Distinguished Hospice, Inc.

“It is required that testing: 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, or 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 IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by document review and interview. A review of the Action Plan revealed the agency did not ensure to follow their action plan to complete a Tabletop Exercise on October 3, 2025. The Action Plan stated, “Completion of Tabletop Exercise on October 3, 2025, the agency conducted a facilitated tabletop exercise using a clinically relevant emergency scenario. The session included: Group discussion of a simulated hurricane evacuation. Problem statements addressing patient mobility, medication continuity, and staff shortages. Directed messages challenging the EP Plan’s communication and coordination protocols. Documentation included the date, facilitator name, participant roster, and summary of findings. There was no documented evidence of a tabletop exercise for October 2025. During a joint review of the Action Plan and interview on 10/22/2025 the Administrator agreed there was no documented evidence that the testing was completed. Additionally, during an interview on 10/22/2025, the Administrator stated, “The consultant is coming back next month to do the testing with us.” A review of the Action Plan revealed the agency did not ensure to follow their action plan to complete a Tabletop Exercise on October 3, 2025. The Action Plan stated, “Completion of Tabletop Exercise on October 3, 2025, the agency conducted a facilitated tabletop exercise using a clinically relevant emergency scenario. The session included: Group discussion of a simulated hurricane evacuation. Problem statements addressing patient mobility, medication continuity, and staff shortages. Directed messages challenging the EP Plan’s communication and coordination protocols. Documentation included the date, facilitator name, participant roster, and summary of findings. There was no documented evidence of a tabletop exercise for October 2025.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s: Well-being; Comfort; Dignity throughout the dying process. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included an assessment of the patient’s psychosocial and spiritual status. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/13/2025. The clinical record included an order for social work and spiritual care visits. The RN documented the initial comprehensive assessment on 10/13/2025. The clinical record included documentation that the patient accepted social work and spiritual care visits. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial and spiritual status and there was no documented evidence in the clinical record that a social worker or spiritual counseling/chaplain visited the patient. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/08/2025. The clinical record included an order for social work visits. The RN documented the initial comprehensive assessment on 10/08/2025. The clinical record included documentation that the patient accepted social work visits. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a social worker visited the patient. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that the spiritual and psychosocial assessments were completed.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/13/2025. The registered nurse (RN) documented the initial comprehensive assessment on 10/13/2025. The clinical record included documentation that the patient accepted social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the social worker or chaplain completed the initial bereavement assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/08/2025. The RN documented the initial comprehensive assessment on 10/08/2025. The clinical record included documentation that the patient accepted social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the social worker or chaplain completed the initial bereavement assessment. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that an initial bereavement assessment was completed.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed revealed the agency did not ensure that nursing services were provided as ordered on the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/11/2025. The plan of care (POC)dated 08/11/2025 through 11/01/2025 included orders for skilled nursing visits one(1) time a week for twelve (12) weeks (1wk12 ). There was no documented evidence that a nursing visit was completed for the week of 10/12/2025 through 10/18/2025. A scheduled visit was missed on 10/17/2025. There was no documented reason for the missed visit skilled nurse visit. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/25/2025. The plan of care ordered nursing visits twice weekly for 07/27/2025 through 10/21/2025. For the week 10/05/2025 through 10/11/2025 a visit was documented on 10/07/2025. For the week of 10/12/2025 through 10/18/2025, a visit was documented on 10/14/2025. There was no documented evidence of a second nursing visit or reason for the missed visits for the weeks of 10/05/2025 through 10/11/2025 and 10/12/2025 through 10/18/2025. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that nursing services were provided as ordered. Additionally, during the interview, the Director of Nursing stated, “If it’s not documented, it’s not done. We haven’t started the audits yet but will be starting soon.””

