Magnolia Hospice

“Based on record review and interviews, the agency failed to provide for and ensure the ongoing sharing of information between all disciplines providing care in 1 out of 3 Patient records reviewed (Patient 1). The agency failed to coordinate care of Patient 1 with Complainant 1 and NP A in that they did not create an effective plan for who was to fill Patient 1’s medication box (box containing the week’s medications, organized by day) and failed to communicate the plan for foley catheter (device allowing urine to drain from the bladder) placement with NP A and Complainant A. This failure resulted in Complainant 1’s dissatisfaction with the services Patient 1 received and put Patient 1 at risk for substandard care. Findings included:Review of Patient 1’s clinical record revealed a document titled, “Hospice Certification and Plan of Care,” dated for the certification period of 5/23/26 to 8/20/26, which showed Patient 1 had a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (failure of the heart and kidney systems), and was to receive skilled nursing, medical social work, home health aide, and chaplain services. Patient 1’s start of care date was 5/23/26. Review of the complaint log revealed a document titled, “Complaint Report,” dated 6/10/26, which contained a complaint by Complainant 1 on behalf of Patient 1. The complaint read in part: “Pill box responsibility: I was told by [Hospice A] that filling and managing [Patient 1]’s pill box was not hospice’s responsibility. This became an unexpected burden on me as the family caregiver. I want to note that our new hospice provider proactively offered to take over pill box management without me having to ask. That is what hospice care coordination should look like.” Review of the texts provided by Complainant 1 revealed messages between her on RNCM. On 5/29/26 Complainant 1 sent a text that read in part, “Great I will do that. Going forward, who’s filling her pillbox for her? When she was on home health the nurse there was doing it or [NP A] did it. Is that something you’ll be helping with or [NP] will continue or is that something I will be expected to do?” In reply, RNCM wrote, “Hi, I need you to fill pill box please.” In reply, Complainant 1 wrote, “Meaning, I need to fill her pillbox now or this is something I’m taking on going forward?” In reply RNCM wrote, “You will take over now but Ithink it has another week until finished.” Further review of the complaint log revealed a document titled, “Complaint Report,” dated 6/10/26, which contained another complaint by Complainant 1 on behalf of Patient 1. The complaint read in part: “Foley catheter: not followed up. A foley catheter was identified as needed for my mother’s comfort and care. An attempt was made but was unsuccessful. I was told on multiple occasions that someone would return “Tonight or tomorrow” to try again. No follow-up ever occurred, and the status was never communicated to me.”In a phone interview with Complainant 1 at 2:11 PM on 6/17/26, Complainant 1 stated she was not aware that it was to be her responsibility to fill the medication box each week for Patient 1 when starting services on May 23, 2026. She stated she had assumed that was the responsibility of the hospice nurses, and it was not communicated to her until May 29 through a text from RNCM that she was supposed to fill it. She stated that she was very surprised by this information, and it added a lot of stress to her at the time. Survyeor asked who had previously been preparing the medication box each week for Patient 1 before they started hospice services. She stated that home health had been doing it previously, and that NP A helped with it sometimes as well. In the same interview, Complainant 1 stated that they had decided jointly with NP A and the hospice nurses that it may benefit Patient 1 to place a foley catheter to help with her incontinence. She stated that the hospice nurses were supposed to do it, and it never occurred. She stated she did not even realize this until several days later when NP A alerted her, and she complained to the hospice at this point.In a phone interview with the RNCM on June 17, 2026, at 3:16 PM., when asked who was responsible for filling Patient 1’s medication box, RNCM stated that Complainant 1 had alleged that hospice staff refused to fill the medication box; however, she stated that this was not true. The RNCM stated, “I never even had an opportunity to fill the box because NP A was refilling the box.” The RNCM stated, “I felt like there were too many chefs in the kitchen.” She explained that NP A would add and remove medications and that she never had the opportunity to fill the pill box. The RNCM stated she did not recall telling Complainant 1 it was her responsibility to fill the pill box, but if she had then it was likely just a one-off situation. The Surveyor asked why Patient 1 never received a foley catheter. RNCM stated that foley placement was attempted several times on the night of May 28, 2026 but was unsuccessful. RNCM stated that the plan was to try again in the morning. RNCM stated that on Friday May 29, she asked PCM A to ask LVN B to attempt to insert the foley. She stated