us.” During an interview with RN B on 01/22/2026 at 11:38AM. SR inquired from RN B, can you tell me the last day that you provided care to patient #1. RN B stated, “I can’t remember the exact day, but I was home, and she (FM A) told me she’s been calling the on-call number, and she couldn’t get nobody to come out there.” SR inquired further from RN B, why did FM A call you. RN B stated, “Because I’m the one that admitted her initially from some weeks ago, I believe because she had questions, she was just trying to get ahold of somebody (RN A) and she asked me to come out there, but I am not the normal RN case manager. But I told her I would come unless somebody didn’t go out there.” SR inquired further from RN B, who’s the normal RN case manager. RN B stated, “[RN A] is.” -Although, RN B did not remember the exact date; RN B conducted a skilled nurse visit with patient #1 on 10/04/2025 at 07:34PM.- During an interview with RN B on 01/22/2026 at 11:41AM. SR inquired from RN B, when you got to patient #1’s home, what was your assessment of the patient. RN B stated, “When I got there, he was screaming in pain, his bladder was so distended, and there was blood everywhere.” SR inquired further from RN B, how did you get the BN-A catheter out. RN B stated, “She (FM A) did it wrong, she said she cut it out; In doing so, it caused so much bleeding. I don’t know if he had a partial BN-A still in him or if like if he had particles of the BN-A in there. I attempted to put in another BN-A catheter, but he was still bleeding. I couldn’t do anything with that, with him bleeding and clots coming out like that. So, I called the doctor and I called EMS (emergency medical services); so, I stayed there until the ambulance arrived and they took him to the nearest hospital. But [FM A] should have never cut that catheter. She should have just let that BN-A catheter stay in there and let us (nurses) take care of that. She should have never cut the BN-A catheter.” During an interview with RN B on 01/22/2026 at 11:44AM. SR inquired from RN B, was the patient and/or patient’s family members aware of how to take care of the BN-A catheter and/or how to remove one. RN B stated, “No. I don’t think anyone taught them how to care for it because the BN-A catheter is something that the hospice nurses care for not the patients. I would never tell any of my patients and/or any of their family members to pull a BN-A catheter out and/or cut it. Because doing any of that is too invasive, and there is no one way any of them unless they are nurses would be able to remove the BN-A catheter out right.” During an interview with RN C on 01/22/2026 at 11:49AM. SR inquired from RN C, can you tell me the last day that you provided care to patient #1. RN C stated, “I think I saw that patient on 10/05/2025. It was a Sunday I believe.” SR inquired further from RN C, are you the RN case manager for the patient. RN C stated, “No. It is [RN A].” During an interview with RN C on 01/22/2026 at 11:50 AM. SR inquired from RN C, what was the nature of the nurse’s visit. RN C stated, “[FM A] called, I think it was around one or something around because I remember I came back from church. So, she called, and she told me he came back from the hospital that he’s having pain in his side, and I asked her to give him morphine and to call me back if his pain symptom did not change. She said okay. She called me back saying that the morphine wasn’t working and that he still had pain in his bladder. So, I went home, and it was about a 2-hour drive and/or more to get there. So, when I got there, I let her know that the MD ordered for the BN-A to be discontinued. As soon as I removed the BN-A catheter, fluid continually flowed out that it soaked the bed, and his bladder was not as distended as it was before.” SR inquired further from RN C, did you see any bleeding. RN C stated, “I didn’t see any blood or anything. It was more like suprapubic (located in the lower abdomen just above the pubic bone) pressure that I saw.”During an interview with RN A on 01/22/2026 at 2:13PM. SR inquired from RN A, when was the last time you saw the patient and what was going on around that time frame. RN A stated, “… From what I can recall, um [patient #1] had cancer. He was bed bound by the time that he came to Hospice. He was complaining of having to urinate and he couldn’t urinate they (patient #1 and FM A) both agreed to do remove the BN-A. I walked FM A through the steps of how to remove a BN-A over the phone. Everyone always thinks that removing a BN-A is hard, but it is not. She said nothing was coming out and might be obstructed somehow. So, I thought that it might be obstructed because of a blood clot. So, I told FM A to just cut the catheter to clear the clot. I think over the weekend he went to the hospital, he was gone and then he came back and then when I did a follow-up, she was mad at the hospital, she was mad at Hospice, she was mad at the whole world. And I got it because her husband is dying. And she told me, you know what bad experience she had at the hospital. Bad experience she was having with Hospice coming out and. I told her, I said, well, I said, I will increase the frequency of the nursing visits. I’ll start coming out more often. To provide him a little bit more comfort measures and you know, just trying to actively listen to her and talk to her, so that she can grief appropriately. When I left, I thought everything was good. She seemed to be more at ease. So, when I left, I called the office, I talked to the scheduler and said go ahead and increase the nurse visits. Said he is declining more. She’s, you know, going to need more help. And so, when I called the office when they said we’ll never mind, she’s already called another Hospice, she’s going with another Hospice, and she did. But what’s so crazy was that she never mentioned any of that when I was talking to her so. That’s all I can remember.” During an interview with SUP Nurse on 01/22/2026 at 2:33PM. SR inquired from SUP, what was the account of the events from 10/04/25 to 10/06/25. SUP Nurse stated, “…So the COMP had originally called the concern into our home health side because the patient was originally from our home health side. So, they (patient and FM A) had an established relationship with the home health nurses in the Location A area. They were calling their concerns into [Agency A] rather than the hospice. I got into the mix because they called the Executive Director (ED) on the home health side and the ED called me saying that the [Agency A] had a problem for [Hospice A] and the ED was trying to reach the Hospice ADM but at the time could not get ahold of her. So, the ED called me instead. What I came to know was that the patient had some issues with the BN-A catheter. Having some probable issues with urinary retention. So, I called the ADM and asked the ADM, if we can get a nurse to go out and address those concerns. But in hindsight, [SR] I should have asked the ED to just go and assess the situation, since the ED was bit closer to the patient’s home.” During an interview with SUP Nurse on 01/22/2026 at 2:38PM. SR inquired from SUP Nurse, who was the nurse that was called to go and help the patient with the patient’s concerns on 10/04/2025. SUP Nurse stated, “If I recall correctly, I believe it was [RN B], and the nurse in that area would be [RN A].” SR inquired further from the SUP Nurse, who was the RN case manager for the patient. SUP Nurse stated, “The nurse assigned to the patient would be [RN A].” During an interview with SUP Nurse on 01/22/2026 at 2:40PM. SR inquired from SUP Nurse, when a patient has any change in health condition, such as an increase in pain; what should the hospice do. SUP Nurse stated, “We generally send a nurse right away. But I think that hospice nurses have different modalities and sometimes they can do assessments over the phone.” During an interview with SUP Nurse on 01/22/2026 at 2:42PM. SR inquired from SUP Nurse, can you tell me how as to why the Hospice would assign nurses that are further out from the patient. SUP Nurse stated, “So you know we have a 50-mile rule, right? Because we feel like we can get there within a timely manner. You know, it’s generally the weekends, it’s who is on call. And it was more than likely that [RN A] may not have been, you know, on-call she might have been on vacation or PTO (paid time off) or something like that. And that would have caused negotiation between the other nurses to have had to now make that long transport. We try again to make sure the nurse that’s the closest to the patient goes and takes care of that patient. But sometimes that option is not available. And so, it does put us in a position that we’ve really struggled with that to talk about what’s reasonably kind of said that 50-mile rule because you can get there within a pretty good decent time.” During an interview with SUP Nurse on 01/22/2026 at 2:45PM. SR inquired from SUP Nurse, Why did it take so long for any nurse to come out and provide care for patient #1. SUP Nurse stated, “I believe it is because we assumed that when we gave the instruction that if he continues to have discomfort, for FM A to give him his pain medication. If the medication doesn’t work and he’s still uncomfortable, for FM A to call us back and then we (myself and the ADM) will send a nurse to get in route. And when we didn’t hear from them, we probably should have made a follow-up phone call. To see right, that it was done but we didn’t do that because when we didn’t hear back from them, we assumed that the patient was resting comfortably…” During an interview with SUP Nurse on 01/22/2026 at 2:48PM. SR inquired from SUP Nurse, who is the individual or the person that supervises the provision of nursing throughout the hospice. SUP Nurse stated, “So I’m on the license as a supervising nurse and [Alt ADM/ Alt SUP Nurse] is the backup supervising nurse.” SR inquired further from the SUP Nurse, who is the individual responsible for the policies and procedures being implemented accordingly throughout the Hospice. SUP Nurse stated, “That would be our compliance department.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:53PM. SR inquired from Alt ADM/ Alt SUP Nurse, what was the account of the events from 10/04/25 to 10/07/25. Alt ADM/ Alt SUP Nurse stated, “I was on leave around that timeframe. When I came back from leave was when I heard in IDG (interdisciplinary group) the issues that the nurses were having with the patient.” SR inquired further from the Alt ADM/ Alt SUP Nurse, what were the issues the nurses were having with the patient. Alt ADM/ Alt SUP Nurse stated, “the issues were with BN-A and the bleeding because [FM A] removed the BN-A catheter solely by herself. But I never saw him, never spoke with him or [FM A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:55PM. SR inquired from Alt ADM/ Alt SUP Nurse, the SUP Nurse stated that you’re the alternate supervising nurse, correct? Alt ADM/ Alt SUP Nurse doesn’t answer but nodded her head yes. SR inquired further from Alt ADM/ Alt SUP Nurse, who is the individual that is to ensure that the policies and procedures of the agency are being implemented accordingly? Alt ADM/ Alt SUP Nurse stated, “that would be [ADM].” SR inquired further from Alt ADM/ Alt SUP Nurse, who was the RN case manager for the patient. Alt ADM/ Alt SUP Nurse stated, “That would have been [RN A].” