Alpha Hospice Plus Inc.

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by document review and interview with the Administrator and Director of Nursing (DON) which revealed the agency Failed to ensure that the emergency preparedness (EP) plan was reviewed and updated every two (2) years [HSEP.2.D/E4]; Failed to ensure that arrangements and an agreement were in place with a facility and other providers as part of their emergency plan [HSEP.3.D/E25]; Failed to ensure that the emergency preparedness (EP) policies and procedures included procedures to follow up with on-duty staff and patients to determine the services needed in the event of an interruption in services during or due to an emergency [HSEP.3.D/E16]; Failed to ensure emergency preparedness (EP) policies and procedures addressed the role of the staff providing care at alternate locations during an emergency [HSEP.3.D/E26]; Failed to ensure to develop and implement an EP plan that was based on a hospice-based and community-based risk assessment, using an “all-hazards” approach [HSEP.2.D/E6]; Failed to ensure that the EP plan included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials [HSEP.2.D/E9]; Failed to ensure that the emergency preparedness communication plan included primary and alternate means for communicating with hospice staff, as well as federal, state, tribal, regional, and local emergency management agencies [HSEP.4.D/E32]; Failed to ensure that the EP plan maintained a communication plan including the names and contact information for hospice employees, patients’ physicians, entities providing services under arrangement, and other hospices [HSEP.4.D/E30]. Failed to ensure that all new hospice employees and those providing services under arrangement receive initial training in EP policies and procedures consistent with their expected roles [HSEP.5.D/E37]; Failed to ensure that exercises were conducted to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years [HSEP.6.I/E39]; and Failed to ensure that the plan included the types of care and services the agency would be able to provide during an emergency or disaster if current staff and leadership were unavailable [HSEP.2.D/E7]. 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 418.113: Emergency Preparedness. 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 develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; and has evidence of action taken that results in improvement in hospice performance. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews with the Administrator and the Director of Nursing (DON) which revealed issues with the organization’s QAPI program in the following areas: Failed to ensure that the governing body appointed an individual as responsible for operating the QAPI program [HQPI.2.I/L576/418.58(e)(3)]; Failed to ensure that the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services in 2023, 2024, and 2025 [HQPI.3.I/L561/418.58(a)(1)]; Failed to ensure the hospice tracked, measured and analyzed quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events [HQPI.4. I/L562/418.58(a)(2)]; Failed to ensure the collection of data to monitor the effectiveness and safety of services and quality of care or identify [HQPI 5.I/L564/418.58(b)(2)(ii)]; Failed to ensure that the governing body approved the frequency and detail of the data collection. [HQPI.5.I/L565/418.58(b)(3)]; Failed to ensure that performance improvement activities track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice [HQPI.7.I/L569/418.58(c)(2)]; Failed to ensure that the hospice took action to improve performance, assess the success of the action after implementing it and track ongoing results to ensure improvement was sustained. There was no documented evidence to show a QAPI program was in place in 2023, 2024, and 2025 [HQPI.8.I/L570/418.58(c)(3)]; Failed to ensure that the hospice documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects [HQPI.9.I/L573/418.58(d)(2)]; Failed to ensure that the hospice conducted PI activities, including the investigation of infectious and communicable diseases within its infection control program [HQPI.6.I/L580/418.60(b)(1)]; and Failed to ensure the implementation and documentation of performance improvement projects conducted annually [HQPI.9.I/L571/418.58(d)]. 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 418.58: Quality assessment and performance improvement. 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 organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review, personnel record reviews, clinical record reviews, and interviews which revealed that the hospice did not ensure that an orientation about the hospice philosophy was provided to all employees and contracted staff who have patient and family contact [HSRM.15.I/L661/418.100(g)(1)]; Failure to ensure that each employee was provided an orientation that addressed the employee’s specific job duties [HSRM.15.I/L662/418.100(g)(2)]; Failure to ensure that the governing body assumed responsibility for the ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually [HSLG.2.I/L574/418.58(e)(1)]; Failure to ensure that the hospice provided care that was consistent with the patient’s and family’s needs and goals, with the patient’s needs and goals as priority [HSLG.4.I/L650/418.100(a)]; and Failure to assess the skills and competency of the individuals providing care [HSRM.14.I/L663/ 418.100(g)(3)]. 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 418.100: Organization and administration of services. The impact of these deficiencies could negatively impact the agency’s provision of safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure that the emergency preparedness (EP) plan was reviewed and updated every two (2) years. A review of the agency’s EP plan and administrative documents on 07/08/2025 revealed no evidence that the EP plan and policies were reviewed every two (2) years. During the joint review of the EP plan and policies on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 23) confirmed that there had been no review of the EP plan in 2023, 2024, or to date in 2025. A review of the agency’s Emergency Preparedness Plan and documentation, as well as interviews with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 23) on 07/08/2025, revealed that there was no evidence of a documented review of the plan in 2023, 2024, or 2025.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served; includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: power failures; natural or man-made disasters; emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. The agency did not ensure that the EP plan was based on a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. A review of the agency’s EP plan and administrative documents revealed no documented evidence of a hospice-based and community-based risk assessment, using an “all-hazards” approach for the agency’s geography and population served. No all-hazards vulnerability analysis was completed. During a joint review of the agency’s EP plan, administrative documentation, and interviews on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) confirmed that the agency’s EP plan lacked documentation of a hazard vulnerability analysis for 2023, 2024, or 2025. A review of the agency’s Emergency Preparedness Plan and documentation, as well as interviews with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) on 07/08/2025, revealed that the agency’s Emergency Preparedness Plan lacked the documentation of a hazard vulnerability analysis for 2023, 2024, or 2025.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: addresses the patient population served, specifically, the care and safety of patients with limited mobility, and those requiring evacuation due to a medical or psychiatric condition, or their home environment; addresses when emergency preparedness officials are contacted regarding evacuation of patients; defines the type of care and services the hospice can provide in an emergency; [and] addresses continuity of business functions essential to operations, including identification of staff or positions that can assume key organization roles if current staff and leadership are not available. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness plan (EP) on 07/08/2025 revealed the hospice did not ensure that the plan included the types of care and services the agency would be able to provide during an emergency or disaster, nor did it outline how essential business functions would be carried out if current staff and leadership were unavailable. During an interview and a joint review of the EP on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) confirmed that the EP did not include a continuity of business plan to ensure ongoing business functions during a natural or man-made disaster. An interview with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) on 07/08/2025, and a review of the agency’s Emergency Preparedness Plan revealed that it did not include a continuity of business plan to ensure ongoing business functions during a natural or man-made disaster.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. The plan: includes a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. This standard was not met as evidenced by document review and interview. The agency did not ensure that the EP plan developed included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. A review of the agency’s EP plan revealed a lack of documentation regarding contact information, coordination, and collaboration with local, regional, state, and federal emergency management officials, as well as efforts to maintain an integrated response during a disaster or emergency. There were no identified local, tribal, regional, state, and federal emergency preparedness officials documented. During a joint review of the agency’s EP plan and administrative documentation, and intrviews on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record emergency policies. d 3) confirmed that the agency did not develop and implemented the agency’s EP plan that contained the required contact information for the local, tribal, regional, state, or federal management officials. A review of the agency’s Emergency Preparedness Plan and documentation, as well as interviews with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) on 07/08/2025, revealed that the agency’ Emergency Preparedness Plan presented for review lacked documentation of any provision or contact information for contacting or coordinating with local, regional, state, or federal emergency managment officials.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment; the documented discussion of the plan provided to the patient/family, and maintained by the hospice; [and] follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. This standard was not met as evidenced by document review and interview. The hospice did not ensure that its emergency preparedness (EP) policies and procedures included procedures to follow up with on-duty staff and patients to determine the services needed in the event of an interruption in services during or due to an emergency. A joint review of the agency’s emergency plan and policies with the Administrator revealed that the agency did not ensure that a communication plan addressed agency-specific procedures to follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency and informing local and state emergency officials of any on-duty employees that the hospice is unable to contact; and specifying when to notify emergency officials if the hospice is unable to contact an employee. During an interview on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) confirmed that there was no documented process for primary and alternate methods of communication in the event of phone or power disruption. There was no agency-specific plan in place to document how follow-up would occur with patients, off-duty staff, and emergency officials. A review of the agency’s Emergency Preparedness Plan and documentation, along with interviews with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) on 07/08/2025, revealed that the plan lacked procedures for tracking on-duty employees or specifying when to notify emergency officials if the hospice is unable to contact an employee.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients This standard was not met as evidenced by document review and interview. The hospice did not ensure that arrangements and an agreement were in place with a facility and other providers as part of their emergency plan. During a joint review of the agency’s emergency preparedness plan (EP) and interviews with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025 revealed no letter of agreement or contract with a faclity or provider to receive the hospice’s patients in the event they could no longer provide the care and services needed to due a natural or man-made emergency. During a joint review of the agency’s Emergency Preparedness Plan (EP) and interviews with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025, it was revealed that there was no letter of agreement or contract with any providers to accept the care of the hospice’s patients in the event the agency can no longer provide the necessary care and services due to a natural or man-made emergency.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: the role of hospice employees in providing care at alternate care sites during emergencies. This standard was not met as evidenced by document review and interview. The hospice did not ensure that EP policies and procedures addressed the role of the staff providing care at alternate locations during an emergency. There was no documented evidence that the EP policies were based on the risk assessment, the communication plan, and the emergency plan. During a joint review of the agency’s EP plan and interviews on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) confirmed that the plan did not include provisions for staff to provide care at other sites during an emergency. During a joint review of the agency’s Emergency Preparedness Plan (EP) and interviews with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025, it was revealed that the plan did not include provisions for staff to provide care at other sites during an emergency.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes the names and contact information for hospice employees, patients’ physicians, entities providing services under arrangement, and other hospices. This standard was not met as evidenced by a review of documents and interviews, which revealed the agency did not ensure that the communication plan included names and contact information for hospice employees. A review of the agency’s emergency preparedness (EP) plan revealed the communication plan did not include hospice employees’ names and contact information. During a joint review of the agency’s emergency plan (EP) and associated documents and interviews on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025 confirmed the agency lacked a comprehensive communication plan that included contact information for staff, patients, contracted services, patient physicians or other hospices. During a joint review of the agency’s Emergency Preparedness Plan (EP) and interviews with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025 revealed the agency lacked a comprehensive communication plan that included contact information for staff, patients, contracted services, patient physicians or other hospices.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes primary and alternate means for communicating with hospice staff, federal, state, tribal, regional, and local emergency management agencies. This standard was not met as evidenced by document review and interview. The hospice did not ensure that the emergency preparedness communication plan included primary and alternate means for communicating with hospice staff, as well as federal, state, tribal, regional, and local emergency management agencies. A review of the emergency preparedness (EP) plan and administrative documents revealed that the EP plan did not document a communication plan including hospice staff, state, tribal, regional, and local emergency management agencies. During a joint review of the agency’s emergency preparedness plan (EP) and interviews on 07/08/2025, the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) verified that the agency lacked documentation of a comprehensive communication plan that includes primary and alternate means for contacting and communicating with staff and local emergency officials. During a joint review of the agency’s Emergency Preparedness Plan (EP) and interviews with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025 revealed the agency lacked documentation of a comprehensive communication plan that includes primary and alternate means for contacting and communicating with staff and local emergency officials.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training, including the date(s), participants, and content. This standard was not met as evidenced by document review and interview. The hospice did not ensure that all new hospice employees and those providing services under arrangement receive initial training in EP policies and procedures consistent with their expected roles. Agency policy “Fire Safety (EC.45)” (last reviewed 09/01/2024) stated, “fire drills will be conducted annually as part of the Emergency Preparedness Plan...” Agency policy “The Emergency Preparedness and Response Plan (EC.40),” (last reviewed 09/01/2024) stated, “The Hospice will develop and maintain an emergency preparedness training and testing program for staff... The Hospice will provide initial training at orientation and at least annually thereafter...” A review of the agency’s Emergency Preparedness documentation and eight of nine personnel records revealed no documentation indicating emergency preparedness education or training was provided to staff upon hire. During an interview and a joint review of the EP plan and policies on 07/08/2025, the Administrator and the Director of Nursing confirmed that there was no documentation of annual fire drills. The agency’s Emergency Preparedness Plan and related documentation were reviewed, and interviews conducted on 07/08/2025 with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) revealed that the agency lacked documentation of any fire drills. The agency policy titled “Fire Safety (EC.45),” last reviewed on 09/01/2024, states that “...fire drills will be conducted annually as part of the Emergency Preparedness Plan...” Upon reviewing the Emergency Preparedness documentation and eight of nine personnel records, it was also found that there was no documentation indicating that any emergency preparedness education or training was provided to staff upon hire. The policy “The Emergency Preparedness and Response Plan (EC.40),” last reviewed on 09/01/2024, specifies that “...The Hospice will develop and maintain an emergency preparedness training and testing program for staff... The Hospice will provide initial training at orientation and at least annually thereafter...” but no evidence of such training was documented.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise; a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure that exercises were conducted to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. The agency’s Emergency Preparedness Plan and related documentation were reviewed, and interviews were conducted on 07/08/2025 with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3), which revealed no documentation of testing the emergency plan or responses to actual events in 2023 or 2024. However, documentation existed of the activation of the emergency plan in response to a storm/tornado warning on 05/06/2025, including a post-event assessment. The agency’s Emergency Preparedness Plan and related documentation were reviewed, and interviews conducted on 07/08/2025 with the Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) revealed no documentation of any testing of the emergency plan or responses to actual events in 2023 or 2024. However, there was documentation of the activation of the emergency plan in response to a storm/tornado warning on 05/06/2025, including a post-event assessment.”