they had a “communication breakdown” because that afternoon around 4pm, she texted LVN B to ask if she had been able to get the foley in and LVN B stated that PCM A had never asked her to place a foley in Patient 1. RNCM then stated she talked to PCM A who told her that the on-call team would place the foley catheter over the weekend. RNCM stated that she “put it on the on-call report and it did not get done.” Further, she said, “I am not sure what happened. We double checked that I had out it in the on-call email. The ball definitely got dropped there.” RNCM stated that on the following week she “just assumed” the foley had been placed, and when she went to see the Patient that week, she did realize during her assessment that the Patient did not have a foley. RNCM confirmed that she did not update Complainant 1 or NP A on the situation. The Surveyor asked RNCM who was responsible to coordinate care between family and other providers involved in the Patient’s care, and RNCM stated it was her responsibility as the RN case manager. The surveyor asked why it was important to ensure ongoing communication and coordination of care between all parties involved in a Patient’s care. RNCM stated it was important to ensure that the Patient received the best care and also to ensure family members are updated on the plan of care. In a phone interview with NP A at 4:45 PM on June 17, 2026, the Surveyor asked whether she recalled an event in which Patient 1 was supposed to receive a Foley catheter but did not. NP A reported that Patient 1 initially declined catheter placement and that discussions regarding the catheter occurred over approximately one week to 10 days before the Patient agreed to proceed. According to NP A, her understanding was that a hospice staff member attempted to insert the Foley catheter but was unsuccessful. She stated that she did not know the details regarding whether hospice staff returned to attempt reinsertion. NP A stated that she did not receive communication directly from hospice regarding the Foley catheter and that all information was relayed through Complainant 1. She reported that when she returned to see Patient 1 the following week (could not recall the day), the Patient did not have a catheter in place. NP A stated that, at that time, she knew Complainant 1 was already pursuing a transfer for Patient 1 to another hospice agency, so she did not pursue the issue. She reiterated that Hospice A staff did not communicate directly with her regarding the Foley catheter. .” When asked whether she spoke directly with Hospice A regarding responsibility for filling the medication box, NP A stated that she did not specifically recall doing so. She reported that Complainant 1 told her that hospice staff were refusing to fill the medication box. NP A stated that prior to hospice involvement, either herself or the home health nurse filled and adjusted the Patient’s medication box. She reported that the home health nurse had completed the majority of the medication management tasks; however, once the Patient transitioned to hospice care, it became unclear who was responsible for filling the medication box. NP A stated that she knew Complainant 1 was uncomfortable filling the pill box because she had not previously been responsible for doing so. NP A stated that she told Complainant 1 that she would complete the task. In an interview with both the Administrator and SN at 12:30 PM on 6/19/26, the Surveyor asked if they had a policy on care coordination and the Administrator stated that he did. He stated that it was their policy that nurses communicated with other providers and family members about the plan of care, changes to the plan of care, and expectations of roles. The SN confirmed this was her expectation of the nurses. The Supervising Nurse stated in this situation it was difficult because usually a primary care provider will back off once the Patient starts hospice services, but in this case NP A stayed very involved and “who was doing what” became difficult. The Administrator stated it was an opportunity for learning and said, “we need to communicate better and draw these lines, so everyone is clear whose responsibility it was.” The Administrator also stated that, as in the case with the foley catheter, if family and providers had been told an intervention would be performed and it never was, they should have both been notified about this by the RN Case Manager, in this case RNCM. The Surveyor asked how coordinating care between providers and family members could affect Patient care. The Administrator stated that “we need to have great communication and make sure everyone understands expectations.” They stated that Patient needs could go unmet if the whole team is not communicating and coordinating care. Review of the agency’s policy titled, “Communication,” last revied 9/24/25, revealed a policy that read in part: “The hospice must: C. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions; D. Assure communication with all physicians/allowed practitioners involved in the plan of care (POC)… G. Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s) as appropriate, in the coordination of care activities.””

