All Compassionate Care Hospice, LLC

“Based on record review and interview, the hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions in the Plans of Care in that the Plans of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for 6 (Patients #1, #3, #5, #6, #9, and #13) of 14 patient records reviewed. The failure placed the patients at risk that care provided would be inadequate resulting in worsening of symptoms. Patient #1:Record review of Patient #1’s clinical record revealed a Plan of Care dated 12/24/2025 to 2/21/2026. The Plan of Care indicated that Patient #1 started on the hospice’s services on 6/27/2025. The Plan of Care listed Malignant (Primary) Neoplasm (Cancer) Unspecified as the terminal diagnosis. The Plan of Care listed Gastro-Esophageal Reflux Disease without Esophagitis (chronic digestive condition where stomach content flows back up into the esophagus (muscular tube where food/fluids travel to the stomach after being swallowed) as a secondary diagnosis. Registered Nurse C conducted a recertification comprehensive reassessment on 12/15/2025. Registered Nurse C documented that Patient #1 had constipation, potential for altered nutritional status related to gastro-esophageal reflux disease, and had the potential to fall. Patient #1’s Plan of Care listed constipation, potential for altered nutritional status, and the potential to fall in the Plan of Care in the intervention and goals portion of the Plan of Care. Patient #1’s Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for constipation, potential for altered nutritional status, and the potential to fall. Patient #3:Record review of Patient #3’s clinical record revealed a Plan of Care dated 9/2/2025 to 10/23/2025. The Plan of Care indicated that Patient #3 started on the hospice’s services on 6/4/2025. The Plan of Care listed Parkinsonism (syndrome characterized by slowness, muscle stiffness, involuntary body movements, and an unstable posture) as the terminal diagnosis. Registered Nurse C conducted a recertification comprehensive assessment on 9/2/2025. Registered Nurse C documented that Patient #3 had communication problem with activity intolerance, anticipatory grieving, compromised family coping, disease process, dying process/imminent death; a caregiver problem regarding a lack of understanding of hospice philosophy services available and knowledge deficit related to the disease process; safety problem with ambulatory aid issues, fall risk, poor coordination and weakness. Patient #3’s Plan of Care listed these problems in the Plan of Care in the intervention and goals portion of the Plan of Care. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for the listed communication problem, caregiver problem, and the fall risk problem. Patient #5:Record review of Patient #5’s clinical record revealed a Plan of Care dated 11/10/2025 to 12/13/2025. The Plan of Care indicated that Patient #5 started on the hospice’s services on 11/10/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline of the brain causing severe impairment in memory, reasoning, and judgement) as the terminal diagnosis. The Plan of Care listed Hypertension (chronic high pressure of the force of the blood against blood vessel walls would be consistently too high, forcing the heart to work harder) as a secondary diagnosis. Registered Nurse D conducted an initial comprehensive assessment on 11/10/2025. Registered Nurse D documented that Patient #5 had the potential for altered cardiac (heart) status related to hypertension. Patient #5’s Plan of Care listed the potential for altered cardiac status related to hypertension in the intervention and goals section of the Plan of Care. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the Plan of Care for the potential for altered cardiac status related to hypertension. Patient #6:Record review of Patient #6’s clinical record revealed a Plan of Care dated 1/15/2026 to 3/15/2026. The Plan of Care indicated that Patient #6 started on the hospice’s services on 10/17/2025. The Plan of Care listed Parkinson’s Disease (progress disorder of the central nervous system causing involuntary body movements, slowness, muscle rigidity -stiffness, and postural balance instability) with Dyskinesia (involuntary movement caused by use of medications to treat Parkinson’s Disease) with Fluctuations (instability) Chaplain E conducted a spiritual counselor assessment as part of the initial comprehensive assessment on 10/20/2025. Chaplain E documented that Patient #6 and Patient #6’s family were grieving the death of a family member and Patient #6 was at risk for loneliness due to not being able to go to an adult day rehab. Registered Nurse C conducted a recertification comprehensive assessment on 1/5/2026. Registered Nurse C documented that Patient #6 and Patient #6’s family were grieving the death of a family member and Patient #6 was at risk for loneliness due to the inability to go to an adult day rehab. Patient #6’s Plan of Care listed Patient #6 and Patient #6’s family were grieving the death of a family member and Patient #6 was at risk for loneliness. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the Plan of Care for grief and risk of loneliness. Patient #9:Record review of Patient #9’s clinical record revealed a Plan of Care dated 1/4/2026 to 3/4/2026. The Plan of Care indicated that Patient #9 started on the hospice’s services on 5/9/2025. The Plan of Care listed Parkinson’s Disease without Dyskinesia, without mention of Fluctuations as the terminal diagnosis. Registered Nurse C conducted a recertification comprehensive reassessment on 1/2/2026. Registered Nurse C documented that Patient #9 had difficulty swallowing and had a reduction in the amount of food Patient #9 was eating. Patient #9’s Plan of Care listed difficulty swallowing and reduced food portion consumption in the intervention and goals section of the plan of care. The Plan of Care did not include measurable outcomes anticipated from implementation and coordination of the Plan of Care for difficulty swallowing and reduced food consumption. Patient #13:Record review of Patient #13’s clinical record revealed a Plan of Care dated 2/8/2026 to 5/8/2026. The Plan of Care indicated that Patient #13 started on the hospice’s services on 2/8/2026. The Plan of Care listed Senile Degeneration of the Brain as the terminal diagnosis. Registered Nurse G conducted an initial comprehensive assessment on 2/8/2026. Registered Nurse G documented that Patient #13 had problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication (drugs to relieve pain) and Cheyne Stoke breathing (severe, abnormal breathing pattern characterized by a repeating cycle of gradually deepening and faster breathing, followed by a gradual decrease in breathing, and ending in a temporary cessation of breathing). Patient #13’s Plan of Care listed problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication, Cheyne Stoke breathing, and hospice philosophy and protocols. The Plan of Care did not include measurable outcomes anticipated from implementation and coordination of the Plan of Care for problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication, Cheyne Stoke breathing, and hospice philosophy and protocols. During an interview on 3/27/2026 at 9:23 AM with the Administrator and the Alternate Supervising Nurse, the surveyor discussed that the plans of care did not contain measurable outcomes for problems identified during the comprehensive assessments. The Surveyor asked who would be responsible to ensure the measurable outcomes would be included in the plans of care. The Alternate Supervising Nurse stated, “I am.” The surveyor asked how the interdisciplinary team reviewed the plan of care. The Alternate Supervising Nurse informed the surveyor that the core team would collaborate; “We go over goals and outcomes, problems and interventions.” The Administrator reviewed the Plans of Care and agreed the measurable outcomes were not included in the Plans of Care. The Alternate Supervising Nurse did not know why the measurable outcomes were not included in the plans of care. Review of the agency’s policy titled “Plan of Care Process PC.30”, last reviewed on 3/16/26 read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy...II. I. The Hospice will develop an individualized written POC for each patient, The POC must reflect patient and family goals and interventions based on the problems identified...Procedure...VI. The POC includes, but is not limited to...C Measurable outcomes anticipated from implementing and coordinating the POC...””