“It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This standard was not met as evidenced by clinical record review, document review, observation, and interview. In 5 of 9 (56%) clinical records reviewed, the agency did not ensure that the patient/representative received a written and verbal review of the Patient’s Rights and Responsibilities, as well as the Rights of the Elderly. SAMPLE ADMISSION PACKET: The agency’s sample “Admission Packet provided for review on 07/09/2025 included Hospice Informed Consent/Election of the Hospice Benefit forms - page 2 of 6, which included the statement “I have received a copy along with a verbal explanation of the following: Patient Rights and Responsibiities and Patient Choice Statement, Rights of the Elderly, Advanced Directives Information, HIPAA/Notice of Privacy Practices Information, Abuse, Neglect, and Exploitation policy, Emergency Preparedness/Natural Disaster Information, Home Safety Information, Medicare Part D information, Home Hazardous Waste Disposal information, Infection Control Education, Hospice Drug Testing policy, Expected Death (At Home) policy Patient Rights and Responsibilities, Rights of the Elderly, Advanced Directives Information, Abuse, Neglect, and Exploitation policy. The policies for “Disposal of Controlled Substances and Medication Disposal” were not included. Agency policy “Patient’s Rights and Responsibilities (RI.10)” (reviewed 10/01/2021) stated in part, “A copy of the notice of the patient’s bill of rights and responsibilities will be given to the patient at the time of the patient’s initial assessment and prior to admission to the Hospice...The Hospice will obtain the patient’s or representative’s signature confirming that he or she has received a copy of he notice of rights and responsibilities and will be witnessed by a Hospice staff member....” Addendum to the agency policy “Patient’s Rights and Responsibilities (RI.10)” (reviewed 05/01/2023) stated in part, “The Hospice will provide a written list regarding the Rights of the Elderly...to each elderly individual and/or representative in advance of furnishing care or during the initial evaluation visit before the initiation of treatment...” Clinical Record 2/Home Visit 1: The patient elected the hospice benefit on 07/02/2025. Included in the Hospice Informed Consent/Election of Hospice Benefit Form, page 2 of 6, the statement, “I acknowledge I have received a copy along with a verbal explanation of the following...Patient Rights and Responsibilities...Rights of the Elderly...” was missing. There was no documentation of a verbal review of the Patient’s Rights and Responsibilities or the Rights of the Elderly in the initial assessment completed by the Registered Nurse (RN) dated 07/02/2025. During the home visit with the RN [Personnel Record 3] on 07/09/2025, a review of the patient’s agency-provided home hospice folder revealed that no copies of the Patient’s Rights and Responsibilities or the Rights of the Elderly policies were present. Clinical Record 3: The patient elected the hospice benefit on 08/09/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement that “I acknowledge I have received a copy along with a verbal explanation of the following...Patient Rights and Responsibilities...Rights of the Elderly...” was missing. There was no documentation that the patient/family was provided with copies of the Patient Rights and Responsibilities or the Rights of the Elderly, and no documentation of a verbal review of the Patient’s Rights and Responsibilities or the Rights of the Elderly in the initial assessment completed by the RN dated 08/09/2024. Clinical Record 4: The patient elected the hospice benefit on 08/09/2024.A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of the following...Patient Rights and Responsibilities...Rights of the Elderly...” was missing. There was no documentation that the patient/family was provided with copies of the Patient Rights and Responsibilities or the Rights of the Elderly, and no documentation of a verbal review of the Patient’s Rights and Responsibilities or the Rights of the Elderly in the initial assessment completed by the RN dated 08/09/2024. Clinical Record 7: The patient elected the hospice benefit on 07/26/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit scanned into the clinical record did not include the statement “I have received a copy along with a verbal explanation of the following: Patient Rights and Responsibilities... Rights of the Elderly.” There was no documentation that the patient/family was provided with copies of the Patient Rights and Responsibilities or the Rights of the Elderly, and no documentation of a verbal review of the Patient’s Rights and Responsibilities or the Rights of the Elderly in the initial assessment completed by the RN dated 07/26/2024. Clinical Record 9: The patient elected the hospice benefit on 08/13/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of the following...Patient Rights and Responsibilities...Rights of the Elderly...” was missing. There was no documentation that the patient/family was provided with copies of the Patient Rights and Responsibilities or the Rights of the Elderly, and no documentation of a verbal review of the Patient’s Rights and Responsibilities or the Rights of the Elderly in the initial assessment completed by the RN dated 08/13/2024. During a joint document review and interview on 07/09/2025, the Director of Nursing (DON) confirmed that the patient admitted on 07/02/2025 was not provided copies of the Patient Rights and Responsibilities or the Rights of the Elderly with their Election of Benefit Form. No additional documentation was produced by the end of the site visit.”