“This failure placed the patient at risk of continued neglect by agency staff and delayed HHSC from performing an investigation. Findings Included:Review of the agency’s Complaint Logs for 2024 – 2026 revealed a complaint dated 08/13/2025 related to Patient #1. The document read in part, “08/13/2025 SW began visit by checking on FM #1’s well-being, offering active listening, empathy, compassion, trust and caring support to her and client. FM #1 voiced frustrations with company and staff members again. Upon arrival to patient’s room, patient appeared to be in terminal distress. Patient had rapid breathing, using accessory muscles to breathe, and although eyes were fixed, patient’s eyes would sometimes move/eye roll to back of head, and patient had death rattle with choking.”Review of an additional complaint dated 08/13/2025 read in part, “08/06/2025 Telephone conversation with FM #1 to check on family. FM #1 states Patient #1 is not doing well and is minimally responsive to talk and touch and will groan if moved or messed with. FM #1 states that patient has not eaten or drank since Monday 08/04/2025, and she is worried to give her anything for fear of her aspirating, but she worries her mouth and lips are dry. No medication has been given either as FM #1 stated Patient #1is unable to swallow pills. SW discussed utilizing a straw to slowly drop tiny amounts of liquids into the patient’s mouth and/or sponges to moisten mouth. FM #1 was thankful for this information. FM #1 states RN #2 has not educated her on these comfort measures. In regards to patient being unable to swallow pills SW also discusses(d) with FM #1 that the nurses discuss with and educate families on the comfort kit and different ways medication can be administered for patients at end of life.” A comfort kit includes medications ordered by the physician so that clients/caregivers have medications readily available to provide comfort to the client. The kit usually includes medications to treat various levels of pain, shortness of breath, anxiety, insomnia, constipation, dry mouth, nausea and vomiting, etc.Review of the clinical record for Patient #1 revealed a start of care date of 08/13/2024 with a diagnosis of lung cancer. Patient #1 was discharged on 08/08/2025 due to death.Surveyor requested documentation of self-reported allegations of abuse, neglect or exploitation as well as Provider Investigation Reports. The Administrator stated, “I don’t think there are any. We will check into it.” Surveyor requested a copy of the agency’s policy for self-reporting allegations of A, N and E.An interview was conducted with the ASN on 03/06/2026 at 4:50 p.m. The ASN stated, “I don’t understand what you are talking about after our telephone conversation this morning. None of these things were mentioned.” Surveyor advised the ASN that the allegations discussed during the telephone interview were related to intake investigations HHSC received. The additional questions regarding the multiple allegations possible neglect of patients by RN #1 were identified during a review of the agency’s complaint log. The ASN stated the agency investigated and nothing was found nor reported to HHSC. An email was received on 03/09/2026 at 8:30 a.m. from the ASN with complaint documentation for 2025. Email was acknowledged. There were no self-reported incidents included in the documentation. An interview was conducted on 03/09/2026 at 2:10 p.m. with Identifier #2 and Market President. Market President felt there were staff that was targeted bullying by staff. LMSW (Comp #5) was mentioned for filing many complaints. The surveyor reminded them the social worker is a mandatory reporter. If she was made aware of allegations of A, N or E she was required to report them. Both verbalized understanding and felt complaints were investigated appropriately. Surveyor explained to the representatives the state requirement for self-reported incidents of A, N, or E. Both verbalized understanding. Review of the agency’s online policies and procedures included a policy titled Abuse, Neglect, Exploitation (ANE) & Complaints (no revision date) read in part, “III. Until September 1, 2023, HCSSAs who have cause to believe a non-Medicaid patient served by the agency has been abused, neglected, or exploited by an agency employee shall report the information immediately, meaning within 24 hours to B. CII at ciicomplaints@hhs.texas.gov or call 1-800-458-9858.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews, observation, and interviews with the Executive Director/RN and Patient Clinical Manager, which revealed the following: Failure of the agency to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for the supervision of the Hospice Aide in 2 of 19 (11%) clinical records reviewed [HCDT.15.I/L625]; Failure of the agency to ensure that the Hospice Aide provided services as instructed in the Hospice Aide care plan in 2 of 19 (11%) clinical records reviewed [HCDT.16.I/L626]; and Failure of the agency to ensure that the Hospice Aide reported changes in the patient’s needs to the RN in 2 of 19 (11%) clinical records reviewed [HCDT.16.