“It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed revealed the agency did not ensure to provide medical social services in accordance with the patient’s and family’s needs and acceptance of services. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/13/2025. The registered nurse (RN)documented the initial comprehensive assessment on 10/13/2025. The clinical record included documentation that the patient accepted medical social services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment/social work visit was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/08/2025. The RN documented the initial comprehensive assessment on 10/08/2025. The clinical record included documentation that the patient accepted medical social services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment/social work visit was completed. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that a psychosocial assessment was completed or that a social worker visited the patient.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed revealed the agency did not ensure to provide spiritual counseling in accordance with the patient’s and family’s needs and acceptance of services. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/13/2025. The Registered Nurse (RN) documented the initial comprehensive assessment on 10/13/2025. The clinical record included documentation that the patient accepted spiritual counseling services. The initial comprehensive assessment did not include an assessment of the patient’s spiritual status and there was no documented evidence in the clinical record that a spiritual assessment/visit was completed. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that spiritual counseling/visits were provided as accepted. Additionally, during an interview on 10/21/2025, the Director of Nursing stated, “More education is needed.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed for patient’s receiving hospice aide services revealed the agency did not ensure that hospice aide services were provided as ordered. CLINICAL RECORD 1: The plan of care dated 10/13/2025 through 01/10/2026 included an order for hospice aide services three (3) times a week for twelve (12) weeks (3wk12). There was no documented evidence that hospice aide services were provided to the patient from 10/13/2025-10/20/2025. CLINICAL RECORD 2: The plan of care dated 10/08/2025 through 10/27/2025 included an order for hospice aide services two (2) times a week for twelve (12) weeks (2wk12) for showering and other tasks. There was no documented evidence that hospice aide services were provided to the patient from 10/08/2025 through 10/20/2025. During an interview on 10/21/2025, the Director of Nursing stated, “The visits weren’t plotted scheduled, but should have been.” During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that hospice aide services were provided as ordered. Additionally, during an interview on 10/21/2025, the Director of Nursing stated, “I am not sure what happened.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patient’s receiving hospice aide services revealed the agency did not ensure the Registered Nurse completed an on-site supervisory visit no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide. CLINICAL RECORD 4: The plan of care dated 07/25/2025 included an order for hospice aide services at a frequency of three visits per week for thirteen weeks. Hospice aide services were provided as ordered from 09/28/2025 through 10/18/2025. The clinical record review revealed no documented evidence that the RN completed aide supervisory visits from 10/01/2025 through 10/20/2025. The clinical record included documentation that the RN provided nursing visits weekly from 09/28/2025 through 10/18/2025, however there was no documentation of aide supervision in the nursing assessments or through 10/20/2025. During a joint record review and interview on 10/21/2025 the Director of Nursing agreed there was no documented evidence that the hospice aide supervisory visits were completed at least every 14 days. Additionally, during an interview on 10/21/2025, the Director of Nursing stated, “they aren’t doing it, we need to make it a hard stop.””

“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 IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review, personnel record review, and interviews with the Administrator and the Director of Nursing (DON), which revealed issues with the hospice organizing, managing, and administering its resources to provide hospice care and services to patients, families, and caregivers in the following area: Failed to ensure that contracted physician services and drugs and biologicals were made routinely available on a 24-hour basis, seven (7) days per week in 2 of 2 (100%) contracts for physicians’ services, and drugs and biologicals [HCDT.4.I/L653/418.100(c)(2)]; Failed to ensure that arranged services were supported by written agreements that require that all services be authorized by the hospice in 4 of 5 (80%) written agreements requested for review [HSLG.14.D/L655/418.100(e)(1); Failed to ensure that the contract for physician services specified the physician who assumes the medical director responsibilities and obligations in 1 of 1 (100%) physician contracts requested [HSLG.15.D/L666/418.102(a)]; Failed to ensure that a written agreement was in place that specified the provision of hospice services in the facility [HSRF.5.I/L763/418.112(c)]; and Failed to ensure that the DMEPOS supplier was accredited by a recognized accreditation organization in 1 of 1 (100%) contract for durable medical equipment services (DME) [HSLG.10.I/ L703/418.106(f)(3)]. . The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality healthcare in a safe environment for the condition of participation, CFR 418.100: Organization and Administration of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that short-term inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This condition was not met, as evidenced by document review and interviews with the Administrator and the Director of Nursing (DON), which revealed that the hospice Failed to ensure that a written agreement was available for short-term inpatient care for pain control, symptom management, and respite purposes. {HSIC.5. D/L711}; 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 418.108: Short-term inpatient care. 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 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 the Emergency Preparedness Plan was reviewed annually as required by agency policy. Agency policy Emergency Preparedness Policy and Plan, dated 05/03/2021, required in part, “E. An annual review of the Emergency Plan will be documented to include the date of the review and any updates made to the Emergency Plan based on the review.” Review of the agency’s Emergency Preparedness (EP) binder and documents revealed that the agency had documented an evaluation of the EP Plan dated 05/07/2025. However, the agency did not have documentation of a review of the EP Plan for calendar years 2023 and 2024. The agency did not review the EP Plan annually as required by agency policy. During a review of the EP plan and interview on 09/10/2025, the Administrator stated, “The only evaluation [of the EP Plan] was in 2025.” The agency did not ensure that the Emergency Preparedness Plan was reviewed annually per the agency’s policy.”