“It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. It is the patient’s right to formulate an advance directive should she or he wish to do so. The hospice maintains written policies and procedures concerning advance directives with respect to all adult individuals receiving care by or through the hospice. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 9 (44%) clinical records reviewed, the agency did not ensure that the patient received information about its policies on advance directives, including a description of applicable state law. Agency policy “Advance Directives (RI.5)” (reviewed 09/01/2024) stated in part “Purpose: To ensure that adult patients and their legal representatives are informed of patient rights under federal and state law to make and direct decisions concerning medical care, and the right to formulate advance directives...The Hospice will distribute to and review with the patient or their legal representative written information relating to the patient’s right to refuse medical or surgical treatment and the right to formulate advance directives, as well as the Hospice policies relating to advance directives at the time of initial receipt of hospice care by the individual...” SAMPLE ADMISSION PACKET: The sample admission packet provided for review on 07/09/2025 included Hospice Informed Consent/Election of the Hospice Benefit forms - page 2 of 6, which included the statement “I have received a copy along with a verbal explanation of the following: Patient Rights and Responsibilities and Patient Choice Statement, Rights of the Elderly, Advanced Directives Information, HIPAA/Notice of Privacy Practices Information, Abuse, Neglect, and Exploitation policy, Emergency Preparedness/Natural Disaster Information, Home Safety Information, Medicare Part D information, Home Hazardous Waste Disposal information, Infection Control Education, Hospice Drug Testing policy, Expected Death (At Home) policy Patient Rights and Responsibilities, Rights of the Elderly, Advanced Directives Information, Abuse, Neglect, and Exploitation policy. The Disposal of Controlled Substances and Medication Disposal policies were not included. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of...Advance Directives Information...” was missing. There was no documentation of a verbal review of advance directives in the initial assessment completed by the Registered Nurse (RN) on 08/09/2024, and no documentation that the patient/family received information on hospice policies and state and federal regulations regarding advance directives upon initiation of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of...Advance Directives Information...” was missing. There was no documentation of a verbal review of advance directives in the initial assessment completed by the Registered Nurse (RN) on 08/09/2024, and no documentation that the patient/family received information on hospice policies and state and federal regulations regarding advance directives upon initiation of hospice care. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/26/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of...Advance Directives Information...” was missing. There was no documentation of a verbal review of advance directives in the initial assessment completed by the Registered Nurse (RN) on 07/26/2024, and no documentation that the patient/family received information on hospice policies and state and federal regulations regarding advance directives upon initiation of hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/13/2024. A review of the patient’s clinical record revealed that the Hospice Informed Consent/Election of the Hospice Benefit Form, with the statement “I acknowledge I have received a copy along with a verbal explanation of...Advance Directives Information...” was missing. There was no documentation that the patient/family received information on hospice policies and state and federal regulations regarding advance directives upon initiation of hospice care. During a joint document review and interview on 07/09/2025, the Director of Nursing (DON) provided no further documentation or information regarding the missing or incomplete documentation. The DON confirmed that the sample admission packet provided for review was distributed as it had been, without the referenced policies included.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies, and procedures on advance directives. This standard was not met as evidenced by document review, interview, and personnel record review. In 7 of 9 (78%) personnel records reviewed, the agency did not ensure that each employee received education and training on infection control and procedures on advance directives. Agency policy “Employee Orientation (HR.40)” (last reviewed 05/12/2025) stated in part, “New employees will be oriented to hospice policies applicable to the employee’s position and will sign an acknowledgment of reading, understanding, and complying with the policies ...The hospice will define the orientation content and proficiency for each job classification. The hospice orientation will include...Safety/OSHA...Exposure Control Plan and the Infection Control Program...Clinical Orientation...Patient care policies and procedures, including...Patient rights and responsibilities...Advance Directives...” PERSONNEL RECORD 2: The Administrator was hired on 11/01/2024. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 3: The Director of Nursing (DON) was hired on 11/01/2024. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 5: The Social Worker (SW) was hired on 04/18/2025. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 6: The Chaplain/Bereavement Coordinator was hired on 11/23/2024. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 7: The Volunteer Coordinator (VC) was hired on 11/21/2024. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 8: The Hospice Aide (HA)/Certified Nursing Assistant (CNA) was hired on 05/29/2025. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. PERSONNEL RECORD 9: The Volunteer was hired on 04/07/2025. A personnel record review revealed no documentation of an initial orientation that addressed infection control education/training and advanced directives. During an interview and a joint personnel record review on 07/10/2025, the Administrator (Personnel Record 2) confirmed that the personnel records were missing documented onboarding and orientation that included education and training regarding infection/exposure control and advance directives.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient received a pain assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024. There was no documentation of an initial or comprehensive assessment completed by a Registered Nurse (RN), and thus, no pain assessment was documented. A document for continuous care by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, included documentation of 0.5 to 1.0 mL of Morphine Sulfate administered to the patient. Written at the top was “RX #741670200,” dated 08/16/2024, for Morphine Sulfate 20mg/mL. The patient was pronounced on 08/17/2024. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) confirmed that there was no documentation of a pain assessment in the patient’s record. During a phone interview on 07/10/2025, the Part Owner/Governing Body Member stated that the patients admitted in August 2024 were “test” patients entered into the Electronic Medical Record (EMR) to learn how to utilize the EMR’s functions. The Part Owner/Governing Body Member was informed that the clinical record contained no documentation stating such, and that the patient records were included as part of the clinical record review for the site visit. The Part Owner/Governing Body Member replied that they understood. During an interview on 07/10/2025, the Administrator stated that the agency did not bill for this patient admission.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 9 (56%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) coordinated care between the Interdisciplinary Team (IDG) and the patient/patient’s family. Agency policy “Interdisciplinary Group Roles and Responsibilities (PC.40)” (reviewed 09/01/2024) stated in part, “The hospice will designate a Registered Nurse (RN) who is a member of the IDG/IDT to provide coordination of care...The IDG/IDT will maintain responsibility for directing, coordinating, and supervising care and services provided...” CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no evidence documenting the coordination of care with the Interdisciplinary Group (IDG) or the patient’s attending physician upon the patient’s discharge from hospice services. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no evidence documenting the coordination of care with the Interdisciplinary Group (IDG) or the patient’s attending physician upon the patient’s discharge from hospice services. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/12/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no evidence documenting the coordination of care with the Interdisciplinary Group (IDG) or the patient’s attending physician upon the patient’s discharge from hospice services. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no evidence documenting the coordination of care with the Interdisciplinary Group (IDG) or the patient’s attending physician upon the patient’s discharge from hospice services. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024. A review of the patient’s clinical record revealed no documentation of an initial or comprehensive assessment completed by a Registered Nurse (RN), and no physician orders or plan of care were documented. A document for continuous care by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, included documentation of 0.5 to 1.0 mL of Morphine Sulfate administered to the patient. There was no documentation of coordination of care between the RN, the LVN, and the physician regarding pain management and continuous care. During a phone interview on 07/10/2025, the Part Owner/Governing Body Member stated that the patients admitted in August 2024 were “test” patients entered into the Electronic Medical Record (EMR) to learn how to utilize the EMR’s functions. The Part Owner/Governing Body Member was informed that the clinical record contained no documentation stating such, and that the patient records were included as part of the clinical record review for the site visit. The Part Owner/Governing Body Member replied that they understood.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient’s and family’s goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 08/09/2024 documented that the patient struggled with a spastic colon and reported experiencing constipation alternating with diarrhea and eight (8) days between bowel movements. Additionally, it was documented that the patient was at high risk for skin tears and pressure ulcers due to poor nutrition. The patient’s plan of care did not include documentation of interventions addressing the identified problems of constipation and high risk for impaired skin integrity. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing confirmed the patient’s plans of care did not include planned interventions based on identified problems in the clinical documentation.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness, including the following: includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included goals with measurable outcomes. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/13/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 08/09/2024, documented that the patient’s pain level was rated “5” and shortness of breath was rated “3” in the symptom assessment. Additionally, the RN documented that the pain was generalized back pain that increased with movement and interfered with daily living activities, and that the patient’s pain level was at a point at which further intervention would be required. By the end of the visit, the RN documented the patient’s pain level to be 3. The caregiver also reported that the patient’s oxygen saturation had been sustained in the 80% range. An oxygen concentrator with tubing was ordered to be delivered (immediately or without delay) “STAT.” A physician’s order was documented at admission for hydrocodone 5mg-325mg to be administered by mouth every 4-6 hours as needed for pain. Pain and shortness of breath were identified as problems in the patient’s plan of care dated 08/09/2024 to 08/13/2024, with the patient’s goal being “monitoring these symptoms at every visit.” The goal “monitoring these symptoms at every visit” does not include a measurable outcome. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing confirmed that the included goal was not measurable.”