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“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: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, “Patient/Family Plan of Care” (dated 06/17/2024) included in part that “...The plan of care is individually tailored to meet the... needs of the patient and family...” In 17 of 19 (89%) clinical records reviewed, the agency did not ensure that each patient’s written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 05/15/2024 with a diagnosis of chronic obstructive pulmonary disorder. The plans of care for the benefit periods dated 01/08/2025 to 03/08/2025 and 11/09/2024 to 01/07/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. Clinical Record 2: The patient elected the hospice benefit on 09/08/2023 with a diagnosis of hypertensive heart disease with heart failure and a history of myocardial infarction. The plans of care for the benefit periods dated 03/01/2025 to 04/29/2025 and 12/31/2024 to 02/28/2025 documented the patient’s goal that safety needs would be met. The plans of care did not identify what safety issues were pertinent to the patient or what would identify when the needs would be met. The comprehensive assessment identified anxiety as a problem for the patient with interventions. The plan of care documented that the patient’s goal was to reduce the patient’s stress/anxiety level. “Reducing” is not a measurable outcome. Clinical Record 3: The patient elected the hospice benefit on 05/17/2024 with a diagnosis of malignant neoplasm of the bladder. The plans of care for the benefit periods dated 03/13/2025 to 05/11/2025 and 01/12/2025 to 03/12/2025 documented the patient’s goal to verbalize or demonstrate an understanding of managing the patient’s disease and/or symptoms. However, no specific symptoms were identified, nor how the verbalizing or demonstration methods would be measured. Clinical Record 4: The patient elected the hospice benefit on 08/16/2024 with diagnoses of Alzheimer’s Disease, dementia with agitation, hallucinations, heart failure, and dysphagia. The plans of care for the benefit period 02/12/2025 to 05/12/2025 and 11/14/2024 to 02/11/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. Clinical Record 5: The patient elected the hospice benefit on 01/29/2025 with diagnoses of neurocognitive disorder and dementia with agitation and anxiety disorder. The plan of care for the benefit period dated 01/29/2025 to 04/28/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. The comprehensive assessment identified constipation as a problem for the patient, but the goal of controlling the patient’s constipation was not measurable. Clinical Record 6: The patient elected the hospice benefit on 05/09/2024 with diagnoses of Parkinson’s disease and dementia with agitation and anxiety disorder. The plans of care for the benefit periods dated 03/16/2025 to 05/14/2025 and 01/15/2025 to 03/15/2025 documented the patient goal “patient/family to verbalize or exhibit signs of symptom reduction or relief.” The plans of care did not specify the patient’s symptoms. “Reduction” is not a measurable outcome. Clinical Record 7: The patient elected the hospice benefit on 10/07/2024 with a diagnosis of multiple sclerosis. The plan of care for the benefit period dated 03/07/2025 to 05/05/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. Additionally, the plans of care documented the patient goal, “patient/family/ caregiver to report changes in pain level to the hospice.” The goal did not include a measurable outcome or parameters of when to call. Clinical Record 9: The patient elected the hospice benefit on 03/05/2025 with a diagnosis of Parkinson’s disease. The comprehensive assessment identified the need for the Social Worker (SW) to work with the family on coping skills. The plan of care for the benefit period dated 03/05/2025 to 06/02/2025 documented the patient goal for the patient/family to exhibit improved coping skills. “Improved” is not a measurable outcome. Clinical Record 10: The patient elected the hospice benefit on 02/27/2025 with a diagnosis of unspecified severe protein-calorie malnutrition. The plan of care for the benefit period dated 02/27/2025 to 04/27/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Clinical Record 11: The patient elected the hospice benefit on 09/16/2024 with the diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 03/15/2025 to 05/13/2025 and 12/15/2024 to 03/14/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. The comprehensive assessment identified