“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. This standard was not met as evidenced by document review and interview. The agency did not ensure that the Emergency Preparedness Plan included a hospice-based and community-based risk assessment using an all-hazards approach specific to the geography and population served. Agency policy Emergency Preparedness Policy and Plan, dated 05/03/2021, required in part, “G. The Emergency Plan will be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. This approach is specific to the location of the agency and considers particular hazards most likely to occur in the surrounding area.” Review of the agency’s Emergency Preparedness (EP) binder and documents revealed that the agency had no documented evidence of a facility-based and community-based risk assessment, using an all-hazards risk assessment for 2023, 2024, and year to date for 2025. The agency did not perform an all-hazard risk assessment per its policy. During a review of the EP plan and interview on 09/10/2025, the Administrator, “There is no documentation of an [all-hazard] risk assessment since 2022.” The agency did not ensure that an all-hazards approach was completed to develop the Emergency Preparedness Plan.”

“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, personnel record review, and interview. In 2 of 10 (20%) personnel records requested for review, the agency did not ensure documentation that employees were educated in EP (emergency preparedness) policies and procedures consistent with their expected roles. Agency policy Emergency Preparedness Policy and Plan, required in part, “Training will be provided to staff and individuals providing services under agreement on hire (during orientation), when there is a significant change in the emergency preparedness plan or policy, when roles or responsibilities change, or at a minimum of every two years.” PERSONNEL RECORD 5: Registered Nurse, date of hire 05/01/2025. The personnel record was not provided for review. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard and the agency did not provide documented evidence that the nurse had received education/training in EP policies and procedures. PERSONNEL RECORD 6: Hospice Aide, date of hire 05/01/2025. The personnel record was not provided for review. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard and the agency did not provide documented evidence that the nurse had received education/training in EP policies and procedures. During an interview on 09/10/2025, the Director of Nursing stated, “I don’t have access to the personnel records.” The Administrator was then interviewed and the Administrator stated, “The personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.””

“It is required that testing: 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, or 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 the Emergency Plan was tested as required by agency policy. Agency policy titled Emergency Preparedness Policy and Plan, required in part, “The agency will conduct one exercise to test the emergency plan at least annually as follows: 1. Participate in a full-scale exercise that is community-based; or 2. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or 3. If the agency experiences an actual natural or man-made emergency that requires activation of the emergency plan, the agency is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. 4 Conduct an additional exercise every two years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or b. A mock disaster drill, or c. A tabletop exercise or workshop that is led by a facilitator and 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 an emergency plan.” Review of the agency’s Emergency Preparedness (EP) binder and documents revealed that the agency had no documented evidence that the EP plan was tested for 2023 and 2024. The agency did not complete testing of the EP plan as required by agency policy. During a review of the EP plan and interview on 09/10/2025, the Administrator stated, “The only drill we did was on 07/18/2025.” A review of the agency’s Emergency Preparedness documentation revealed that it did not ensure that testing of the Emergency Plan occurred per its policy.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an assessment of the patient’s psychosocial status. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. The skilled nurse (SN) documented the initial comprehensive assessment on 07/02/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/04/2025 with diagnosis of Parkinson’s disease. The SN documented the initial comprehensive assessment on 08/04/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 with diagnosis of cerebrovascular disease. The SN documented the initial comprehensive assessment on 07/25/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. The SN documented the initial comprehensive assessment on 06/20/2025. The clinical record included an order for social work services, however there were no documented social work visits in the clinical record. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/02/2025 with diagnosis of Alzheimer’s disease. The SN documented the initial comprehensive assessment on 07/02/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. The SN documented the initial comprehensive assessment on 07/09/2025. The clinical record included an order for social work services, however there were no documented social work visits in the clinical record. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/07/2025 with diagnosis of Alzheimer’s disease. The SN documented the initial comprehensive assessment on 08/07/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/18/2025 with diagnosis of malignant neoplasm of the cervix. The SN documented the initial comprehensive assessment on 07/18/2025. The clinical record included documentation that the patient declined social work services. The initial comprehensive assessment did not include an assessment of the patient’s psychosocial status and there was no documented evidence in the clinical record that a psychosocial assessment was completed. During a joint review of the records and interview on 09/09/2025, the Director of Nursing stated, “If the patient declines social work services, the nurse should document the psychosocial assessment in the initial nursing comprehensive assessment. There is a form in [the electronic medical record] that the nurse should pull in. This was not done in these patients.””