“It is required that the QAPI program demonstrates improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met, as evidenced by document review and interview. A review of the QAPI plan revealed the agency did not ensure that the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services in 2023, 2024, and 2025. There was no documented evidence to show a QAPI program was in place in 2023, 2024, and 2025. The QAPI plan and documentation were lacking the required analysis of indicators by the QAPI committee, as required by agency policy. Agency policy “Medical Record Review/Utilization Review (IM.9)” (12/01/2019) stated in part, “At quarterly intervals, a random sampling of services furnished to patients obtained in both active and closed records will be selected for review. This sampling should contain all disciplines offered by the Agency...The results will be analyzed through the QAPI Committee’s performance improvement process, presented to the Board of Directors, and presented to appropriate Agency staff.” During a joint review of the Quality Assurance and Performance Improvement (QAPI) Plan and its associated documentation with the Director of Nursing (DON) on July 8, 2025, no supporting documents were found regarding data collection for a performance improvement project. Additionally, there was no available data tracking for measurable indicators. During a review of the QAPI Plan and documentation, along with an interview with the Director of Nursing (DON) (Personnel Record 3) on 07/08/2025, it was found that no documentation could be provided regarding data collection to support a performance improvement project, nor was any data tracking of measurable indicators available. Medical Record Review/Utilization Review (IM.9) 12/01/2019 “...At quarterly intervals, a random sampling of services furnished to patients obtained in both active and closed records will be selected for review. This sampling should contain all disciplines offered by the Agency...The results will be analyzed through the QAPI Committee’s performance improvement process, presented to the Board of Directors, and presented to appropriate Agency staff.””