constipation as a problem for the patient, but the goal of controlling the patient’s constipation was not measurable. Clinical Record 12: The patient elected the hospice benefit on 07/10/2024 with the diagnosis of senile degeneration of the brain. The plans of care for the benefit periods dated 03/07/2025 to 05/05/2025 and 01/06/2025 to 03/06/2025 documented the patient’s goal for the patient/caregiver to verbalize/demonstrate how to correct safety hazards in the home. The plans of care did not identify what safety hazards existed in the house or what changes in the home environment needed to be made. There was no measurable outcome. Clinical Record 13: The patient elected the hospice benefit on 12/27/2024 with a diagnosis of amyotrophic lateral sclerosis with a comorbid condition of polyneuropathy. The plan of care for the benefit period dated 12/27/2024 to 03/26/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. The comprehensive assessment identified depression and isolation as issues for the patient. The plan of care documented that the patient’s goal was for the depression/isolation to be reduced or eliminated, but it did not indicate what symptoms would be assessed. “Reduced” is not a measurable outcome. Clinical Record 15: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of atherosclerotic heart disease. The plans of care for the benefit periods dated 11/27/2024 to 01/25/2025 and 08/29/2024 to 11/26/2024 documented the patient’s goal for the patient/family to understand measures to manage immediate cardiac/respiratory symptoms. The cardiac/respiratory symptoms to manage were not specified. The goal included notifying the hospice nurse if “measures” to manage those symptoms were ineffective. No parameters or measures were documented for when the hospice nurse should be called. Clinical Record 16: The patient elected the hospice benefit on 04/19/2024 with the diagnosis of Alzheimer’s disease with a comorbid condition of anxiety disorder. The care plans for the benefit periods dated 12/15/2024 to 02/12/2025 and 10/16/2024 to 12/14/2024 documented the patient’s goal that the patient’s safety needs be met. The plan of care did not document specific safety needs or the measures required to meet the safety needs. Clinical Record 17: The patient elected the hospice benefit on 12/20/2024 and died on 12/27/2024 with a diagnosis of malignant neoplasm of the pancreas. The plan of care for the benefit period dated 12/20/2024 to 03/19/2025 documented the patient’s goal for pain to be managed at an acceptable level. The plans of care did not document what the patient/family considered to be an acceptable level of pain. Acceptable” is not a measurable outcome. The plan of care patient goal for the patient/caregiver to verbalize/demonstrate an understanding of pain management measures did not include specific pain management methods or a measurement of the visualization/demonstration. Clinical Record 18: The patient elected the hospice benefit on 04/19/2024 with the diagnosis of hypertensive heart disease with comorbidities of restlessness, agitation, and anxiety disorder. The plans of care for the benefit periods dated 12/19/2024 to 02/16/2025 and 10/20/2024 to 12/18/2024 documented the patient’s goal for the patient/family to understand measures to manage immediate cardiac/respiratory symptoms. The cardiac/respiratory symptoms to manage were not specified. The goal included notifying the hospice nurse if “measures” to manage those symptoms were ineffective. No parameters or measures were documented for when the hospice nurse should be called. The comprehensive assessment identified a problem of anxiety for the patient. The plan of care documented that the patient’s goal was to reduce the patient’s stress/anxiety level. “Reducing” is not a measurable outcome. Clinical Record 19: The patient elected the hospice benefit on 12/14/2024 with the diagnosis of senile degeneration of the brain with the comorbidity of dementia with agitation. The plan of care for the benefit period 12/14/2024 to 02/19/2025 included safety interventions for identified safety needs. Still, the goal that the patient’s safety needs would be met did not determine what safety issues were pertinent to the patient or what would identify when the needs would be met. The comprehensive assessment identified a problem of anxiety for the patient. The plan of care documented that the patient’s goal was to reduce the patient’s stress/anxiety level. “Reducing” is not a measurable outcome. During a joint clinical record review and interview on 03/19/2025, the Executive Director/Register Nurse, the Patient Care Managers, and the Director of Clinical Education confirmed that the goals included in the plans of care were not specific to the patient or measurable.