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Agency policy Bereavement Counseling Services, dated 01/31/2015, required in part, “E. The bereavement program will include, but not limited to, the following: 1. Upon admission: a. Medical Social Worker (MSW) will complete, no later than 5 days after the election of hospice care, an initial bereavement risk assessment on the primary caregiver and each other bereaved identified. i. If MSW services are declined, Spiritual Counseling Coordinator (SCC) will perform. ii. If MSW and SCC services are declined, Registered Nurse (RN) will perform.” CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. The Registered Nurse (RN) documented the initial comprehensive assessment on 07/02/2025. The clinical record included documentation that the patient declined social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the nurse completed the initial bereavement assessment as required by agency policy. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/04/2025 with diagnosis of Parkinson’s disease. The RN documented the initial comprehensive assessment on 08/04/2025. The clinical record included documentation that the patient declined social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the nurse completed the initial bereavement assessment as required by agency policy. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 with diagnosis of cerebrovascular disease. The RN documented the initial comprehensive assessment on 07/25/2025. The clinical record included documentation that the patient declined social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the nurse completed the initial bereavement assessment as required by agency policy. CLINICAL RECORD 7: A review of the clinical record revealed that the patient was admitted to the hospice services on 07/02/2025. The initial nursing assessment was documented on 07/02/2025. There were no documented visits in the record by either Social Work or Spiritual Counselor services. There was no initial bereavement assessment documented by the Registered Nurse per the agency’s policy. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/07/2025 with diagnosis of Alzheimer’s disease. The RN documented the initial comprehensive assessment on 08/07/2025. The clinical record included documentation that the patient declined social work services and spiritual counseling services. The initial comprehensive assessment did not include an initial bereavement assessment and there was no documented evidence in the clinical record that the nurse completed the initial bereavement assessment as required by agency policy. During a joint review of the records and interview on 09/09/2025, the Administrator stated, “Since the patient declined the social worker and spiritual counselor, the nurse should have pulled in the Bereavement Risk assessment form and completed the assessment. The nurse did not do this.””

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the update of the comprehensive assessment was completed by the Interdisciplinary Group (IDG) no less frequently than every 15 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. Clinical record review revealed the IDG completed updates to the comprehensive assessments on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an updated assessment from 07/02/2025 to 07/30/2025, a total of 28 days between assessments and 13 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. Clinical record review revealed the IDG completed updates to the comprehensive assessments on 07/02/2025 and 07/30/2025. There was no documented evidence that the IDG completed updates to the comprehensive assessment from 07/02/2025 to 07/30/2025, a total of 28 days between assessments and 13 days outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/01/2025 with diagnosis of malignant neoplasm of the breast. The patient was recertified for hospice care on 07/30/2025. Clinical record review revealed the IDG completed updates to the comprehensive assessments on 07/02/2025 and 07/30/2025. There was no documented evidence that the IDG completed updates to the comprehensive assessment from 07/02/2025 to 07/30/2025, a total of 28 days between assessments and 13 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/02/2025 with diagnosis of Alzheimer’s disease. Clinical record review revealed the IDG completed updates to the comprehensive assessments on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an updated assessment from 07/02/2025 to 07/30/2025, a total of 28 days between assessments and 13 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. Clinical record review revealed the IDG completed updates to the comprehensive assessments on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an updated assessment from 07/02/2025 to 07/30/2025, a total of 24 days between assessments and 9 days outstanding. During a joint review of the records and interview on 09/09/2025, the Administrator stated, “We have IDG every other Wednesday. The meeting minutes may not have gotten into the medical record.” The Administrator was unable to provide any documentation of an IDG meeting held on 07/16/2025.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan, as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group (IDG) updated the individualized plan of care no less frequently than every 15 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. Clinical record review revealed the IDG completed updates to the plan of care on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an update to the plan of care from 07/02/2025 to 07/30/2025, which was 28 days after the initial assessment and 13 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. Clinical record review revealed the IDG completed an update to the plan of care on 07/02/2025 and 07/30/2025. There was no documented evidence that the IDG completed an update to the plan of care from 07/02/2025 to 07/30/2025, a total of 28 days between updates to the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/01/2025 with diagnosis of malignant neoplasm of the breast. The patient was recertified for hospice care on 07/30/2025. Clinical record review revealed the IDG completed updates to the plan of care on 07/02/2025 and 07/30/2025. There was no documented evidence that the IDG completed an update to the plan of care from 07/02/2025 to 07/30/2025, a total of 28 days between updates to the plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/02/2025 with diagnosis of Alzheimer’s disease. Clinical record review revealed the IDG completed updates to the plan of care on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an update to the plan of care from 07/02/2025 to 07/30/2025, a total of 28 days and 13 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. Clinical record review revealed the IDG completed updates to the plan of care on 07/30/2025, 08/13/2025, and 08/27/2025. The IDG did not document an update to the plan of care from 07/02/2025 to 07/30/2025, a total of 24 days and 9 days outstanding. During a joint review of the records and interview on 09/09/2025, the Administrator stated, “We have IDG every other Wednesday. The meeting minutes may not have gotten into the medical record.” The Administrator was unable to provide any documentation of an IDG meeting held on 07/16/2025.”