“Based on record review and interview, the interdisciplinary group- core group of a physician, registered nurse, chaplain, and social worker that provides/supervises all care and services, ensuring a holistic approach to terminal illness and bereavement, (in collaboration with the individual’s attending physician, in any) failed to review, revise and document the patient’s individualized plan of care as frequently as the patient’s condition required but no less frequently than every 15 days, in that the interdisciplinary group failed to revise the plan of care regarding wound care for 1 (Patient #7) of 3 patient records reviewed where the hospice nursing staff provided wound care. The failure placed Patient #7 at risk of the wound becoming infected or worsening. Client #7:Record review of Client #7’s clinical record revealed a Plan of Care dated 12/30/2025 to 2/27/2026. The Plan of Care indicated that Client #7 started on the hospice’s services on 7/3/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in memory, reasoning, and judgment) as the terminal diagnosis. Patient #7’s clinical record contained a physician order dated 12/31/2025 for a skilled nurse to make a skilled nurse visit to evaluate Patient #7 due to reports that Patient #7 had a wound to the sacral (lower back) area. Registered Nurse C conducted a skilled nurse visit on 12/31/25. Registered Nurse C documented that Patient #7 had a Stage II Pressure Ulcer (partial-thickness loss of skin, open ulcer with a moist, pink/red wound bed, or as an intact/ruptured serum-filled blister caused by friction, sheering or pressure) to the sacrum (lower back) that measures 3 centimeters by 3 centimeters. Registered Nurse C documented cleaning the wound with saline (sterile solution of salt and purified water, matching the body’s physiological concentration and used to clean wounds) wound cleanser and applied a wound dressing with border (sterile dressing featuring a central absorbent pad surrounded by skin-friendly adhesive border. Registered Nurse C conducted skilled nurse visits on 1/4/2026, 1/11/2026, and 1/18/2026. Registered Nurse C documented at each of the visits that Registered Nurse C cleaned Patient #7’s wound with saline wound cleanser and applied a wound dressing with a border. Registered Nurse C conducted a skilled nurse visit on 1/28/2026 and documented that Patient #7’s sacral wound had healed. Patient #7’s clinical record contained documentation of interdisciplinary group meetings on 1/12/2026 and 1/26/2026. The interdisciplinary group failed to review and revise the Plan of Care regarding wound care orders for Patient #7’s wound. During an interview on 3/27/2026 at 9:23 AM with the Administrator and Alternate Supervising Nurse, the surveyor discussed that Patient #7 had a sacral wound and that the Plan of Care did not contain orders for wound care and the Plan of Care was not revised by the interdisciplinary group. The surveyor asked how the interdisciplinary group reviewed the Plan of Care. The Alternate Supervising Nurse informed the surveyor that the core team would collaborate. The Alternate Supervising Nurse stated, “We look at the plan of care and update it. We go over goals and outcomes, problems and interventions.” The surveyor asked why the plan of care was not updated. The Alternate Supervising Nurse reviewed the interdisciplinary group documentation. The Alternate Supervising Nurse did not know why the Plan of Care had not been revised for the wound care. Review of the agency’s policy titled “Plan of Care Process PC.30,” last reviewed 3/16/2026 read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy...III The Hospice will review and revise patient care in accordance with changes in the patient’s condition: spiritual status; psychosocial status; residential environment; patient’s response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations. Procedure...VI. The POC includes, but is not limited too...D. Drugs and treatments necessary to meet the needs of the patient...VII. The Hospice IDG/IDT (Interdisciplinary Group/Team), in collaboration with the individual’s attending physician, if any, will review, revise, and document the individualized plans as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days...” Review of the agency’s policy titled “Timelines IM.40,” last reviewed on 1/1/2026, read in part; “Purpose To establish timely parameters for medical record information. Policy I. The Hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations...Procedure...D. The IDG/IDT (Interdisciplinary Group/Team) Plan of Care (POC) will be developed within 15 days of the start of care, and updated at least every 15 days...””