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:57PM. SR inquired from Alt ADM/ Alt SUP Nurse, who handles the coordination of care/services when it comes to the supervision of the nurses. Alt ADM/ Alt SUP Nurse stated, “Probably [SUP Nurse].” SR inquired further from Alt ADM/ Alt SUP Nurse, when the nurse has any type of concern, who is the nurse to report to. Alt ADM/ Alt SUP Nurse stated, “A lot of them do come to me because I have a lot of experience. But to say they are actually assigned to report to me, I would say no. But they do come to me a lot. But SUP Nurse is over all the nurses.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 2:59PM. Alt ADM/ Alt SUP Nurse stated, “I can only tell you what I know. And there have been a lot of changes in staffing around here too, which has made things more difficult. The DON (Director of Nursing) just up a quit three weeks and I don’t really understand what all happened because I thought she was good at what she was doing so… That was the person who everyone was going to be the DON.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:03PM. SR inquired from Alt ADM/ Alt SUP Nurse, so when the DON left and there was a gap in supervision, what you are saying is that the nurses began to report to you. Alt ADM/ Alt SUP Nurse stated, “I was not told that. They (the nurses) just do it. They just report to me. The hospice is currently looking for one.” SR inquired further from the Alt ADM/ Alt SUP Nurse, so although you are the Alt ADM/ Alt SUP Nurse are you saying that you don’t have a clue as to what is going on at this hospice. Alt ADM/ Alt SUP Nurse stated, “Yes. I don’t know.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:06PM. SR inquired from Alt ADM/ Alt SUP Nurse, what are your roles and responsibilities as an administrator. Alt ADM/ Alt SUP Nurse stated, “At this time, just to be here to support the nurses. To go out and see the patients that they’re having difficulties with, that they need help with… Contact the doctors when there are problems and we need medication changes or having issues with the patient. To help write some orders when the nurses call and say hey, you know, this patient needs an extra visit and write the orders for that.” During an interview with Alt ADM/ Alt SUP Nurse on 01/22/2026 at 3:07PM. SR inquired from Alt ADM/ Alt SUP Nurse, who is to ensure that the policies and procedures are implemented throughout the Hospice. Alt ADM/ Alt SUP Nurse stated, “The ADM.” SR inquired further from the Alt ADM/ Alt SUP Nurse, are not an additional ADM. Alt ADM/ Alt SUP Nurse stated, “I am. I have not been given those duties.” During an interview with ADM on 01/22/2026 at 3:31PM. SR inquired from the ADM, what was the account of the events from 10/04/25 to 10/07/25. ADM stated, “The biggest challenge that I think that we had with communication as far as this family goes is they (patient #1 FMs) continued to call the home health nurse side. So, they were originally from our home health service, out of the Location A office. So, they were calling that home health nurse directly instead of calling the 800 number (the hospice’s main number). So, when we finally got a call on 10/05/2025 around 10AM or so from the on-call staff that they needed somebody to come out, that’s when we went out. [RN C] did go out and do a visit on 10/05/2025… I know that previous day on 10/04/2025, they (patient #1’s FMs) had sent him to the ER under the MD’s recommendation and the nurse that was out there was [RN B]… and so, by the time [RN B] got that second call. You know, it was already 7:30PM in the evening, so that’s what made the visit so late on 10/04/2025. But after that visit, I know [RN A] went out to do the visit the next day (on 10/06/2025) and she asked the family, you know, would you like me to increase frequency? Would you like me to know, get some additional support here. And the family was agreeable and the very next day they transferred to another service, which is certainly their right to do… One of the things that I feel like are the reasons I feel like that they ended up transferring was because they wanted somebody local and they felt like maybe they would receive a better response time… We (ADM team) would have gotten that a little bit quicker than getting it (the initial call) from individual nurses. Yeah, so. I hope that wasn’t a delay in care, but that’s my only reasoning for thinking that it might have been so, or that they (FMs of patient #1) might not have felt as supported.” During an interview with ADM on 01/22/2026 at 3:40PM. SR inquired from the ADM, are you aware of any nurses walking a patient over the phone on how to remove BN-A catheter. ADM stated, “I am personally not aware. I don’t know if I would be as I’m not a clinician. So, you know, that’s not really something that would have come to my attention. I would discourage that. 100%. Even as a non-clinician, I would discourage that because count as an invasive procedure.” During an interview with ADM on 01/22/2026 at 3:41PM. SR inquired from the ADM, who is responsible for ensuring that the policies and procedures of the Hospice is implemented accordingly. ADM stated, “Myself with in conjunction with compliance.” SR inquired further from the ADM, what is the roles and responsibilities of the ADM. ADM stated, “… Just the oversight of the entire program… making sure that we’re following the policies and procedures, making sure that on call rotations or cover on call is followed through that. If there are things that need to be. Followed up on complaints, concerns, patient questions, family questions, caregiver questions, things like that…” Record review of the agency’s policy manual included a policy entitled, “Policy: Medical Record Content Hospice” with an effective date of 07/13/2022 unrevised reads in part, “Policy: The Agency will provide an accurate and current medical record for every patient seen by the Agency. Purpose: To ensure documentation of patient status, home care services and outcomes. Procedure… 3. Each patient’s clinical record includes, at a minimum, the following… • the initial plan of care and updated plans of care… • documentation of the patient’s responses to medications, symptom management,• treatments and services;• outcome measure data elements… • signed physician orders…” Record review of Title 42, Chapter IV, Subchapter B, Part 418, Subpart C, §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services up to date as 02/13/2026 reads in part, “The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified i n the comprehensive assessment as such needs relate to the terminal illness and related conditions… (c) Standard: Content of the plan of care. The hospice must develop an individualized written plan of care foreach patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:(1) Interventions to manage pain and symptoms.(2) A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.(3) Measurable outcomes anticipated from implementing and coordinating the plan of care.(4) Drugs and treatment necessary to meet the needs of the patient.(5) Medical supplies and appliances necessary to meet the needs of the patient.(6) The interdisciplinary group’s documentation of the patient’s or representative’s level ofunderstanding, involvement, and agreement with the plan of care, in accordance with the hospice’s own policies, in the clinical record…””

“It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) applicable clinical records of patients who elected hospice services after the date of the last site visit 2/29/2024, the hospice did not ensure the hospice RN implemented the interdisciplinary plan of care. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. There was no documented initial hospice interdisciplinary plan of care until the first scheduled IDG meeting plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. Physician’s orders were documented on 3/14/2024 for medications. The initial nursing assessment on 3/14/2024 documented the identified nursing care plan problems, goals, and interventions that did not get on the hospice interdisciplinary (IDG) plan of care until the first scheduled IDG meeting plan of care. The first interdisciplinary (IDG) hospice plan of care was established at the first IDG meeting on 3/21/2024 and did not include staff visit frequencies. The next IDG hospice plan of care was dated 4/4/2024 and did not include staff visit frequencies. Clinical Record 2: The patient elected the hospice benefit on 4/8/2024. There was no documented initial hospice interdisciplinary plan of care and/or physician’s orders for nursing visit frequencies. The initial nursing assessment on 4/8/2024 documented the identified nursing care plan problems, goals, and interventions that did not get documented on a hospice interdisciplinary plan of care. No documented IDG plan of care since the first IDG meeting had occurred. A review of the electronic medical record (EMR) visit calendar identified scheduled nursing visits. A physician’s order for medications was documented on 4/8/2024. Clinical Record 5: The patient elected the hospice benefit on 3/16/2024. There was no documented initial hospice interdisciplinary plan of care until the first scheduled IDG meeting plan of care on 3/25/2024. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide, nursing, and spiritual counselor visits. Physician’s orders were documented on 3/16/2024 for medications. The initial nursing assessment on 3/16/2024 documented the identified nursing care plan problems, goals, and interventions that did not get on the hospice interdisciplinary (IDG) plan of care until the first scheduled IDG meeting plan of care dated 3/25/2024. The first IDG hospice plan of care was established at the first IDG meeting on 3/25/2024 and included spiritual counselor visit frequency and did not include nursing and aide visit frequencies. The next IDG hospice plan of care dated 4/8/2024 included spiritual counselor visit frequency and did not include nursing and aide visit frequencies. During an interview on 4/12/2024, the VP of Compliance stated, “Before we implemented this new electronic medical record (EMR) format in January 2/2024, we used to do an initial plan of care on admission to the hospice which included the staff visits frequency orders”, “We have calls out to the EMR company to assist us in locating the missing hospice plan of care to include staff visit frequency orders”, “I can only pull up the first IDG plan of care at the first scheduled IDG meeting and I see the missing staff visit frequencies on the IDG meeting plans of care”, and “The orders for the staff visit frequencies must be in the EMR since the staff visits are on the EMR calendar but I cannot see the hospice plan of care until the first IDG meeting” and “I have several calls out to the (EMR company) to be able to see the missing orders and initial plans of care which contain the visit frequencies”. THIS IS A CONTINUED REQUIRED ACTION. During an interview on 4/12/2024, the VP of Compliance stated, “Before we implemented this new electronic medical record (EMR) format in January 2/2024, we used to do an initial plan of care on admission to the hospice which included the staff visits frequency orders”, “We have calls out to the EMR company to assist us in locating the missing hospice plan of care to include staff visit frequency orders”, “I can only pull up the first IDG plan of care at the first scheduled IDG meeting and I see the missing staff visit frequencies on the IDG meeting plans of care”, and “The orders for the staff visit frequencies must be in the EMR since the staff visits are on the EMR calendar but I cannot see the hospice plan of care until the first IDG meeting” and “I have several calls out to the (EMR company) to be able to see the missing orders and initial plans of care which contain the visit frequencies”.”