“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, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review and interview. In 2 of 10 (20%) personnel records requested for review, the agency did not ensure documentation that employees were educated on infection control. PERSONNEL RECORD 5: Registered Nurse, date of hire 05/01/2025. The personnel record was requested for review; however, the record was not provided to the site visitor for review by the requested submission time. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard and the agency did not provide documented evidence that the nurse had received education in infection control. PERSONNEL RECORD 6: Hospice Aide, date of hire 05/01/2025. The personnel record was requested for review; however, the record was not provided to the site visitor for review by the requested submission time. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard and the agency did not provide documented evidence that the hospice aide had received education in infection control. During an interview on 09/10/2025, the Director of Nursing stated, “I don’t have access to the personnel records.” The Administrator was then interviewed and the Administrator stated, “The personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.””

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure that nursing services were provided as ordered on the hospice plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. The plan of care dated 07/02/2025 to 09/29/2025 included an order for the Skilled Nursing (SN) services with a frequency of two visits each week for fourteen weeks, with three as-needed (PRN) visits for symptom management. The skilled nurse documented visits as ordered from 07/02/2025 through 08/29/2025, however there were no further SN visits documented after 08/29/2025. The Director of Nursing was interviewed on 09/09/2025 and stated that “the nurse may not have completed her documentation for the visits yet.” The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed SN visits. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/04/2025 with diagnosis of Parkinson’s disease. The plan of care dated 08/04/2025 to 11/01/2025 included an order for SN services at a frequency of two visits for the first week, then one visit each week for twelve weeks, with three as-needed visits for symptom management. The skilled nurse documented nursing visit notes dated 08/04/2025, 08/08/2025, and an on-call as-needed visit on 08/24/2025. However, there were no documented SN visits for the weeks of 08/10/2025, 08/17/2025, and 08/31/2025. The Director of Nursing was interviewed on 09/09/2025 and stated that “the nurse may not have completed her documentation for the visits yet.” The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed SN visits. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 with diagnosis of cerebrovascular disease. The plan of care dated 07/25/2025 included an order for SN services with a frequency of one visit for the first week, then two visits each week for thirteen weeks, with three as-needed visits for symptom management. The skilled nurse documented visits as ordered from 07/25/2025 through 08/22/2025, however the skilled nurse documented one nursing visit a week for the weeks of 08/24/2025 and 08/31/2025. The Director of Nursing was interviewed on 09/09/2025 and stated, “The nurse wrote the visit frequency incorrectly on the plan of care.” The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed SN visits. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. The plan of care dated 06/20/2025 to 09/17/2025 included an order SN services with a frequency of two visits weekly for twelve weeks, with three as-needed visits for symptom management. The skilled nurse documented one nursing visit for the weeks of 06/20/2025, 06/22/2025, 07/20/2025, 07/27/2025, 08/17/2025, and 08/24/2025, and there was no documented SN visit for the week of 08/10/2025. The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed SN visits. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/01/2025 with diagnosis of malignant neoplasm of the breast. The recertification plan of care dated 07/30/2025 to 09/27/2025 included an order for SN services with a frequency of one visit weekly for eight weeks, with three as-needed visits for symptom management. The skilled nurse documented one nursing visit the first week of care, then the skilled nurse documented two nursing visits a week for the subsequent weeks, through the date of record review on 09/09/2025. The clinical record did not include orders to change the frequency of SN visits or documentation that the physician was notified of the change in SN visit frequency. SN visits were not provided as ordered on the plan of care. The Administrator was interviewed on 09/09/2025 and stated, “The nurse entered the visit frequency on the plan of care incorrectly.” CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. The plan of care dated 07/09/2025 to 09/05/2025 included an order for SN services with a frequency of two visits weekly for fourteen weeks, with three as-needed visits for symptom management. The skilled nurse documented two nursing visits during the first week of care, then the skilled nurse documented one nursing visit a week from 07/13/2025 through 09/01/2025. The clinical record did not include orders to change the frequency of SN visits or documentation that the physician was notified of the change in SN visit frequency. SN visits were not provided as ordered on the plan of care. The Administrator was interviewed on 09/09/2025 and stated, “The nurse entered the visit frequency on the plan of care incorrectly.” During a joint review of records and interview on 09/09/2025, the Administrator stated, “The nurses are still getting used to [the new medical record] and are not entering the visit frequencies correctly.””