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy “Infection Prevention & Control in the Home Setting” read in part, “Hand hygiene shall be performed...After contact with...body fluids... Moving from a contaminated body site to a clean body site during patient care...” In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed as indicated per agency policy. Home Visit 3: The patient elected the hospice benefit on 09/16/2024 with the diagnoses of dementia with agitation, anxiety, depression, and insomnia. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 6] on 03/19/2025, the HA prepared to shower the patient. The HA assisted the patient into the shower. The patient stood up and held onto the safety grab bar while the HA removed the patient’s pants and wet adult briefs. The brief was wet, as were the patient’s pants. Once undressed, the HA guided the patient to sit down on the shower chair and moved on to shower the patient. After handling the wet brief, the HA did not change gloves or perform hand hygiene. Once the shower was completed, the patient urinated while still in the shower. The HA assisted the patient in standing. While the patient was standing, the HA took wet wipes and wiped the patient’s peri area since the patient had urinated. The HA applied barrier cream to the patient’s peri area, applied the briefs, and pulled up the patient’s pants. After providing the peri-care, the HA did not change their gloves or perform hand hygiene. Once the patient was fully dressed and placed back in the wheelchair, the HA performed appropriate hand hygiene before providing oral care. Upon completion of care, during an interview, the HA confirmed that they did not change their gloves or perform hand hygiene after handing the patient’s wet brief or providing peri-care.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Assignment and Supervision” (dated 06/17/2024) stated in part, “The RN will provide a written assignment/care plan for patient care... All care will be rendered according to the assignment/care plan...” In 2 of 19 (11%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient instructions from the RN to meet the patient’s needs. Clinical Record 14: The patient elected the hospice benefit on 02/09/2025 with a diagnosis of Guillain-Barre syndrome. On admission, there was a stage four pressure ulcer to the patient’s lower right buttocks. The plan of care for the benefit period dated 02/09/2025 to 05/09/2025 ordered HA services five (5) times a week. On 02/11/2025, the physician ordered skilled nursing for wound care, “cleansing with sterile water, applying a calcium alginate pad, covering with Mepilex, and changing three times a week and as needed.” On 02/17/2025, the skilled nurse (SN) assessed an additional stage-two pressure ulcer wound to the patient’s coccyx with a physician’s order on the same date to include this new wound in the treatment orders. On 02/24/2025, the SN restaged the coccyx wound from stage two to stage four, and a physician’s order was documented to “cleanse the coccyx wound with sterile water and pack it with Xeroform dressing. Layer calcium alginate pad and bandage and change the dressing three times a week and as needed.” The Hospice Aide care plan dated 02/12/2025 assigned the HA the relevant tasks: perineal care every visit and instructions for the HA to provide a bed bath three times weekly. The HA did not receive written patient care instructions from the Registered Nurse (RN) regarding care of the wound dressings during perineal care and the bed bath should they become wet, soiled, or dislodged. Clinical Record 18: The patient elected the hospice benefit on 04/19/2024. The plans of care for the benefit periods dated 10/20/2024 to 12/18/2024 and 12/19/2024 to 02/16/2025 ordered HA services two (2) times a week until the visits were increased to three (3) times a week on 10/24/2024. On 11/07/2024, the physician ordered skilled nursing services for treatments of the patient’s bilateral lower extremities, “cleansing the wound with Hibiclens and patting it dry. Calcium alginate was applied between the toes on the left foot and other affected areas.” The dressing was “covered with fluffs and Coban twice a week.” On 12/16/2024, the physician ordered skilled nursing for the dressing changes to be increased to three (3) times a week. The Hospice Aide care plans dated 10/22/2024, 12/09/2024, 12/17/2024, and 12/23/2024 assigned the HA the relevant tasks: shower twice a week. The HA did not receive written patient care instructions from the Registered Nurse (RN) regarding care of the wound and the wound dressing during the shower should they become wet, soiled, or dislodged. During a joint clinical record review on 03/20/2025, the Patient Care Manager [Personnel Record 3] confirmed that the RN did not provide the aide with instructions about each patient’s wounds.”