“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: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) clinical records reviewed, the hospice did not ensure the plan of care and/or physician’s orders contained a detailed statement of the scope and frequency of services for hospice staff visiting the patient. Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. There were no documented nursing and aide visit frequencies on an order, a hospice plan of care, and/or an IDG plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. No interdisciplinary (IDG) hospice plan of care was established on admission on 3/14/2024 and there were no documented physician’s orders to include staff visit frequencies. A physician’s order for medications was documented on 3/14/2024. The first interdisciplinary (IDG) hospice plan of care was established at the first IDG meeting on 3/21/2024 and did not include staff visit frequencies. The next IDG hospice plan of care was dated 4/4/2024 and did not include staff visit frequencies. Clinical Record 2: The patient elected the hospice benefit on 4/8/2024. There were no documented nursing visit frequencies on a physician’s order or a hospice plan of care. No IDG plan of care since the first IDG meeting had occurred. review of the electronic medical record (EMR) visit calendar identified scheduled nursing visits. A physician’s order for medications was documented on 4/8/2024. Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. For nursing and aide visit frequencies during the dates of service reviewed 3/1/2024 through 4/1/22024, there were no documented nursing and aide visit frequencies on an order, a hospice plan of care, and/or an IDG plan of care. A review of the electronic medical record (EMR) visit calendar identified scheduled hospice aide and nursing visits. During the dates of service reviewed, the IDG plans of care dated 3/11/2024, 3/25/2024, and 4/8/2024 did not include nursing and aide visit frequencies. During an interview on 4/12/2024, the VP of Compliance stated, “On these clinical records of patients that were on service in January 2024 when we implemented the new electronic medical record (EMR) system, we needed to re-entry all the information, orders, and plans of care into the new EMR system”, and “I can only see the staff visit frequencies on the visit calendar in the EMR and I cannot see or open an order or a plan of care to see the staff visit frequencies.” During an interview on 4/12/2024, the VP of Compliance stated, “We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician’s order, a hospice plan of care or an IDG plan of care”, “I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician’s order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies”, “I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies”, and “Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies”. During an interview on 4/12/2024, the VP of Compliance stated, “We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician’s order, a hospice plan of care or an IDG plan of care”, “I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician’s order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies”, “I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies”, and “Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies”.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) applicable clinical records of patients receiving hospice aide services at the time of review, the agency did not ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide. THIS IS AN CONTINUED REQUIRED ACTION The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that “... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide’s services are reviewed in the IDG (Interdisciplinary Group Meeting), and included in the patient’s plan of care...” Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of three times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/14/2024 did not include the assigned task of bathing the patient. The RN’s supervisory visits dated 3/28/2024 and 4/8/2024 included, “Hospice aide responsibilities: bathing”. Specific instructions to the aide for bathing the patient were not documented on the aide plan of care until the aide plan of care was updated on the date of review 4/11/2024. During an interview on 4/12/2024, the VP of Compliance stated, “We have a new electronic medical record (EMR) format that we implemented in January 2024 and I cannot pull up the missing staff visit frequencies on a physician’s order, a hospice plan of care or an IDG plan of care”, “I can only see the staff visit frequencies on the electronic medical record visit calendar so the order must be in the system, but I cannot pull up or see a physician’s order, a hospice plan of care, or an IDG plan of care that contains the missing staff visit frequencies”, “I have several calls out to the (EMR company) to be able to see the missing orders and plans of care which contain the visit frequencies”, and “Before we implemented this new EMR format, we used to do an initial plan of care that included staff visit frequencies”. During joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, the aide plans of care are not specific to the tasks that the aides need to perform”, “The RN is documenting aide responsibilities in the supervisory visits that do not match the tasks on the aide plan of care”, “We assigned our aide scheduler to do aide plan of care audits and we knew from the audit findings that we still needed to work on the aide plans of care”, “We have new nurses in the field and we now have the new QAPI Coordinator that training nurses in the field”, and “Each morning during standup report, I am doing training with the nurses on what is expected in the aides’ plan of care”. THIS IS AN CONTINUED REQUIRED ACTION. During joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, the aide plans of care are not specific to the tasks that the aides need to perform”, “The RN is documenting aide responsibilities in the supervisory visits that do not match the tasks on the aide plan of care”, “We assigned our aide scheduler to do aide plan of care audits and we knew from the audit findings that we still needed to work on the aide plans of care”, “We have new nurses in the field and we now have the new QAPI Coordinator that training nurses in the field”, and “Each morning during standup report, I am doing training with the nurses on what is expected in the aides’ plan of care”. The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that “... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide’s services are reviewed in the IDG (Interdisciplinary Group Meeting), and included in the patient’s plan of care...””

“It is required that a hospice aide provides service ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) applicable clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided visits and/or tasks as ordered by the Interdisciplinary Group and included in the plan of care. THIS IS AN CONTINUED REQUIRED ACTION. The policy “Timely Submission of Patient Documentation”, (Reference #11.05.1) effective 03/21/2021, included, in part, “The agency will ensure timely and proper submission of patient documentation, Clinical documentation will be complete and submitted within 24 hours from patient encounter...”. The hospice’s policy “Hospice Aide Supervision”, (Reference #14.21.1) effective 07/13/2022, included, in part, “...The supervisory visits are documented in the patient’s clinical record every two weeks and include notations whether the aide is following the patient’s plan of care...”. Clinical Record 1: The patient elected the hospice benefit on 3/14/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of three times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/14/2024 included, in part, the assigned tasks of “Temperature” (T), “pulse” (P), “respirations” (R), “blood pressure” (BP), “pulse oximetry”, and “weight”. During the dates of service reviewed, the hospice aide visit notes dated 3/15/2024, 3/18/2024, 3/20/2024, 3/25/2024, 3/27/2024, and 3/29/2024 included a “checkmark” as “completed” for the assigned tasks of “Temperature” (T), “pulse” (P), “respirations” (R), “blood pressure” (BP), “pulse oximetry”, and “weight”. There were no TPR, BP, weight, or pulse oximetry results documented by the hospice aide in the clinical record. Additionally, a review of the clinical record revealed missing hospice aide visit notes to review after 3/29/2024. Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 12/29/2023 included, in part, the assigned tasks of, “Barrier products (specify)”, “range of motion (specify)”, “fall precautions (specify)”, and “Tasks: height and weight, special tasks, and No Tasks”. The hospice aide’s care plan was not specific and did not specify the barrier products, range of motion, fall precautions, special tasks, or instructions on what “no tasks” were to be performed by the aide. During the dates of service reviewed, the clinical record was missing one visit for 3/16/2024. The aide visit was scheduled for 3/15/2024 and moved per request to 3/16/2024. Additionally, there were two missed aide visits the week of 3/18/2024 (scheduled on the visit calendar for 3/18/2024 and 3/19/2024). There was no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. Additionally, a clinical record review revealed missing hospice aide visit notes after 3/28/2024. Additionally, the hospice aide visit notes dated 3/20/2024, 3/21/2024 3/22/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, and 4/2/2024 included a “checkmark” as “not completed” for the assigned tasks of “Barrier products”, “specify)”, “range of motion”, “fall precautions”, “height and weight”, “special task” and the assigned “No Tasks”. There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide’s plan of care tasks was not completed. Clinical Record 6: The patient elected the hospice benefit on 3/22/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/22/2024 included, in part, the assigned tasks of, “Temperature” (T), pulse” (P), “respirations” (R), “blood pressure” (BP), and “pulse oximetry”. During the dates of service review, a clinical record review revealed four missing hospice aide visit notes for the weeks of 3/25/2024 and 4/1/2024. There was no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. Additionally, the hospice aide visit note dated 4/8/2024 included a “checkmark” as “not completed” for the assigned tasks of “TPR, BP, and pulse oximetry” and no TPR, BP, and/or pulse oximetry was documented by the hospice aide. There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide’s plan of care tasks was not completed. Additionally, the hospice aide visit notes dated 3/23/2024, 3/25/2024, and 4/5/2024 included a “checkmark” as “completed” for the assigned tasks of “TPR, BP, and pulse oximetry” and no TPR, BP, and/or pulse oximetry results were documented by the hospice aide. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, the aides are not documenting all the tasks as assigned on the aide plan care and there is no documentation that the aides communicated with the RN as to why the assigned tasks were not performed”, “The missing aide visit notes are not documented in the clinical record”, “I do not see the aide missed visit reports, orders and/or a plan of care for the missing aide visit notes”, “We assigned our aide scheduler to do aide visit note audits and we know from our audit results that we still needed to work on the aide visit notes”, “We have a new electronic medical record format since January 2024 and I cannot pull up the missing aide visit frequencies on an order, hospice plan of care or an IDG plan of care, I can only see the aide visit frequencies on the electronic medical record visit calendar”, “We have new nurses in the field and we now have the new QAPI Coordinator for the past 2 weeks that is training staff in the field”, and “Each morning during standup report, I am doing training with the nurses and aides on what is expected in the aide visit notes”. THIS IS AN CONTINUED REQUIRED ACTION. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, the aides are not documenting all the tasks as assigned on the aide plan care and there is no documentation that the aides communicated with the RN as to why the assigned tasks were not performed”, “The missing aide visit notes are not documented in the clinical record”, “I do not see the aide missed visit reports, orders and/or a plan of care for the missing aide visit notes”, “We assigned our aide scheduler to do aide visit note audits and we know from our audit results that we still needed to work on the aide visit notes”, “We have a new electronic medical record format since January 2024 and I cannot pull up the missing aide visit frequencies on an order, hospice plan of care or an IDG plan of care, I can only see the aide visit frequencies on the electronic medical record visit calendar”, “We have new nurses in the field and we now have the new QAPI Coordinator for the past 2 weeks that is training staff in the field”, and “Each morning during standup report, I am doing training with the nurses and aides on what is expected in the aide visit notes”. The policy “Timely Submission of Patient Documentation”, (Reference #11.05.1) effective 03/21/2021, included, in part, “The agency will ensure timely and proper submission of patient documentation, Clinical documentation will be complete and submitted within 24 hours from patient encounter...”. The hospice’s policy “Hospice Aide Supervision”, (Reference #14.21.1) effective 07/13/2022, included, in part, “...The supervisory visits are documented in the patient’s clinical record every two weeks and include notations whether the aide is following the patient’s plan of care...”.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) applicable clinical records of patients receiving hospice aide service, the hospice did not ensure the RN documented supervisory visits at least every 14 days and/or the RN documented the assessment of the quality of care and services provided by the hospice aide and that services meet the patient’s need. THIS IS AN CONTINUED REQUIRED ACTION. The agency policy “Hospice Aide Supervision”, (#14.21.1) effective 07/13/2022, included, in part, “... A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need...The supervisory visits are documented in the patient’s clinical record every 2 weeks...”. The hospice’s policy “Timely Submission of Patient Documentation”, (Reference #11.05.1) effective 03/12/2021, included, in part “The agency will ensure the timely and proper submission of patient documentation...Clinical documentation will be complete and submitted within 24 hours from the patient encounter...”. Clinical Record 4: The patient elected the hospice benefit on 12/25/2023. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. The hospice aide plan of care dated 12/29/2023 included the assigned tasks of “barrier products (specify)”, “ROM (specify)”, “fall precautions (specify)”, and “TASKS: height, weight, special tasks, NO tasks”. The hospice aide plan of care did not provide specific instructions to the aide for the barrier product to use, the specified ROM (range of motion), fall precautions, and special tasks to provide, and did not specify the “no tasks” to not perform. During the dates of service reviewed, the clinical record was missing one visit for 3/16/2024. The aide visit was scheduled for 3/15/2024 and moved per request to 3/16/2024. Additionally, there were two missed aide visits the week of 3/18/2024 (scheduled on the visit calendar for 3/18/2024 and 3/19/2024). There were no documented missed aide visit reports, orders, and/or hospice plans of care for the missed aide visits. A clinical record review also revealed missing hospice aide visit notes after 3/28/2024. Additionally, the hospice aide visit notes dated 3/20/2024, 3/21/2024 3/22/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, and 4/2/2024 included a “checkmark” as “not completed” for the assigned tasks of “Barrier products”, “specify)”, “range of motion”, “fall precautions”, “height and weight”, “special task” and the assigned “No Tasks”. There was no documentation in the clinical record that the hospice aide communicated with the RN about why the aide’s plan of care tasks were not completed. During the dates of service reviewed, the RN documented the hospice aide supervisory visits on 3/16/2024 and 3/29/2024. A review of the RN’s supervisory visit documentation for the hospice aide dated 3/16/2024 included, “Hospice aide responsibilities: TPR”, which was not included in the aide plan of care. The RN’s supervisory visit for the aide dated 3/29/2024 included, “Hospice aide responsibilities: TPR and BP”, which was not included in the aide plan of care. The RN’s supervisory visits documentation included, “following the aide plan of care” and “no changes to the aide plan of care”. There was no RN documentation as to why the tasks assigned on the aide plan of care were not completed by the aide and why the fall precautions, ROM, height, weight, special tasks, and NO tasks” were not documented as performed by the hospice aide. Clinical Record 6: The patient elected the hospice benefit on 3/22/2024 and was transferred to another hospice on 4/9/2024. A review of the clinical record revealed no documented aide visit frequency on an order, the hospice plan of care, and/or an IDG plan of care. The electronic medical record visit calendar identified the hospice aide visit frequency of five times a week. A review of the clinical record revealed that the hospice aide plan of care dated 3/22/2024 included, in part, the assigned tasks of, “Temperature” (T), pulse” (P), “respirations” (R), “blood pressure” (BP), and “pulse oximetry”. The hospice aide visit note dated 4/8/2024 included a “checkmark” as “not completed” for the assigned tasks of “TPR, BP, and pulse oximetry” and no TPR, BP, and/or pulse oximetry was documented by the hospice aide. The hospice aide visit notes dated 3/25/2024 and 4/5/2024 included a “checkmark” as “completed” for the assigned tasks of “TPR, BP, and pulse oximetry”, and no TPR, BP, and/or pulse oximetry results were documented by the hospice aide. There was no documentation in the clinical record that the hospice aide communicated with the RN as to why the aide’s plan of care tasks were not completed and documented. During the dates of service review, a clinical record review revealed four missing hospice aide visit notes for the weeks of 3/25/2024 and 4/1/2024. The hospice aide’s first visit was dated 3/23/2024. There were no documented RN supervisory visits for the hospice aide from 3/23/2024 through the date of discharge 4/9/2024. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, I do not see the missing RN supervisory visits for the hospice aide and I opened up each RN visit note to try and find the missing aide supervisory notes”, “I see the RN is documenting aide responsibilities in the supervisory visit note that did not get on the aide plan of care”, and “Yes, the RN is documenting in the supervisory visit note that the aide plan of care is being followed when the tasks assigned on the aide plan of care are not completed”. THIS IS AN CONTINUED REQUIRED ACTION. During a joint clinical record review and interview on 4/12/2024, the VP of Compliance stated, “Yes, I do not see the missing RN supervisory visits for the hospice aide and I opened up each RN visit note to try and find the missing aide supervisory notes”, “I see the RN is documenting aide responsibilities in the supervisory visit note that did not get on the aide plan of care”, and “Yes, the RN is documenting in the supervisory visit note that the aide plan of care is being followed when the tasks assigned on the aide plan of care are not completed”. The agency policy “Hospice Aide Supervision”, (#14.21.1) effective 07/13/2022, included, in part, “... A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need...The supervisory visits are documented in the patient’s clinical record every 2 weeks...”. The hospice’s policy “Timely Submission of Patient Documentation”, (Reference #11.05.1) effective 03/12/2021, included, in part “The agency will ensure the timely and proper submission of patient documentation...Clinical documentation will be complete and submitted within 24 hours from the patient encounter...”.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) applicable clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient’s discharge summary was forwarded to the Medicare-certified facility upon discharge. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 7: The patient elected hospice on 11/3/2023 and was live discharged to a non-contracted Medicare hospital on 4/9/2024. A review of the clinical record identified a discharge summary which was dated 4/9/2024. There was no documented evidence that the discharge summary was forwarded to the receiving facility. During an interview on 4/12/2024, the VP of Compliance stated, “I do not see a note or documentation in the clinical record that the discharge summary was forwarded to the facility” and “I checked with the person who forwards the documents to the facilities and confirmed that a copy of the discharge summary was not sent to the facility. THIS IS A CONTINUED REQUIRED ACTION.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) applicable live discharged patients, the hospice did not ensure the discharge summary contained all the required elements. THIS IS A CONTINUED REQUIRED ACTION. Clinical Record 7: The patient elected hospice on 11/3/2023 and was live discharged to a non-contracted Medicare hospital on 4/9/2024. A review of the clinical record identified a discharge summary which was dated 4/9/2024. There was no documented evidence that the discharge summary also included the required elements of the hospice plan of care and the latest physician’s orders. During an interview on 4/12/2024, the VP of Compliance stated, “The discharge summary format does not include the hospice plan of care and physician’s orders, “I checked with the person who usually forwards the documents to the facilities and confirmed that a copy of the discharge summary, the hospice plan of care and orders were not sent to the facility”, and “On the other patient’s chart we reviewed, we found copies of the hospice plan of care and orders that were sent along with the discharge summary to another facility”. THIS IS A CONTINUED REQUIRED ACTION.”