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of: processes of care; hospice services; operations; [and] adverse patient events. This standard was not met, as evidenced by a document review. A review of the QAPI program and associated documents revealed the agency did not ensure the hospice tracked, measured and analyzed quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events. There was no documented evidence to show a QAPI program was in place in 2023, 2024, and 2025. There was no documented evidence of operational and quality measures that included infection tracking, adverse event reporting, complaints, clinical record audits, HR file audits, contract review documentation, QAPI meeting minutes, and performance improvement projects. During an interview on 07/09/2025, the Director of Nursing (Personnel Record 3) confirmed that the organization had not evaluated progress toward outcomes or identified areas for improvement based on the data analysis results. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025 revealed only the initial QAPI Plan. No supporting documentation was found regarding data collection, infection tracking, adverse events, complaints, clinical record reviews or audits, HR file audits, contract review documentation, QAPI meeting minutes, or Performance Improvement Projects. Furthermore, the organization has not demonstrated any evaluation of progress toward outcomes or identified areas for improvement based on data analysis results.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data collected is used to: monitor the effectiveness and safety of services and quality of care; [and] identify opportunities and priorities for improvement. This standard was not met as evidenced by document review and interview, which revealed that the governing body did not utilize quality indicator data in its QAPI program to monitor the effectiveness and safety of services, as well as the quality of care, while identifying opportunities and priorities for improvement. A joint review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/08/2025, revealed only the initial QAPI Plan. No supporting documentation was available to demonstrate that any quality indicator data was collected or monitored. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/08/2025, revealed only the initial QAPI Plan. No supporting documentation was available to demonstrate data collection, infection tracking, adverse events, complaints, clinical record reviews or audits, HR file audits, contract review documentation, QAPI meeting minutes, or Performance Improvement Projects.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. The frequency and detail of the data collection is approved by the hospice’s governing body. This standard was not met, as evidenced by document review and interview. A review of the QAPI program and related documents and governing body minutes revealed the agency did not ensure that the governing body approved the frequency and detail of the data collection A review of the agency’s governing body meeting minutes for 2023, 2024, and 2025 revealed no documentation indicating the governing body’s approval of the frequency and detail of the QAPI program’s data collection. The Administrator (Personnel Record 2) and the Director of Nursing (Personnel Record 3) verified that there was no approval for the frequency and detail of the data collection. They were unable to provide additional supporting documentation on this matter as of the exit conference on 07/10/2025. Review of the Governing Body Meeting minutes for 2023, 2024, and 2025 revealed no documentation indicating the Governing Body’s approval of the frequency and detail of the QAPI program’s data collection. Neither the Administrator (Personnel Record 2) nor the Director of Nursing (Personnel Record 3) were able to provide any additional supporting documentation on this matter.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met, as evidenced by a document review and interview. A review of the QAPI plan and associated documents revealed the agency did not ensure that the agency did not ensure that performance improvement activities; tracked adverse patient events, analyzed their causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice.There was no documented evidence to show that a QAPI program was in place in 2023, 2024, and 2025.There was no documented evidence that the agency’s QAPI plan identified performance improvement activities or analysis. During an interview on 07/09/2025, the Director of Nursing (Personnel Record 3) confirmed the presence of only the initial QAPI plan, stating that it did not include any data collection, trending, or analysis of information. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025 revealed the presence of only the initial QAPI Plan. The review did not find any data collection, trending, or analysis of information.”

“It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it, and tracks ongoing results to ensure improvement is sustained. The standard was not met, as evidenced by document review and interviews. A review of the QAPI plan and associated documents revealed the agency did not ensure that the hospice took action to improve performance, assess the success of the action after implementing it and track ongoing results to ensure improvement was sustained. There was no documented evidence to show a QAPI plan, processes to improve performance, assess the success of the action after implementation, and tracking of ongoing results for sustained improvement in 2023, 2024, and 2025. A joint review of the QAPI plan and associated documents and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025 identified the absence of any current or past performance improvement projects or plan for 2023, 2024, or 2025. The DON confirmed that they had not taken actions to improve performance. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025, revealed the absence of any current or past performance improvement projects for 2023, 2024, or 2025.”

“It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served and the internal needs of the organization, and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. The agency did not ensure the implementation and documentation of performance improvement projects conducted annually. A review of the agency’s QAPI (Quality Assurance and Performance Improvement) program and activities revealed no documented evidence that performance improvement projects had been conducted since the initial QAPI Plan was developed. No performance improvement projects were documented for 2023, 2024, or 2025 to date. During a joint QAPI program review and interview on 07/09/2025, the Director of Nursing (Personnel Record 3) acknowledged that the agency did not utilize data from the QAPI program to identify and implement performance improvement projects. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025 revealed the presence of only the initial QAPI Plan and no performance improvement project documentation for 2023, 2024, or 2025.”

“It is required that the hospice governing body is responsible for ensuring an ongoing program for quality improvement and patient (QAPI). The hospice governing body is responsible for ensuring that the QAPI plan is evaluated annually. This standard was not met as evidenced by document review and interview. A review of the governing body minutes and the QAPI program revealed that the hospice did not ensure that the governing body defined, implemented, maintained, and evaluated the performance improvement program (QAPI) annually. There was no documented evidence that the governing body evaluated and was involved in the performance improvement program annually in 2023, 2024, and 2025. There was no documented evidence that the agency maintained an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program in 2023, 2024, and 2025. A joint review of the QAPI Program and related documentation with the Director of Nursing (DON) (Personnel Record 3) was conducted on 07/08/2025. The DON verified only their initial QAPI Plan was documented, and that there was no documented evidence available to demonstrate that the QAPI program had been implemented and maintained beyond the initial QAPI plan. There was no documented evidence of QAPI meeting minutes or performance improvement projects. Additionally, the DON verified that the Governing Body meeting minutes from 2023, 2024, or 2025 lacked evidence of an annual review of the QAPI program. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/08/2025 produced only the initial QAPI Plan. No supporting documentation was available to demonstrate data collection, infection tracking, adverse events, complaints, clinical record reviews, audits, personnel file audits, contract review documentation, QAPI meeting minutes, or Performance Improvement Projects. Additionally, the Governing Body meeting minutes from 2023, 2024, or 2025 lacked evidence of an annual review of the QAPI program. This indicates that the hospice governing body has not fulfilled its responsibility to ensure that a continuous program for quality improvement and patient safety is defined, implemented, maintained, and evaluated on an annual basis.”

“It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s: overall management and operation; provision of care and services; and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually This standard was not met as evidenced by document review and interview. The hospice did not ensure that the governing body assumed responsibility for defining, implementing and evaluating annually the hospice’s ongoing program for quality improvement and patient safety. Review of the governing body (GB) minutes provided revealed no evidence that the governing body addressed the agency’s quality program and patient safety. There was no evidence that the GB defined and implemented and evaluated the QAPI program. Agency policy “Governing Body (LD.15)” (last reviewed 02/01/2025) stated that the Governing Body “will have ultimate responsibility and legal authority for the management of the Hospice’s...Ongoing Quality Assessment Performance Improvement (QAPI) program that is defined, implemented, maintained, and evaluated annually.” A joint review of the governing body meeting minutes dated 09/28/2023, 12/27/2024, and 01/15/2025 with the Administrator revealed no documentation indicating Governing Body oversight of the Quality Assessment and Performance Improvement (QAPI) program or evidence of an annual review of the program. A review of Governing Body Meeting minutes from 09/28/2023, 12/27/2024, and 01/15/2025, along with an interview with the Administrator (Personnel Record 2) on 07/10/2025, revealed no documentation indicating the Governing Body’s oversight of the Quality Assessment and Performance Improvement (QAPI) program or evidence of an annual review of the program. The agency’s policy “Governing Body (LD.15),” last reviewed on 02/01/2025, states that the Governing Body “will have ultimate responsibility and legal authority for the management of the Hospice’s...Ongoing Quality Assessment Performance Improvement (QAPI) program that is defined, implemented, maintained, and evaluated annually.””