“It is required that a hospice aide provide services: included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Assignment and Supervision” (dated 06/17/2024) stated in part, “The RN will provide a written assignment/care plan for patient care... All care will be rendered according to the assignment/care plan.” In 2 of 19 (11%) clinical records reviewed and home visits observed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 05/09/2024 with the diagnoses of Parkinson’s Disease dementia with agitation, anxiety, constipation, and chronic kidney disease (CKD) stage 3. The plans of care for the benefit periods dated 01/15/2025 to 03/15/2025 and 11/16/2024 to 01/14/2025 ordered HA services five (5) times weekly. The Hospice Aide care plan dated 05/10/2024 assigned the HA the relevant tasks to provide shampoo weekly and a shower three (3) times weekly. During the weeks of 01/26/2025 and 02/19/2025, the HA documented providing four (4) showers. During the week of 02/02/2025, the HA documented providing five (5) showers. The HA documented providing four (4) showers and three (3) shampoos to the patient the week of 02/09/2025. During the week of 02/17/2025, the HA documented that five (5) showers and two (2) shampoos were provided. During the week of 02/23/2025, the patient received five showers. The HA did not follow the HA care plan assigned tasks as written by the Registered Nurse (RN). Clinical Record 11/Home Visit 3: The patient elected the hospice benefit on 09/16/2024 with the diagnoses of Alzheimer’s Disease, dementia with agitation, anxiety, depression, and insomnia. The plans of care for the benefit periods dated 12/14/2024 to 03/14/2025 and 03/15/2025 to 05/13/2025 ordered HA service five (5) times a week. During the home visit with the HA [Personnel Record 6] on 03/19/2025, the HA assisted the patient in eating as they could no longer feed themselves. During an interview, the HA was asked if they regularly assisted the patient with feeding, and the HA responded that they did. A clinical record review revealed that the HA care plan dated 09/16/2024 did not assign the HA the task of assisting the patient with feeding. During an interview and a joint record review on 03/20/2025, the Patient Care Manager [Personnel Record 3] and the Executive Director/RN confirmed that the aide did not complete the tasks on the care plan as written. Additionally, it was confirmed that feeding was not included in the care plan for clinical record 11.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA notified the Registered Nurse (RN) when the tasks on the care plan could not be provided. Clinical Record 7: The patient elected the hospice benefit on 07/22/2022 with the diagnoses of stage 2 sacral pressure ulcer, dysphagia, dementia with mood disturbance, anxiety, depression, and seizure disorder. The plan of care for the benefit period dated 01/24/2025 to 03/24/2025 ordered HA services five (5) times a week. The Hospice Aide care plan dated 07/22/2024 assigned the HA the relevant tasks: skin care, oral care, and peri-care to be provided each visit. The HA was to provide a bed bath and shampoo three times a week. The HA visit note dated 02/12/2025 documented that the patient refused her shampoo, bed bath, and oral care. The HA documented that the “Patient wasn’t feeling well.” The facility RN stated during an interview that “they had given her a muscle relaxer earlier for pain.” A clinical record review revealed no documentation that the HA notified the RN of the change to the care plan. Clinical Record 9: The patient elected the hospice benefit on 03/05/2025 with the diagnoses of Parkinson’s Disease, dementia with anxiety, anxiety disorder, epilepsy, depression, and moderate protein-calorie malnutrition. The plan of care for the benefit period dated 03/05/2025 to 06/02/2025 ordered Hospice Aide services twice a week for the first week after admission and then to increase visits to five (5) times a week. The Hospice Aide care plan dated 03/05/2025 assigned the HA the relevant tasks: hair care, nail care, oral care, and peri-care to be provided each visit. The HA was to provide a shower, shampoo, and shave three (3) times a week. The HA visit note dated 03/12/2025 documented that the patient refused to be showered, shampooed, or shaved. Nail care and oral care were also refused. On 03/14/2025, the HA documented that the patient declined a shower, shampoo, shave, and oral care. The patient refused to be shampooed, showered, or shaved and to have oral and nail care done on 03/17/2025. The HA visit note dated 03/18/2025 documented that the patient refused oral care, to be showered or shaved. On 03/20/2025, the visit note documented that the patient declined to be showered, shampooed, or shaved. Hair, skin, peri-care, and oral care were also declined. A clinical record review revealed no documentation that the HA notified the RN of the changes to the care plan. During a joint clinical record review and interview on 03/20/2025, the Patient Care Manager confirmed that the aide did not notify the nurse that the care plan was not followed.”