“It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the medication profile included all of the patient’s current prescription and over the counter (OTC) drugs [HCPC. 15. I/L530]; and Failed to ensure that the patient’s updated comprehensive assessment was completed by all members of the Interdisciplinary Group and included documentation of the patient’s response to care and/or progress toward identified goals{HCPC.17. I/L533}; Failed to ensure that the Registered Nurse ensured the implementation and coordination of the patient’s plan of care and provided continuous assessment of the patient’s and family’s needs {HCPC.19. I/L540}; and Failed to ensure that every member of the Interdisciplinary Group completed the Initial Assessments within five days of the patient’s election of hospice care {HCPC.9. I/L523}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section. Hospice aide provides services; ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide {HCDT.15. I/L625}; Failed to ensure that the Hospice Aide completed visits and/or documented those visits in the same frequency as the patient’s Plan of Care ordered {HCDT.16. I/L626}; and Failed to ensure that the RN documented supervision of the Hospice Aide every fourteen days {HSRM.25. I/L629}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure that every member of the Interdisciplinary Group completed the Initial Assessments within five days of the patient’s election of hospice care. Comprehensive Assessment of Patient (Reference #14.16.1) effective date of 07/13/2022, “...The hospice IDG (Interdisciplinary Group) conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care, including medical, nursing, psychosocial, emotional, and spiritual care...The comprehensive assessment is competed by the designated members of the IDG ... no later than five calendar days after the patient elects the hospice benefit...Each member of the IDG provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient...” Clinical Record 1: The patient elected the hospice benefit on 01/20/2024. The Initial Chaplain Assessment was not documented until 01/27/2024 - 7 days after admission. There was nothing noted in the Chaplain’s assessment documentation as to why the visit was postponed. There was no missed visit documented and nothing noted in the Interdisciplinary Group Meeting 01/26/2024 regarding the delay. Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. The first Chaplain visit was not documented until 01/30/2023. The noted documented 01/30/2023 included no reason the Initial Assessment was postponed outside the five-day regulation. There was no missed visit documented. The Interdisciplinary Group Meetings documented 01/23/23 and 02/06/2023 included no documentation for the delay in the initial Chaplain visit. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The Initial Chaplain Assessment was not documented until 9 days after admission on 12/27/2022. There was no communication note, no missed visit, and no documentation in the Interdisciplinary Group Meetings 12/27/2022 or 01/09/2023 regarding the delay. During an interview with the Director of Nursing (DON) on 02/29/2024, it was confirmed there was no documented reason noted for the delay of the initial assessment visit outside the five-day regulatory window.”

“It is required that the medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 13 of 19 (68%) clinical records reviewed revealed that the agency did not ensure that the patient’s medication profile review was documented at least every fifteen days. Agency policy: Hospice Medication Profile (Reference #14.14.1) effective 07/13/2022 read in part that “A patient-specific medication profile is maintained for each patient and reviewed, at minimum, every 15 days...The patient’s medication profile must be reviewed by the IDG (Interdisciplinary Group) whenever there is a significant change and, at a minimum, every fifteen days... The patient’s medication profile review includes, but is not limited to determining accuracy and completeness of the profile, monitoring medication effectiveness, actual or potential medication-related effects and untoward interactions...” Hospice Medication Management (Reference #14.13.1), effective 07/13/2022, included in part that “...A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ... Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 and 01/18/2024 included no medications listed or documented medication review. There was not another IDG meeting documented until 02/12/2024. There was no documented evidence of a medication review in the clinical record. Clinical Record 4: The patient elected the hospice benefit on 02/12/2023. As of 02/28/2024, there was a thirty-four-day gap between documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/18/2024. There was no medication review documented during this time period. The Interdisciplinary Group Meetings (IDG) documentation on 01/18/2024 and 02/01/2024 included no medications listed and no documented medication review. During this site visitor’s observation on home visit with the registered nurse (Personnel Record 5) on 02/28/2024, the patient’s son and primary caregiver brought the patient’s medications to the patient’s room for the RN to review. These medications included Quetiapine 50mg by mouth twice a day and what the son reported to be Hydrocodone/Acetaminophen. The Hydrocodone was in a bottle with a label completely faded without the patient’s name visible, the name of the medication, or the directions and frequency of use. There was no medication list in the patient’s home. When questioned, the RN responded she would have to print one but that I could look at the chart on her iPad. Upon record review, the patient’s medication list had documented both the Quetiapine 50mg by mouth twice daily and the Hydrocodone/Acetaminophen 5/325mg: one by mouth every four hours as needed for pain listed as discontinued. The nurse verified with the son that the patient was taking the Hydrocodone. There was no documented evidence of a medication review in the clinical record. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. A gap in documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/17/2024 in which no medication review was documented. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024, 01/29/2024, and 02/12/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, 01/29/2024, and 02/12/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024 and 01/17/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 9: The patient elected the hospice benefit on 12/23/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. The Interdisciplinary Group Meetings (IDG) held on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The Interdisciplinary Group Meetings (IDG) documentation on 01/05/2024, 01/17/2024, and 01/29/2024 included no medications listed or documented medication review. There was no documented evidence of a medication review in the clinical record. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. As of 02/28/2024, there was a thirty-seven-day gap between documented Interdisciplinary Group Meetings (IDG) from 12/11/2023 to 01/17/2024. No Medication review was documented during this time period. The Interdisciplinary Group Meetings (IDG) documentation on 01/17/2024 included no medications listed and no documented medication review. During interviews with the Director of Nursing and the Administrator on 02/27/2024, 02/28/2024, and 02/29/2024, there was ongoing discussion of the difficulties the hospice experienced when switching from one electronic medical record (EMR) to another as of 01/01/2024. In addition to the change in EMRs, there was a change in the Director of Nursing staff. I questioned if there were any backup paper Interdisciplinary Meeting minutes or documentation related to reviewed patients, updates to care plans, medication reviews, signatures, etc. There was mentioned a signature sheet from the Medical Director, but no documentation was produced by the end of the site visit.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 19 (74%) clinical records reviewed revealed the agency did not ensure that the patient’s updated comprehensive assessment was completed by all members of the Interdisciplinary Group and included documentation of the patient’s response to care and/or progress toward identified goals. Document 1: Hospice Updates (Reference #14.20.1) effective 07/13/2022 “The hospice’s IDG updates the comprehensive assessment and reassesses the patient’s response to care on a regular basis. A patient’s progress toward desired outcomes and response to care is reassessed as often as required by the patient’s condition but no less frequently than every 15 days. Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient’s plan of care as needed. Documentation of the IDG’s care planning meeting reflects the ongoing reassessment of the patent/family’s status and needs. Hospice Coordination of Services (Reference #14.7.1) effective 03/12/2021 “...The IDG meets regularly to provide care planning for the hospice’s patients/caregivers....All members of the IDG participate in care planning and document problems, interventions, goals, observations, and outcomes based on the assessed and reassessed needs of the patient/family...” Comprehensive Assessment of Patient (Reference #14.16.1) effective 07/13/2022 “...Each member of the IDG provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient...” Comprehensive Assessment - Patient Outcome Measure (Reference #14.19.1) effective 07/13/2022 “...The data collected from the patient’s comprehensive assessment is used to provide individualized care planning, appropriate interventions and for the coordination of services for each patient...” Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An Interdisciplinary Group Meeting (IDG) was held on 12/07/2024. There was a forty-five-day gap between the Interdisciplinary Group Meeting (IDG) documented on 12/07/2023 to the next IDG on 01/17/2024. There was no documented evidence on the IDG note dated 01/17/2024 that included notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented. It was only electronically signed (e-signed) by the RN and the LVN. There were no e-signatures by the Medical Director, Social Worker, or the Chaplain. Clinical Record 3: The patient elected the hospice benefit on 01/09/2023. There was a twenty-seven-day gap in IDG documentation 12/21/2023 to 01/17/2024. Then, there was a twenty-five-day gap in documented IDG meetings from 01/18/2024 to 02/12/2024. There was no documented evidence on the IDG not dated 01/17/2024 that included notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented and no electronic signatures from the Medical Director, RN, Social Worker, or the Chaplain. The IDG documented on 01/18/2024 included notes from the Chaplain, Social Worker and Volunteer Coordinator documenting the patient declined all those services. There were no medications listed and no medication review documented. There were no electronic signatures on the document from the team. The IDG documentation on 02/12/2024 included only the Social Worker and the LVN electronic signatures. Clinical Record 4: The patient elected the hospice benefit on 02/12/2023. A thirty-four-day gap in Interdisciplinary Group Meetings was documented from 12/11/2023 to 01/18/2023. The IDG documented on 01/18/2024 included no team notes or updates except for the Volunteer Coordinator and the Social Worker, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures from the Social Worker or Chaplain. The IDG documentation 02/01/2024 included no medications listed or reviewed and no electronic signatures from the Social Worker and Chaplain. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. A thirty-three-day gap in Interdisciplinary Group Meetings was documented from 12/11/2023 to 01/17/2023. The IDG documentation on 01/17/2024 included no medications listed or reviewed and no electronic signatures from the Social Worker or Chaplain. The IDG documentation on 01/29/2024 included no notes or updates from the team, medications listed or reviewed, and the only electronic signature was from the Social Worker. The IDG documentation on 02/12/2024 included only electronic signatures from the Social Worker and the LVN. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. Th IDG documentation on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed, or medication review documented. It was only electronically signed (e-signed) by the Social Worker. There were no e-signatures by the Medical Director, Nurse, or the Chaplain. The IDG documentation 01/17/2024 included notes from the Volunteer Coordinator’s initial notes. There was no documentation from the Nurse, Social Worker, or Chaplain or progress toward goals were documented. There were no e-signatures by the Medical Director, Nurse, Social Worker, or the Chaplain. The IDG note on 01/29/2024 lacked evidence of progress toward goals, medications, medication review and no updated information except for the nurse. There was no electronic signatures Medical Director, Nurse, Social Worker, or Chaplain. The IDG noted dated lacked a medication review and electronic signatures of the Medical Director, Nurse, Social Worker, or Chaplain. Clinical Record 7: The patient elected the hospice benefit on 12/18/2022. The IDG dated 01/05/2024 did not include any updated information from the team, no progress toward goals documented, no medications listed, or medication review documented. There were no e-signatures by the Medical Director, Nurse, Social Worker, or the Chaplain. The IDG dated 01/17/2024 included only notes from the Volunteer Coordinator and did not include any updated information from the team, no progress toward goals documented, no medications listed, or medication review documented. The only e-signature was the RN. The IDG dated 01/29/2024 included notes and updates from the Volunteer Coordinator and RN only. The only e-signature was by the RN. The Interdisciplinary Group Meeting (IDG) documented on 02/12/2024 included no electronic signatures of the Medical Director, Nurse, Social Worker, or Chaplain. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no note or update from the nurse. No Medications were listed, and no medication review was documented. The documented e-signature of the Social Worker was missing. The Interdisciplinary Group Meeting (IDG) held on 01/29/2024 included notes and updates from the Social Worker, and Volunteer Coordinator only. There were no updates from the other team member or progress toward goals documented, no medications listed or reviewed. The Social Worker did not electronically sign the document. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 9: The patient elected the hospice benefit on 12/23/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed, no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, no progress toward goals documented, no medications listed or reviewed, and no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team except for the Social Worker, no progress toward goals documented, no medications listed or reviewed, and no core team electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 02/12/2024 included no notes or progress toward goals documented, no medications listed or reviewed, only electronic signatures from the Social Worker and Hospice Aide. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. The Interdisciplinary Group Meeting (IDG) documented on 01/18/2024 included no medications listed and only electronically signed by the Chaplain and Nurse. The Interdisciplinary Group Meeting (IDG) documented on 02/01/2024 included no medications listed or reviewed and only electronically signed by the Nurse, Chaplain, and Nurse. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no medications listed and was missing the Medical Director and Chaplain’s electronic signatures. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included notes from the Nurse and the Volunteer Coordinator only, no notes or updates from the Social Worker or Chaplain, no progress toward goals documented, no medications listed or reviewed, and only electronically signed by the RN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no team notes or updates, no progress toward goals documented, no medications listed or reviewed, and no electronic signatures. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. There was a sixteen-day gap between the Interdisciplinary Group Meeting (IDG) documented on 11/21/23 to the next documented IDG on 12/07/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronic signatures from the RN and LVN. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team except the Volunteer Coordinator, and the nurse no progress toward goals documented, no medications listed or reviewed, only electronically signed by the RN and the LVN. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only electronic signatures by the RN and LVN. No Interdisciplinary Group Meeting minutes were produced on paper or scanned into the clinical record. Clinical Record 14: The patient elected the hospice benefit on 11/03/2023. The Interdisciplinary Group Meeting (IDG) documented on 01/05/2024 included no notes or updates from the team, no progress toward goals documented, no medications listed or reviewed, and only the electronic signatures of the RN and Social Worker. The Interdisciplinary Group Meeting (IDG) documented on 01/17/2024 included no notes or updates from the team. The notes documented were copied from the IDG notes from 01/05/2024. No progress toward goals was documented, no medications were listed or reviewed, and only the Social Worker’s electronic signature was documented. The Interdisciplinary Group Meeting (IDG) documented on 01/29/2024 included no notes or updates from the team. The notes documented were copied from the IDG on 01/05/2024. No progress toward goals documented, no medications listed or reviewed, and only the Social Worker’s electronic signature. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. A thirty-seven-day gap between Interdisciplinary Group Meetings (IDG) was documented from 12/11/2023 to 01/17/2024. The IDG Meeting documented on 01/17/2024 included a note from the Volunteer Coordinator and a note from the Nurse in which it was noted that the patient revoked the hospice benefit, which did not occur until 01/26/2024. There were no medications listed or reviewed and no electronic signatures. During interviews with the Director of Nursing and the Administrator on 02/27/2024, 02/28/2024, and 02/29/2024, there was ongoing discussion of the difficulties the hospice experienced when switching from one electronic medical record (EMR) to another as of 01/01/2024. In addition to the change in EMRs, there was a change in the Director of Nursing staff. I questioned if there were any backup paper Interdisciplinary Meeting minutes or documentation related to reviewed patients, updates to care plans, medication reviews, signatures, etc. The Administrator said there was a signature sheet from the Medical Director, but no documentation was produced by the end of the site visit.”

“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 6 of 19 (32%) clinical records reviewed revealed the agency did not ensure that the Registered Nurse ensured the implementation and coordination of the patient’s plan of care and provided continuous assessment of the patient’s and family’s needs. Agency policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 included in part that “The Agency will ensue the timely and proper submission of patient documentation ...Clinical documentation will be complete and submitted within 24 hours from patient encounter...” Clinical Record 3: The patient elected the hospice benefit on 01/09/2023 with the diagnosis of Liver Failure. There was an order documented on 01/01/2024 for RN visits every fourteen days. There was a sixteen-day gap in documented RN visits from 01/03/2024 to 01/19/2024. On 01/03/2024 the RN documented that the patient had 3+ non-pitting edema to the left lower extremity red scaly areas. The patient reported intermittent cramping to fingers and upper thighs. The patient walked with a shuffle and was a fall hazard. The patient reported pain in the left lower leg that is chronically swollen. The LVN documented on 01/23/2024 that the patient complained of pain to the left lower extremity and took Tramadol for the pain. The nurse reviewed medications with the patient and caregiver and instructed the patient to adhere to the pain medication regimen. Clinical Record 4: The patient elected the hospice benefit on 02/12/2024 with the diagnosis of Prostate Cancer. On 02/28/2024 review of the clinical recorded revealed there was not a Plan of Care in the EMR. Under the Assignments for the patient, there was a documented RN frequency of once a week visits. As of 02/28/2024, no RN visit was documented the week of 01/28/2024, and no missed visit was documented. On 01/18/2024, the RN documented that the nurse provided education of the disease process related to possible weight loss, nutrition, and hydration and that ongoing teaching needs will be assessed at each nursing visit. The nurse documented a review of the patient’s Hydrocodone and Quetiapine. On 01/25/2024, the RN noted that the patient used oxygen as needed and had an oxygen saturation of 95%. The caregiver reported that the patient’s appetite declined and only ate 10-20% of child-sized meals. The patient had an unsteady gait and used a walker on standby assist and the nurse provided education on fall prevention. The patient appeared to have anxiety during the nurses’ assessment, and the nurse educated the caregiver on the use of Lorazepam 1mg as needed. Then, on 02/07/2024, the nurse documented that the patient denied pain but did have occasional pain to his right knee that was managed with Hydrocodone. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023 with the diagnosis of Heart Failure. A Physicians Order on 01/01/2024 documented RN visits twice a week. The week of 01/01/2024 there was only one RN. The week of 01/07/2024, the patient was seen by the LVN, not the RN; the week of 01/14/2024 there was one RN visit documented. A Physician’s Order dated 01/20/2024 decreased the frequency of RN visits from twice to once a week. The week of 01/21/2024 there were no nursing visits documented. The last nursing visit documented was an RN visit on 01/29/2024. The RN documented in part during the RN visit on 01/02/2024 was “…wounds to right lower leg and left heel, pt has no open wounds to bil buttocks pt has redness to bil buttocks…PCG is using moisture barrier/triad paste to reduce redness and protect skin from incontinent bowel episodes…. .” Then on 01/15/2024 the RN documented the patient had “… wounds to right lower leg, and left heel, pt has open wounds to bil buttocks and redness to bil buttocks, wound care performed as ordered by physician, tol well. Pt has skin breakdown to bil buttocks and to right leg… Pt resides Son and DIL’s home with son and DIL who provide care…” There was no documented evidence of teaching to the family on wounds. There were scanned Progress Notes, wound assessments, and dressing changes for 01/12/2024, 02/12/2024, and 02/23/2024 performed by the Wound RN and NP and signed by the wound care Medical Director. On 01/12/2024, the progress note included the following: Right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) - Cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. Right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) - Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Clinic to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024 with the diagnosis of Colon Cancer. There was no plan of care documented for the patient as of 02/27/2024. The assignments effective 01/21/2024 documented the frequency of team visits, which included for the skilled nurse to visit the patient twice a week. RN visits were documented on 01/18/2024, 01/19/2024, 01/24/2024, and 01/30/2024. There was no nurse visit documented after 01/30/2024. It was observation during Home Visit 4 with the Social Worker (Personnel Record 6) on 02/28/2024), that the patient and spouse had a significant language barrier, had teaching needs about what medications the patient was to take and for what those medications were to be used, overall did not appear to have a good understanding of the disease progression. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023 with the diagnosis of Heart Failure. A physician order dated 01/06/2024 stated the RN to make weekly visits and the LVN to make weekly visits. There was a fifteen-day gap between RN visits from 01/10/24 to 01/25/24. At the time of clinical record review, no RN visits were documented after 01/25/2024, which is a thirty-two-day gap from 01/25/2024 to 02/25/2024. Clinical Record 14: The patient elected the hospice benefit on 11/3/2023 with the diagnosis of Cerebrovascular Disease. A Physician Order was documented on 01/06/2024 for the RN to make weekly visits and the LVN to make weekly visits. There was a nineteen-day gap between nursing visits from 01/13/2024 to 02/01/2024 and a twenty-five-day gap between RN visits from 01/13/2024 to 02/07/2024. The patient’s medication list included Eliquis to prevent blood clots, Tramadol for pain, and Levetiracetam for seizures. The missing nurse visit documentation was discussed during an interview with the Director of Nursing (DON) on 02/28/2024 and 02/29/2024. The DON stated there was difficulty transitioning from the previous electronic medical record (EMR) to the new EMR with order entry and access to the clinician’s portable devices. A couple of nurses were contacted by phone by the DON and the nurses indicated that the visits had been performed but not documented. I reviewed the agency’s policy on timely patient documentation, which states that clinical documentation will be submitted within twenty-four hours.”