“It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview revealed that the governing body did not ensure that an individual(s) was appointed to be responsible to operate the QAPI program. A review of the Governing Body Meeting minutes from 2023, 2024, and 2025 revealed that no individual had been appointed to oversee or operate the agency’s QAPI program. Additionally, a review of personnel records on 07/10/2025 showed that no staff members were assigned these duties or responsibilities. During interviews on 07/09/2025, the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) confirmed that no one had actively reviewed or taken action regarding the QAPI program. A review of the Governing Body Meeting minutes from 2023, 2024, and 2025 revealed that no individual had been appointed to oversee or operate the agency’s QAPI program. Additionally, a review of personnel records on 07/10/2025 showed that no staff members were assigned these duties or responsibilities. During interviews conducted with the Administrator (Personnel Record 2) and the Director of Nursing (DON) (Personnel Record 3) on 07/09/2025, it was confirmed that no one had actively reviewed or taken action regarding the QAPI program.”

“It is required that hospice performance improvement (PI) activities: include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met, as evidenced by a document review and interview, which revealed that the agency’s governing body did not ensure that the hospice conducted PI activities, including the investigation of infectious and communicable diseases within its infection control program. A joint review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025, confirmed that no data was gathered on patient or employee infections, and no analysis or tracking of infection data was conducted. A review of the QAPI Program documentation and an interview with the Director of Nursing (Personnel Record 3) on 07/09/2025, confirmed that there was no data gathered on patient or employee infections and no analysis or tracking of infection data.”

“It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This standard was not met as evidenced by document review and interview. The agency did not ensure that a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases was maintained. Agency policy “Exposure Control Plan (IC.5)” (reviewed 05/01/2025) stated in part, “The Hospice will design, implement, and evaluate annually an Exposure Control Plan that will include identifying which job-related tasks will put Healthcare Personnel (HCP) at an increased risk for exposure to an airborne or bloodborne pathogen...Ensuring that education, exposure follow-up, and documentation will be completed as outlined in the Bloodborne Pathogen Program, per Occupational Safety and Health Administration...On hire and annually, all HCP will be provided education on the exposure control program...Hospice Responsibilities...to provide training and information related to airborne and bloodborne pathogens for all HCP upon hire and annually thereafter...” During a joint review of the agency’s QAPI documentation and interviews on 07/10/2025, the Director of Nursing (DON) and the Administrator confirmed that there was no monitoring, tracking, trending, analysis, or reporting of any patient or employee infections, no education provided to staff members, and no TB screening or testing upon hire. A review of the agency’s QAPI documentation and interviews with the Director of Nursing (DON) (Personnel Record 3) and the Administrator (Personnel Record 3) on 07/10/2025, confirmed that there was no monitoring, tracking, trending, analysis, or reporting of any patient or employee infections, no education provided to staff members, and no TB screening or testing upon hire. The hospice’s policy “Exposure Control Plan (IC.5)” last reviewed 05/01/2025, read in part that “...the Hospice will design, implement, and evaluate annually an Exposure Control Plan that will include identifying which job-related tasks will put Healthcare Personnel (HCP) at an increased risk for exposure to an airborne or bloodborne pathogen...Ensuring that education, exposure follow-up, and documentation will be completed as outlined in the Bloodborne Pathogen Program, per Occupational Safety and Health Administration...On hire and annually, all HCP will be provided education on the exposure control program...Hospice Responsibilities...to provide training and information related to airborne and bloodborne pathogens for all HCP upon hire and annually thereafter...””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: education of employees. This standard was not met as evidenced by document review, interview, and personnel record review. In 7 of 7 (100%) personnel records reviewed for employees who required infection control education, the agency did not ensure that employees received infection control training and information upon hire and annually per the agency’s policy. Agency policy “Employee Orientation (HR.40)” (reviewed on 05/12/2025) stated, “The hospice orientation will include...Safety/OSHA...Exposure Control Plan and the Infection Control Program...” Agency policy “Exposure Control Plan (IC.5)” (reviewed 05/01/2025) stated in part, “On hire and annually, all HCP will be provided education on the exposure control plan...” PERSONNEL RECORD 2: The Administrator was hired on 11/01/2024. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 3: The Director of Nursing (DON) was hired on 11/01/2024. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 5: The Social Worker (SW) was hired on 04/18/2025. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 6: The Chaplain/Bereavement Coordinator was hired on 11/23/2024. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 7: The Volunteer Coordinator (VC) was hired on 11/21/2024. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 8: The Hospice Aide (HA)/Certified Nursing Assistant (CNA) was hired on 05/29/2025. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. PERSONNEL RECORD 9: The Volunteer was hired on 04/07/2025. A review of the personnel record and in-service records on 07/10/2025 revealed no documentation of education on infection control for the employee upon hire. During a joint personnel and in-service record review and interview on 07/10/2025, the Administrator confirmed that no infection control education had been provided to the staff since their hire.”

“It is required that licensed professionals participate in hospice-sponsored in-service training. This standard was not met as evidenced by document review and interview. The agency did not ensure that the licensed professionals participated in agency-sponsored in-services. During a joint review of personnel records and an interview on 07/10/2025, the Administrator could not provide documentation that in-service training had occurred. Nor was agency-sponsored in-service education documented in the personnel records. During a joint review of personnel records and an interview with the Administrator (Personnel Record 2) on 07/10/2025, it was revealed that no in-service training had been provided nor any documented in the employee files.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure that ongoing efforts to recruit and retain volunteers were documented. During a review of the volunteer program documentation and an interview on 07/10/2025, the Administrator confirmed that no documentation could be provided to demonstrate activities to recruit and retain volunteers, despite the agency meeting the 5% requirement for volunteer hours. A review of the volunteer program documentation and an interview with the Administrator (Personnel Record 2) on 07/10/2025 confirmed that no documentation could be produced to demonstrate a volunteer orientation and training program, nor any records outlining activities to recruit and retain volunteers, despite the agency meeting the 5% requirement for volunteer hours.”