“Based on record review and interview, the agency failed to include in the patient record clinical notes of the continuous care staff for 1 (Patient #2) of 2 patient records reviewed of patients that died while on the hospice’s services. The failure placed the patients at risk of receiving inadequate care, safety issues, and increased risk of harm. Code of Federal Regulation, Title 42, Chapter IV, Subchapter B, Part 418, reviewed August 4, 2021, read in part; ...”418.3 Definitions...Clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient’s reaction and/or response, and any changes in physical, emotional, psychosocial or spiritual condition during a given period of time...” Patient #2: (record reviewed on 3/20/2026)Record review of Patient #2’s clinical record revealed a Plan of Care dated 12/17/2025 to 12/18/2025. The Plan of Care indicated that Patient #2 started on the hospice’s services on 12/17/2025. The Plan of Care listed Cerebral Infarction Unspecified (blocked blood vessel leading to brain tissue death) as the terminal diagnosis. Registered Nurse F conducted an initial comprehensive assessment on 12/17/2025. Registered Nurse F documented that Patient #2 was in respiratory distress, had moderate pain, was non-responsive, and Registered Nurse F was unable to obtain a heart rate or blood pressure. Registered Nurse F documented that continuous care was initiated for management of respiratory distress and pain. Patient #2’s record did not contain documentation of continuous care. On 3/20/2026 the surveyor requested the continuous care documentation. The agency was unable to provide documentation of the continuous care provided to Patient #2. During an interview on 3/20/2026 at 11:53 AM with the Administrator, the surveyor was informed that the agency did not meet the criteria of 8 hours of continuous care. Registered Nurse F was not at Patient #2’s home for 8 hours; Registered Nurse F’s care time was 3:30 pm to 10:35 pm. During an interview on 3/202026 at 12:21 PM with the Administrator and Registered Nurse F, the surveyor asked about continuous care for Patient #2. Registered Nurse F informed the surveyor; Patient #2 was actively dying; Registered Nurse F administered Morphine (medication used for pain) and Lorazepam (used for anxiety) before the continuous care nurse arrived; the continuous care documentation would be in the continuous care book in the home; and the nurse that pronounced death would bring the book back to the office. The Administrator informed the surveyor that the Administrator thought only Registered Nurse F had been there. The Administrator stated, “We called (Agency Z) staffing agency, we were told the notes were in the book.” The Administrator informed the surveyor that the continuous care nurse stayed at the home for 4 hours plus 3 hours and Agency Z did not have the continuous care notes. Review of the agency’s invoice from Agency Z revealed that Agency Z provided a continuous care nurse on 12/17/2025 for 3 hours and on 12/18/2025 provided a continuous care nurse for 6 hours. During an interview on 3/23/2026 at 12:48 pm with the Alternate Supervising Nurse, the Alternate Supervising Nurse brought two documents regarding continuous care for Patient #2. The documents were physician’s orders dated 12/17/2025 for continuous care, medications, and care to be provided. The Alternate Supervising Nurse informed the surveyor that the continuous care nurse handed Registered Nurse G the notes, but Registered Nurse G did not look at it to make sure the notes were there. Review of the agency’s policy titled “Timelines IM.40,” last reviewed on 1/1/2026 read in part; “Purpose To establish timely parameters for medical record information. Policy...II. The Hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information including, but not limited to: visit notes and assessments, physician orders, certifications and recertification, transfer and discharges. Procedure I. All hospice, staff, physicians(s) and/or other licensed independent practitioner(s) and physician office staff as appropriate, will be oriented to the following parameters...III. All medical record information will be incorporated into the patient’s medical record in a timely manner…” Review of the agency’s policy titled “Timelines-Addendum IM.40 TX,” last reviewed on 4/14 2023 read in part; “ Procedure I. In addition to the requirements defined in the Timelines policy in the Information Management section of the Administrative Policy Manual, the following requirement will be met: A. All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days.” Review of the agency’s policy titled “Medical Record Content IM.30,” last reviewed on 9/1/2024 read in part; “Purpose To ensure each medical record contains complete, correct information which identified the patient, describes problems, and needs of the patient, justifies patient care, and accurately describes care provided, outcomes, significant events and continuity/coordination of care. Policy I. The Hospice will initiate and maintain an individual and accurate medical record containing past and current information for each patient accepted for care. The record will contain correct information that is available to the patient’s attending physician and hospice staff...Procedure I. The content of the medical record will include, at a minimum...D. Clinical notes...III. Additionally, the medical record will contain, but not be limited to, the following...D. Clinical notes documenting functional and activity limitations, all actions, interventions, and procedures provided by the Hospice, including medication administration, treatments and services, the responses to interventions and..7. Care provided through contracted staff...””