“It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that there were identified problems with planned interventions to address the patient’s wounds and the coordination with the wound care specialists. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. Documented in part during the RN visit on 01/02/2024 was “…wounds to right lower leg and left heel, pt has no open wounds to bil buttocks pt has redness to bil buttocks…PCG is using moisture barrier/triad paste to reduce redness and protect skin from incontinent bowel episodes…. .” On 01/15/2024, the RN noted that the patient “… wounds to right lower leg, and left heel, pt has open wounds to bil buttocks and redness to bil buttocks, wound care performed as ordered by physician, tol well. Pt has skin breakdown to bil buttocks and to right leg… Pt resides Son and DIL’s home with son and DIL who provide care…” There was no documentation of teaching to family on wounds. Progress Notes, wound assessments, and dressing changes for 01/12/2024, 02/12/2024, and 02/23/2024 were from an outside wound specialist. The Wound RN and NP documented the assessments and dressing changes and signed them by the wound care Medical Director. On 01/12/2024, the progress note included the following: Right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) - Cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. Right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) - Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Clinic clinician to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. There was no identified problem for the patient’s wounds and no planned interventions for hospice wound assessments, how often the hospice was providing dressing changes, or if the hospice was also teaching the caregivers how to care for the wound per the wound care orders provided by the specialists. It was confirmed during an interview with the Director of Nursing (DON) on 02/29/2024 that the wound specialists continued seeing the patient to address the patient’s wounds. During the joint clinical record review, it was also confirmed that the hospice clinical record did not include any identified interventions to address the wound care frequency and responsibility between wound care specialist visits.”

“It is required that the agency provide Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed revealed that the agency did not ensure that spiritual counseling was provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. A Physician’s Order was dated 01/15/2024 for once-a-month Chaplain visits. There were no documented Chaplain visit for January 2024. A note was entered as a missed visit by the Chaplain on 02/17/2024 that read, “Patient load doubled in the middle of the month. Unable to visit them all.” There was no documentation of any attempts to have the visit covered by another Chaplain or the patient/family declined the Chaplain visit ordered by the Interdisciplinary Group. Clinical Record 5: The patient elected the hospice benefit on 01/22/2023, A Plan of Care Order dated 12/11/2023 included a once-a-month Chaplain visit frequency. Then, a Physician’s Order dated 01/01/2024 documented a one-time Chaplain visit to determine frequency. Again, under Assignments effective 01/22/2024 (per Physician Order dated 01/22/2024) documented a Chaplain frequency of once a month. There was no documented evidence of Chaplain visit for the month of January 2024 or documentation of why the visit was missed. The clinical record lacked evidence of Chaplain notes in the Interdisciplinary Group Meetings on 01/17/2024 or 01/29/2024. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician’s Order dated 01/01/2024 for a Chaplain visit frequency of once a month. There were no Chaplain visits documented from 01/01/2024 to 02/29/2024. There was no documentation of a missed visit and no note regarding any missing Chaplain visits in the Interdisciplinary Group Meetings 01/05/2024, 01/17/2024, 01/29/2024, or 02/12/2024. During an interview with the Director of Nurse and the Administrator on 02/29/2024, no evidence could be produced for the missed Chaplain visits.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a registered nurse who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 12 (17%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure the hospice registered nurse (RN) provided complete and patient-specific instructions to the hospice aide. The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that “... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided. The hospice aide’s services are reviewed in the IDG (Interdisciplinary Group Meeting), included in the patient’s plan of care...” The hospice’s policy Hospice Aide Supervision (Reference #14.21.1) effective 07/13/2022 read in part “...The supervisory visits are documented in the patient’s clinical record every two weeks and include notations ... whether the aide is following the patient’s plan of care...” The policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/21/2021 included in part “The agency will ensure timely and proper submission of patient documentation ...Clinical documentation will be complete and submitted within 24 hours from patient encounter...” Clinical Record 12: The patient elected the hospice benefit on 04/20/2023. There was a Physician’s Order dated 01/01/2024 for Hospice Aide visits four times a week, effective 01/28/2024. Hospice Aide visits were documented four times a week the week of 01/01/2024 and five times a week from 01/08/2024 to the week of 01/28/2024. The week of 02/04/2024 there were four Aide visits documented and five Aide visits documented the week of 02/11/204.The clinical record lacked evidence of a hospice aide care plan for visits from 01/02/2024 to 02/16/2024. The Hospice Aide Visit Notes contained only the visit date, the time in and time out of the visit, and the mileage. There were no interventions, no interventions documented as completed, and no narrative. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician’s Order dated 01/01/2024 for Hospice Aide visits three times a week. On 02/29/2024, an order was written for Hospice Aide visits five times a week. The patient had a right medial stage 3 pressure ulcer (3.92 x 5.22 x 0.11) with orders for dressings changes by an outside wound care consultant to cleanse the wound with cleaner and pat dry with gauze. Apply skin prep to the peri-wound. Apply topical antibiotic spray and Therahoney to the wound bed, followed by alginate. Cover with foam and silicone-bordered dressing three times a week and as needed when soiled or loose. Wound Pros clinician to change once weekly and the agency/caregiver twice a week and available as needed for soiled or loose dressing changes. The patient also had a right lateral lower leg venous stasis ulcer (8.69 x 18.67 x 0.11) with orders for dressing changes by an outside wound consultant to cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by collagen and oil emulsion gauze. Cover with absorbent pad dressing and wrap with rolled gauze three times a week and as needed for soiled or loose dressing. Secure the dressing with tape as needed. Wound Pros clinician to change once weekly and the agency/caregiver twice weekly and be available to change soiled or loose dressing. The Hospice Aide Care Plan does not include instructions from the RN to the Aide about what to do with the patient’s wounds/dressings if they become wet or soiled during the Hospice Aide visit. It was confirmed during interviews with the Director of Nursing on 02/28/2024 and 02/29/2024 that Clinical Record #2 did not have a Hospice Aide Care Plan documented and that Clinical Record #6 did not include instructions to the Aide regarding the patient’s wounds.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 12 (50%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that the Hospice Aide completed visits and/or documented those visits in the same frequency as the patient’s Plan of Care ordered. The agency policy Hospice Aide Services (Reference #14.22.1) effective 07/13/2022 included in part that “... The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide on the patient-specific care to be provided. The hospice aide’s services are reviewed in the IDG (Interdisciplinary Group Meetings), included in the patient’s plan of care ...” The hospice policy Hospice Aide Supervision (Reference #14/21/1) effective date of 07/13/2022 read in part that “...The supervisory visits .... include ... whether the aide is following the patient’s plan of care... Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An order documented on 01/01/2024 included the patient’s Hospice Aide frequency for three times weekly. The week of 01/01/2024 there was only one Aide Visit documented on 01/05/2024 (2 missing). There were no Hospice Aide visits documented the weeks of 01/14/2024 and 01/21/2024 (3 missing each week). On 01/22/2024 there were two orders for the Hospice Aide to visit once/one time to equal two Aide visits. Again, there were no Hospice Aide visits this week. Then on 01/28/2024 the order read for the Hospice Aide to visit once/one time to equal one Aide visit. Documented on 01/29/2024 was another order for a one visit/one time Hospice Aide Visit. The week of 01/28/2024, there was one Aide visit documented on 01/29/2024. There was an order on 02/01/2024 for a Hospice Aide frequency of three times weekly. The week of 02/04/2024, there was one Aide visit documented on 02/10/2024 (missing 2 visits). The week of 02/11/2024 there were two Aide visits documented on 02/14/2024 and 02/16/2024. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. An order documented on 01/12/2024 included the Hospice Aide frequency of three times weekly. Then on 01/21/2024 there was another order documenting Hospice Aide visits three times a week. There were no Aide visits until the week of 01/21/2024. Aide visit was documented on 01/26/2024 - missing two visits that week. Then the week of 01/28/2024 there were Hospice Aide visit documented on 01/29/2024 and 02/02/2024 - missing one visit that week. The week of 02/04/2024 there were no Aide visits documented. Clinical Record 9: The patient elected the hospice benefit on 12/22/2023. On 01/01/2024, a Physician’s Order was documented for Hospice Aide visits three times a week. It also included one Hospice Aide visit five times to equal five Aide visits. On 01/08/2024, a Physician’s Order was documented for Hospice Aide visits twice weekly. There were no Hospice Aide visits during the weeks of 01/01/2024, 01/07/2024, and 01/14/2024 Beginning the week of 01/21/2024, there were five Hospice Aide visits a week, but the order for five times weekly wasn’t documented until 02/01/2024. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. A Physician’s Order dated 01/21/2024 documented twice weekly Hospice Aide visits. The week of 01/21/2024, one Aide visit was documented on 01/25/2024 - missing one visit. The week of 01/28/2024, one Aide visit was documented on 01/30/2024 - missing one aide visit. Clinical Record 11: The patient elected the hospice benefit on 09/28/2023. A Physician’s Order dated 01/21/2024 documented the Hospice Aide frequency three times weekly. There were no Hospice Aide visits documented until the week of 02/04/2024. Clinical Record 13: The patient elected the hospice benefit on 04/22/2022. A Physician’s Order dated 01/15/2024 documented the Hospice Aide frequency three times weekly. Another Physician’s Order was documented on 01/28/2024 for Hospice Aide visits three times a week. There were no Aide visits documented in the week of 01/15/2024, 01/21/2024, and the week of 2/4/2024. During an interview with the Director of Nursing (DON) on 02/27/2024, 02/28/2024, and 02/29/2024, she stated that many visit notes were likely not documented yet and that she just found out recently that one of the Hospice Aides could not yet access the new Electronic Medical Record (EMR) on her portable device.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 12 (33%) clinical records reviewed revealed the agency did not ensure that the RN documented supervision of the Hospice Aide every fourteen days. The agency policy Hospice Aide Supervision (#14.21.1) effective 07/13/2022 included in part that “... A registered nurse makes an on-site visit to the patient’s home no less frequently than ever 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need...The supervisory visits are documented in the patient’s clinical record every 2 weeks ...” The hospice’s policy Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 read in part that “The agency will ensure the timely and proper submission of patient documentation... Clinical documentation will be complete and submitted within 24 hours from patient encounter...” Clinical Record 2: The patient elected the hospice benefit on 03/23/2022. An order documented on 01/01/2024 included the patient’s Hospice Aide frequency three times weekly. The week of 01/01/2024, only one Aide Visit was documented on 01/05/2024 (2 missing). There were no Hospice Aide visits documented the weeks of 01/14/2024 and 01/21/2024 (3 missing each week). On 01/22/2024, there were two Physician’s Orders each for the Hospice Aide to visit once/one time to equal two Aide visits. There were no Hospice Aide visits this week. Then on 01/28/2024 a Physician’s Order documented for the Hospice Aide to visit once/one time to equal one Aide visit. On 01/29/2024 was another one-visit/one-time Hospice Aide Visit order. The week of 01/28/2024, there was one Aide visit documented on 01/29/2024. A Physician’s Order dated 02/01/2024 for a Hospice Aide frequency of three times weekly. The week of 02/04/2024, one Aide visit was documented on 02/10/2024 (missing 2 visits). During the week of 02/11/2024, two Aide visits were documented on 02/14/2024 and 02/16/2024. There was no documented evidence of aide supervisory visits by the RN 1/10/2024, 1/23/2024, 1/28/2024, 2/6/2024, and 2/17/24. Clinical Record 6: The patient elected the hospice benefit on 12/25/2023. A Physician’s Order dated 01/01/2024 documented Hospice Aide visits three times weekly. Then on 01/21/2024 another Physician’s Order increased the Hospice Aide frequency to five times a week. Beginning the week of 01/01/2024, there were Hospice Aide visits three times a week. During the week of 01/28/2024, there were four Hospice Aide visits documented. Then, in the week of 02/04/2024, five Aide visits were documented. The last RN visit documented was 01/29/2024 and included Hospice Aide supervision. The next Aide supervision should have been performed on 02/12/2024. Clinical Record 8: The patient elected the hospice benefit on 01/12/2024. A Physician’s Order documented 01/12/2024 included the Hospice Aide frequency of three times weekly. Then on 01/21/2024 there was another order documenting Hospice Aide visits three times a week. There were no Aide visits until the week of 01/21/2024. The Aide visit was documented on 01/26/2024 - missing two visits that week. Then the week of 01/28/2024 there were Hospice Aide visit documented on 01/29/2024 and 02/02/2024 - missing one visit that week. The week of 02/04/2024 there were no Aide visits documented. The RN visits were dated 1/12/2024, 1/26/2024 but did not include documentation of aide supervision. Clinical Record 10: The patient elected the hospice benefit on 01/18/2024. A Physician’s Order documented on 01/21/2024 included twice weekly Hospice Aide visits. The week of 01/21/2024, one Aide visit was documented on 01/25/2024 - missing one visit. The week of 01/28/2024, one Aide visit was documented on 01/30/2024 - missing one aide visit. There were documented RN visits on 01/18/2024, 01/29/2024, 01/24/2024, and 01/30/2024 none of which included documentation of hospice aide supervision. During interviews with the Director of Nursing on 02/27/2024, 02/28/2024, and 02/29/2024 it was confirmed that the Hospice Aide Supervisory visits above were not documented in the clinical record. The DON did state that the visits were made but the documentation was not yet submitted and present in the clinical record. The DON and the Administrator further explained that in the switch from the prior Electronic Medical Record System (EMR) to the new EMR there have been struggles.”

“The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the Hospice Election of Benefits form was completed with the effective date of the patient’s hospice election. Agency Policy: Timely Submission of Patient Documentation (Reference #11.05.1) effective 03/12/2021 “The agency will ensure timely and proper submission of patient documentation ... All documentation related to patient care will be complete and submitted.” Medical Record Content (Reference #11.01.1A) effective 03/21/2021 “...The agency will provide an accurate and current medical record for every patient seen by the Agency ... The record is complete, promptly and accurately documented ... Each patient’s clinical record includes ...signed copies of the notice of patient rights and election statement...” Clinical Record 5: The patient elected the hospice benefit on 01/22/2023. The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022.The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. Clinical Record 18: The patient elected the hospice benefit on 10/13/2022. The effective date of the hospice election on page one of the Informed Consent and Election of Hospice Benefit document was left blank. There was the only part of the consent forms where there was a place to document the effective date of election. In an interview and joint document review with the Administrator on 02/29/2024, she confirmed that the effective date of the hospice election was missing/blank from the Informed Consent and Hospice Election forms as presented in evidence. The Administrator stated that ongoing, after training, the admission nurses will complete the admission forms in the Electronic Medical Record (EMR).”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient’s discharge summary was forwarded to the Medicare certified facility upon discharge. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. The Discharge Summary documented the patient’s demographics and hospice diagnosis, medication allergies, which disciplines were vising the patient, but not the frequency of visits, the plan of care, the medication list, summary of care, or physician orders. There was an Administrative Clinical Summary note that had a box checked that the patient’s primary physician was called, but patient revoked services to go to the hospital for surgical correction of a fracture. There was no documented evidence that any of the required information was sent to either the attending physician or the hospital where the patient was admitted for care. During an interview and joint record review with the Director of Nursing (Staff 2) and the Administrator (Staff 1) on 02/28/2024 confirmed that there was no information documented in the patient’s medical record that the patient’s Discharge Summary was sent to the receiving hospital or to the patient’s attending physician.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which there was a live discharge from the hospice agency revealed the agency did not ensure that the patient’s discharge summary was forwarded to the Medicare certified facility upon discharge. Clinical Record 15: The patient elected the hospice benefit on 11/26/2022 and revoked the hospice benefit on 01/26/2024. The Discharge Summary documented the patient’s demographics and hospice diagnosis, medication allergies, which disciplines were vising the patient, but not the frequency of visits, the plan of care, the medication list, summary of care, or physician orders. There was an Administrative Clinical Summary note that had a box checked that the patient’s primary physician was called, but patient revoked services to go to the hospital for surgical correction of a fracture. There was no documented evidence that any of the required information was sent to either the attending physician or the hospital where the patient was admitted for care. During an interview and joint record review with the Director of Nursing and the Administrator on 02/28/2024 confirmed that there was no information documented in the patient’s medical record that the patient’s Discharge Summary was sent to the receiving hospital or to the patient’s attending physician.”

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the patient’s full name, generic, trade, or brand name of the medication, as well as amount dispensed, directions for use, including route, rate, frequency, and method of administration, prescriber’s name, expiration date, and cautionary instructions. This standard was not met as evidenced by clinical record review and observation. In 1 of 4 (25%) home visits observed revealed the agency did not ensure that the patient’s medication was labeled with the required information. Home Visit 3: The patient elected the hospice benefit on 02/12/2023. During the home visit observation with the registered nurse (Personnel Record 5) on 02/28/2024, the patient’s son and primary caregiver brought the patient’s medications to the patient’s room for the RN to review. These medications included what the son reported to be Hydrocodone/Acetaminophen. The Hydrocodone was in a bottle with a label completely faded without the patient’s name visible, the name of the medication, or the directions and frequency of use. There was no medication list in the patient’s home. When questioned, the RN responded she would have to print one but that I could look at the chart on her iPad. Upon record review, the patient’s medication list had documented both the Hydrocodone/Acetaminophen 5/325mg: one by mouth every four hours as needed for pain listed as discontinued. The nurse verified with the son that the patient was taking the Hydrocodone.”