“It is required that the management and governing body (or designated persons so functioning) of the hospice is responsible to provide care that: optimizes comfort and dignity; [and] is consistent with patient and family needs and goals, with the patient’s needs and goals as priority. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 9 (100%) clinical records reviewed, the agency management and governing body did not ensure that the hospice provided care that was consistent with the patient’s and family’s needs and goals, with the patient’s needs and goals as priority. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024. A review of the patient’s clinical record revealed no documentation of an initial or comprehensive assessment completed by a Registered Nurse (RN); thus, no pain assessment was completed. There were no physician orders or plan of care documented in the clinical record. A scanned document that included continuous care notes by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, had written at the top - “RX #741670200,” dated 08/16/2024, for Morphine Sulfate 20mg/ml, which was documented as 0.5 to 1.0 ml Morphine Sulfate administered to the patient 12 times. Lorazepam 2mg/ml was also written and dated 08/16/2024, with the “RX #741671200.” The LVN documented that 0.5 ml of Lorazepam had been administered nine (9) times. A scanned document entitled ‘Medication Profile and Teaching Form’ documented the medications and was signed by the Registered Nurse (RN) as a telephone order; however, it did not include the physician’s name or signature. There were no medication orders documented in the patient’s clinical record/plan of care. There was no documentation of coordination of care between the RN, the LVN, and the physician regarding pain management and continuous care. During a joint clinical record review and interviews on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that the patient’s clinical record was missing an initial plan of care, physician medication orders, and comprehensive assessments, including a pain and bereavement risk assessment. No further documentation was provided prior to the end of the site visit.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, interview, and personnel record review. In 8 of 9 (89%) personnel records reviewed, the agency did not ensure that all employees and contracted staff were oriented to the hospice philosophy. Agency policy “Employee Orientation (HR.40)” (last reviewed on 05/12/2025) stated in part, “The hospice will provide orientation about the philosophy of hospice to all employees, including volunteers and contracted staff who have patient and family contact...” PERSONNEL RECORD 1: The contracted Medical Director had an effective hire date of 11/22/2024. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 2: The Administrator was hired on 11/01/2024. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 3: The Director of Nursing (DON) was hired on 11/01/2024. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 5: The Social Worker (SW) was hired on 04/18/2025. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 6: The Chaplain/Bereavement Coordinator was hired on 11/23/2024. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 7: The Volunteer Coordinator (VC) was hired on 11/21/2024. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 8: The Hospice Aide (HA)/Certified Nursing Assistant (CNA) was hired on 05/29/2025. A personnel record review revealed no documentation of orientation to the hospice philosophy. PERSONNEL RECORD 9: The Volunteer was hired on 04/07/2025. A personnel record review revealed no documentation of orientation to the hospice philosophy. During an interview and a joint personnel record review on 07/10/2025, the Administrator confirmed that personnel records did not include the required documentation of education regarding the philosophy of hospice.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. This standard was not met as evidenced by document review, interview, and personnel record review. In 8 of 9 (89%) personnel records reviewed, the agency did not ensure that an initial hospice orientation was provided for each employee that addressed the employee’s specific job duties. Agency policy “Employee Orientation (HR.40)” (last reviewed on 05/12/2025) stated in part, “The Hospice will orient each employee, as necessary and appropriate, to their respective job responsibilities and Hospice policies and procedures prior to performing job duties independently...” PERSONNEL RECORD 1: The contracted Medical Director (MD) had an effective hire date of 11/22/2024. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 2: The Administrator was hired on 11/01/2024. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 3: The Director of Nursing (DON) was hired on 11/01/2024. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 5: The Social Worker (SW) was hired on 04/18/2025. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 6: The Chaplain/Bereavement Coordinator was hired on 11/23/2024. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 7: The Volunteer Coordinator (VC) was hired on 11/21/2024. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 8: The Hospice Aide (HA) was hired on 05/29/2025. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. PERSONNEL RECORD 9: The Volunteer was hired on 04/07/2025. A personnel record review revealed no documentation of orientation to their job-specific duties or job responsibilities. During an interview and a joint personnel record review on 07/10/2025, the Administrator confirmed that the personnel records did not include a description of the new hire’s job responsibilities or a signed job description or orientation to the required job duties and responsibilities.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 9 (22%) personnel records reviewed of individuals providing care, the agency did not ensure that a competency skills assessment was completed. Agency policy “Staff Competency (HR.10)” (last reviewed 01/15/2024) stated in part, “The hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill level for all staff providing care, including volunteers...” PERSONNEL RECORD 7: The Volunteer Coordinator hired was on 11/21/2024. A personnel record review revealed no evidence of a competency skills assessment upon hire. PERSONNEL RECORD 9: The Volunteer was hired on 04/07/2025. A personnel record review revealed no evidence of a competency skills assessment upon hire. Following a joint personnel record review and interview on 07/10/2025, the Administrator confirmed that there were no competency skills assessments in the above personnel records.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included an initial plan of care, including care and services to be provided. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024 and died on hospice services on the continuous level of care on 08/17/2024. A clinical record review revealed no evidence of admission orders or an initial plan of care. The clinical record included documentation of the patient’s continuous care, which was scanned into the clinical record from 08/16/2024 at 1600 to 08/17/2024 at 1500. A scanned document that included continuous care notes by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, had written at the top - “RX #741670200,” dated 08/16/2024, for Morphine Sulfate 20mg/ml which was documented as 0.5 to 1.0 ml Morphine Sulfate administered to the patient 12 times. Lorazepam 2mg/ml was also written and dated 08/16/2024 with the “RX #741671200.” The LVN documented that 0.5 ml of Lorazepam had been administered nine (9) times. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that the patient’s clinical record was missing an initial plan of care, no assessments had been completed, and no documentation was produced prior to the end of the site visit. All patients were admitted and discharged before the DON’s employment with the agency on 11/01/2024.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included signed copies of the notice of patient rights and the hospice election statement. CLINICAL RECORD 3: The patient elected hospice care on 08/09/2024. A review of the clinical record revealed no paper or scanned signed Hospice Informed Consent/Election of the Hospice Benefit. CLINICAL RECORD 4: The patient elected hospice care on 08/09/2024. A review of the clinical record revealed no paper or scanned signed Hospice Informed Consent/Election of the Hospice Benefit. CLINICAL RECORD 9: The patient elected hospice care on 08/16/2024. A review of the clinical record revealed no paper or scanned signed Hospice Informed Consent/Election of the Hospice Benefit. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that no hospice election statements could be produced during the site visit. All patients were admitted and discharged before the DON’s employment with the agency on 11/01/2024.”