“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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients discharged, the agency did not ensure that the discharge summary was documented. Clinical Record 16: The patient elected the hospice benefit on 04/19/2024 and revoked hospice services to seek aggressive treatment at the hospital on 01/25/2025. A review of the clinical record revealed no evidence that a discharge summary was documented. An interview conducted on 03/20/2025 with the Corporate Director of Clinical Education confirmed that no discharge summary was documented in the clinical record.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) home visits observed in a nursing facility, the agency did not ensure that the facility was provided with the hospice election of benefits forms. Home Visit 1: The patient elected the hospice benefit on 10/07/2022 with the diagnosis of multiple sclerosis. The patient resided in a nursing facility (NF). The hospice NF chart was reviewed during the home visit with the Registered Nurse (RN) [Personnel Record 4] on 03/19/2025. It did not include the patient’s hospice election of benefits forms. During a joint facility chart review and an interview with the RN [Personnel Record 4] on 03/19/2025, when questioned about the missing hospice election forms, the RN stated that they only ever bring the patient’s plan of care/plan of care updates to place in the facility chart. The RN contacted the Patient Care Manager, who confirmed that the hospice does not provide the nursing facility with the hospice election forms and certifications. During an interview and a joint review of the finding on 03/19/2025, the Administrator and the Corporate Director of Clinical Education asked where this requirement was included in the regulations. The regulation was reviewed jointly with both.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) home visits observed in a nursing facility, the agency did not ensure that the facility was provided with the physician certification/ recertifications of terminal illness. Home Visit 1: The patient elected the hospice benefit on 10/07/2022 with the diagnosis of multiple sclerosis. The patient resided in a nursing facility (NF). The hospice NF chart was reviewed during the home visit with the Registered Nurse (RN) [Personnel Record 4] on 03/19/2025. The hospice NF chart did not include the physician’s certification or recertifications of terminal illness for the benefit periods: 10/07/2022 to 01/04/2023; 01/0452023 to 04/04/2023; 04/05/2023 to 06/03/2023; 06/04/2023 to 08/02/2023; 08/03/2023 to 10/01/2023; 10/02/2023 to 11/30/2023; 12/01/2023 to 01/29/2024; 01/30/2024 to 03/29/2024; 03/30/2024 to 05/28/2024; 05/29/2024 to 07/27/2024; 07/28/2024 to 09/25/2024; 09/26/2024 to 11/24/2024; 11/25/2024 to 01/23/2025; and 01/24/2025 to 03/24/2025. During a joint facility chart review and an interview with the RN [Personnel Record 4] on 03/19/2025, when questioned about the missing physician certification/recertifications of terminal illness, the RN stated that they only ever bring the patient’s plan of care/plan of care updates to place in the facility chart. The RN contacted the Patient Care Manager, who confirmed that the hospice does not provide the nursing facility with the hospice election forms and certifications. During an interview and a joint review of the finding on 03/19/2025, the Administrator and the Corporate Director of Clinical Education asked where this requirement was included in the regulations. The regulation was reviewed jointly with both.”