“It is required It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 6 of 9 (67%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included a physician certification and recertification of terminal illness as required. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A verbal physician certification was documented on 08/09/2024. A clinical record review revealed no evidence of a written physician certification of terminal illness for the benefit period dated 08/09/2024 to 08/14/2024. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/13/2024. A clinical record review revealed no evidence of a verbal or written physician certification of terminal illness for the benefit period dated 08/09/2024 to 08/13/2024. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/12/2024 and was discharged on 08/13/2024. A verbal physician certification was documented on 08/12/2024. A clinical record review revealed no evidence of a written physician certification of terminal illness for the benefit period dated 08/12/2024 to 08/13/2024. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A clinical record review revealed no evidence of a verbal or written physician certification of terminal illness for the benefit period dated 08/09/2024 to 08/14/2024. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/26/2024 and died on hospice on 07/27/2024. A verbal physician certification was documented on 07/26/2024. A clinical record review revealed no evidence of a signed written physician certification of terminal illness for the benefit period dated 07/26/2024 to 07/27/2024. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024 and died on hospice on 08/17/2024. A verbal physician certification was documented on 08/16/2024. A clinical record review revealed no evidence of a written physician certification of terminal illness for the benefit period dated 08/16/2024 to 08/17/2024. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that the clinical records were missing the physician certifications and recertifications for terminal illness. No further documentation was provided prior to the end of the site visit. All patients were admitted and discharged before the DON’s employment with the agency on 11/01/2024.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 9 (56%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included physician orders for the care and services provided. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no documented discharge order. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no documented discharge order. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/12/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no documented discharge order. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no documented discharge order. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/16/2024 and died on hospice services on the continuous level of care on 08/17/2024. There were no orders for admission or continuous care services. There was no documentation of an initial or comprehensive Registered Nurse Assessment, and no physician orders or plan of care were documented. A scanned document that included continuous care notes by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, had written at the top - “RX #741670200,” dated 08/16/2024, for Morphine Sulfate 20mg/ml which was documented as 0.5 to 1.0 ml Morphine Sulfate administered to the patient 12 times. Lorazepam 2mg/ml was also written and dated 08/16/2024 with the “RX #741671200.” The LVN documented that 0.5 ml of Lorazepam had been administered nine (9) times. A scanned document entitled ‘Medication Profile and Teaching Form’ documented the medications and was signed by the Registered Nurse (RN) as a telephone order; however, it did not include the physician’s name or signature. There were no medication orders documented in the patient’s clinical record/plan of care. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (Personnel Record 3) confirmed the clinical record contained no physician medication orders. No further documentation was provided during the site visit.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed of patients who were discharged, the agency did not ensure that a discharge summary was provided to the patient’s attending physician. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024. The patient was discharged from hospice services on 08/14/2024 without a reason noted as to why the discharge occurred or evidence that a discharge summary or any clinical record information was provided to the attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024. The patient was discharged from hospice services on 08/13/2024, without any reason noted for the discharge or evidence that a discharge summary or any clinical record information was provided to the attending physician. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/12/2024. The patient was discharged from hospice services on 08/13/2024, without any reason noted for the discharge or evidence that a discharge summary or any clinical record information was provided to the attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024. The patient was discharged from hospice services on 08/14/2024, without any reason noted for the discharge or evidence that a discharge summary or any clinical record information was provided to the attending physician. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that the clinical record did not include documentation that a discharge summary was provided to the patient’s attending physician; however, she could not provide any information since these discharges occurred before her employment with the agency on 11/01/2024. During a phone interview on 07/10/2025, the Part Owner/Governing Body Member of the hospice stated that the patients admitted in August 2024 were “test” patients entered into the electronic medical record (EMR) to learn how to utilize the EMR’s functions. The site visitor informed the Part Owner/Governing Body that there was no documentation in the patient’s clinical record stating such, and that the patient was part of the clinical record review for the site visit. They replied that they understood.”

“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 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 4 of 5 (80%) clinical records reviewed of discharged patients, the agency did not ensure that a discharge summary was documented in the clinical record. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no documented reason for discharge, nor a discharge summary. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no documented reason for discharge, nor a discharge summary. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/12/2024 and was discharged on 08/13/2024. A review of the clinical record revealed no documented reason for discharge, nor a discharge summary. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/09/2024 and was discharged on 08/14/2024. A review of the clinical record revealed no documented reason for discharge, nor a discharge summary. During a joint clinical record review and interview on 07/09/2025, the Director of Nursing (DON) (Personnel Record 3) confirmed that no discharge summaries were documented. Furthermore, these discharges occurred prior to the DON’s employment with the agency, which began on 11/01/2024. During a phone interview on 07/10/2025, the Part Owner/Governing Body Member stated that the patients admitted in August 2024 were “test” patients entered into the Electronic Medical Record (EMR) to learn how to utilize the EMR’s functions. The Part Owner/Governing Body Member was informed that the clinical record contained no documentation stating such, and that the patient records were included as part of the clinical record review for the site visit. The Part Owner/Governing Body Member replied that they understood.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by clinical record review, document review, observation, and interview. In 4 of 9 (44%) clinical records reviewed and home visits observed, the agency did not ensure that the policy for the management and disposal of controlled substances was provided and reviewed when controlled medications were first ordered. The sample admission packet provided for review on 07/09/2025 included the forms “Hospice Informed Consent/Election of the Hospice Benefit” (page 2 of 6), which stated in part, “I have received a copy along with a verbal explanation of the following...Disposal of Controlled Substances and Medication Disposal Policies...” No policies were included. Clinical Record 2/Home Visit 1: The patient elected the hospice benefit on 07/02/2025. On 07/02/2025, the physician ordered “Hydrocodone-Acetaminophen Oral Tablet 10-325 MG - 1 tablet by mouth every 4 hours as needed for pain, and on 7/06/2025, the physician ordered “Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML - 0.4 to 1.0ml by mouth every 4 hours as needed for pain or shortness of breath.” There was no documentation of a verbal review of the management and disposal of controlled substances in the initial assessment completed by the Registered Nurse (RN) on 07/02/2025. During the home visit with the RN on 07/09/2025, a review of the patient’s agency-provided admission packet revealed that it did not include the hospice’s policy for the management and disposal of controlled substances. Clinical Record 4: The patient elected the hospice benefit on 08/09/2024. A clinical record revealed no evidence of the form “Hospice Informed Consent/Election of the Hospice Benefit,” which included the statement, “I have received a copy along with a verbal explanation of the following...Disposal of Controlled Substances and Medication Disposal Policies...” On 08/09/2024, the physician ordered “Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML - 0.25 to 2ml by mouth every hour as needed for shortness of breath or pain, Tramadol HCL Oral Tablet 50 MG - 1 tablet twice a day for pain, and Hydrocodone-Acetaminophen Oral Tablet 10-325mg - 1 tablet by mouth every 6 hours as needed for pain.” There was no documentation of a verbal review of the management and disposal of controlled substances in the initial assessment completed by the RN on 08/09/2024. Clinical Record 7: The patient elected the hospice benefit on 07/26/2024. A clinical record revealed no evidence of the form “Hospice Informed Consent/Election of the Hospice Benefit,” which included the statement, “I have received a copy along with a verbal explanation of the following...Disposal of Controlled Substances and Medication Disposal Policies...” On 07/26/2024, the physician ordered “Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML - 0.5 to 1.0 mL by mouth every 2 hours as needed for pain or shortness of breath.” There was no documentation of a verbal review of the management and disposal of controlled substances in the initial assessment completed by the RN on 07/26/2024. Clinical Record 9: The patient elected the hospice benefit on 08/16/2024. A review of the patient’s clinical record revealed no evidence of the form “Hospice Informed Consent/Election of the Hospice Benefit,” which included the statement, “I have received a copy along with a verbal explanation of the following...Disposal of Controlled Substances and Medication Disposal Policies...” There was no documentation of an initial or comprehensive Registered Nurse Assessment, and no physician orders or plan of care were documented. A document for continuous care by the Licensed Vocational Nurse (LVN) for the dates/times 08/16/2024 1400 to 08/17/2024 1200, included documentation of 0.5 to 1.0 mL of Morphine Sulfate 20mg/mL administered to the patient. Written at the top was “RX #741670200,” dated 08/16/2024. During a joint document review and interview on 07/08/2025, the Director of Nursing (DON) confirmed that no policies were included in the admission documents provided to patients/families; however, she could not provide any information on patients admitted before her employment with the agency on 11/01/2024.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 8 (12%) contracts reviewed, the agency did not ensure that the contract required that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. CONTRACT 5: The Physical Therapy/Occupational Therapy/Speech Therapy contract was effective on 02/28/2022. A review of the contract revealed no language stating that the contracted employees with direct patient contact or access to patient records were required to obtain a criminal background check. During a joint contract and CHAP Standard/Regulatory review on 07/10/2025, the Administrator confirmed that the contract language did not meet the requirement for criminal background checks for the contracted employees who come into contact with patients or the patient records.”