“It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with social work services ordered on the plan of care, the agency did not ensure medical social services were provided per the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. The plan of care dated 06/20/2025 to 09/17/2025 included an order for social work services with a frequency of one visit each month for three months. The clinical record did not include documentation that MSW (Medical Social Work) visits were provided to the patient. The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed MSW visits. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. The plan of care dated 07/09/2025 to 09/05/2025 included an order for social work services with a frequency of one visit each month for three months. The clinical record did not include documentation that MSW visits were provided to the patient. The clinical record did not include documentation of missed visits or documentation that the physician was notified of the missed MSW visits. During a joint review of records and interview on 09/09/2025, the Administrator stated, “Patients change their minds. They accept the services on admission, but then they refuse the services. The nurse didn’t document or write an order to discontinue the service.””

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) clinical records reviewed with spiritual counselor services provided, the agency did not ensure that spiritual counseling services were provided as ordered on the plan of care and in accordance with the patient’s and family’s needs and acceptance of services. CLINICAL RECORD 4/HOME VISIT 2: The patient elected the hospice benefit on 06/20/2025 with diagnosis of cerebrovascular disease. The plan of care dated 06/20/2025 to 09/17/2025 included an order for spiritual counselor services with a frequency of one visit each month for one month. Clinical record review revealed no documented evidence that the Spiritual Counselor documented visits to the patient. During the home visit observation on 09/09/2025 with the Spiritual Counselor (SC) (Personnel Record 8), the patient’s caregiver was interviewed and stated, “[The SC] visits every couple of weeks.” The SC was also interviewed during the home visit and stated, “I visit the patient every other week to pray with him.” The clinical record did not include documentation that the SC provided services as ordered on the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. The plan of care dated 07/09/2025 to 09/05/2025 included an order for spiritual counselor services with a frequency of one visit each month for one month. Clinical record review revealed no documented evidence that the Spiritual Counselor documented visits to the patient. The clinical record did not include documentation that the SC provided services as ordered on the plan of care. During a joint review of the records and interview on 09/10/2025, the Administrator stated, “[The SC] mostly delivers supplies, but sometimes he goes and prays with the patient. It may not always be a [SC] visit, but he should be documenting all visits.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 6 of 9 (67%) clinical records reviewed with hospice aide services ordered on the plan of care, the agency did not ensure the hospice aide provided services as ordered on the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. The plan of care dated 07/02/2025 to 09/29/2025 included an order for the hospice aide (HA) to provide visits three times a week for thirteen weeks. Clinical record review revealed the HA provided visits three times a week from 07/03/2025 through 08/30/2025, however there was no further HA visits documented in the clinical record after 08/30/2025. During an interview on 09/08/2025, the Director of Nursing stated, “The facility had an increase in COVID, so the aide services were on hold.” The clinical record did not include orders to discontinue or hold aide services, documentation of missed visits, or documentation that the physician was notified of the missed aide visits. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 with diagnosis of cerebrovascular disease. The plan of care dated 07/25/2025 included an order for the HA to provide visits three times a week for thirteen weeks. The HA documented visits at the ordered frequency from 07/30/2025 to 08/29/2025, however, there were no further HA visits documented after 08/29/2025. During an interview on 09/08/2025, the Director of Nursing stated, “The patient changed their mind about the aide services and didn’t want it anymore.” The clinical record did not include orders to discontinue aide services, documentation of missed visits, or documentation that the physician was notified of the missed aide visits. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/01/2025 with diagnosis of malignant neoplasm of the breast. The recertification plan of care dated 07/30/2025 to 09/27/2025 included an order for the HA to provide visits three times a week for thirteen weeks. The HA documented a visit on 07/30/2025, however, there were no further HA visits documented after 07/30/2025. During an interview on 09/08/2025, the Director of Nursing stated, “The patient changed their mind about the aide services and didn’t want it anymore.” The clinical record did not include orders to discontinue aide services, documentation of missed visits, or documentation that the physician was notified of the missed aide visits. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2025 with diagnosis of malignant neoplasm of the pelvis. The plan of care dated 07/09/2025 to 09/05/2025 did not include an order for HA services. Clinical record review revealed the HA documented aid visits dated 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025, 08/15/2025, 08/18/2025, 08/20/2025, 08/22/2025, 08/25/2025, 08/27/2025, 08/29/2025, 09/01/2025, and 09/03/2025. The patient died on 09/05/2025. An aide care plan was present in the clinical record dated 08/06/2025, however the clinical record did not include orders for the HA services. During an interview on 09/08/2025, the Director of Nursing stated, “The patient originally declined aide services, but wanted them later. The nurse did not document an order for the aide to start.” CLINICAL RECORD 8: The patient elected the hospice benefit on 08/07/2025 with diagnosis of Alzheimer’s disease. The plan of care dated 08/07/2025 to 11/04/2025 included an order for the HA to provide visits three times a week for thirteen weeks. There was no documented evidence in the clinical record that the HA provided visits to the patient. The patient died on 08/30/2025. During an interview on 09/08/2025, the Director of Nursing stated, “The patient’s family wanted aide services at the start of care but then changed their mind.” CLINICAL RECORD 9: The patient elected the hospice benefit on 07/18/2025 with diagnosis of malignant neoplasm of the cervix. The plan of care dated 07/18/2025 to 10/15/2025 included an order for the HA to provide visits three times a week for fourteen weeks. Clinical record review revealed no documented evidence of HA visits from 07/18/2025 through 08/02/2025. The HA documented visits at the ordered frequency from 08/04/2025 through 08/29/2025. The patient revoked hospice service on 08/29/2025. During an interview on 09/09/2025, the Director of Nursing stated, “The patient changed their mind about the aide services and didn’t want it at first, but then they wanted it later.” The clinical record did not include orders to discontinue aide services, documentation of missed visits, or documentation that the physician was notified of the missed aide visits. During a joint review of the records and interview on 09/09/2025, the Administrator stated, “Patients change their minds about aide services, and sometimes the orders aren’t updated. Aides should write missed visit notes if the visit was not provided.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed an on-site supervisory visit no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/02/2025 with diagnosis of chronic diastolic heart failure. The plan of care dated 07/02/2025 to 09/29/2025 included an order for hospice aide services at a frequency of three visits per week for thirteen weeks. Hospice aide services were provided as ordered from 07/03/2025 through 07/30/2025. Clinical record review revealed no documented evidence that the Registered Nurse (RN) completed aide supervisory visits from 07/03/2025 through 08/29/2025. The clinical record included documentation that the RN provided nursing visits twice a week from 07/02/2025 through 08/29/2025, however there was no documentation of aide supervision in the nursing visit notes. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 with diagnosis of cerebrovascular disease. The plan of care dated 07/25/2025 included an order for hospice aide services at a frequency of three visits per week for thirteen weeks. Hospice aide services were provided as ordered from 07/30/2025 through 08/29/2025. Clinical record review revealed no documented evidence that the RN completed aide supervisory visits from 07/30/2025 through 08/29/2025. The clinical record included documentation that the RN provided nursing visits twice a week from 07/25/2025 through 08/29/2025, however there was no documentation of aide supervision in the nursing visit notes. During a joint review of the records and interview on 09/10/2025, the Director of Nursing stated, “The aide supervision should be documented in the ‘supervision’ section of the visit note. The nurses did not complete the supervision section of the visit notes.””

“It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) contracts for physicians’ services, and drugs and biologicals, the agency did not ensure that contracted physician services and drugs and biologicals were made routinely available on a 24-hour basis, seven (7) days per week. CONTRACT 2: A contract for Pharmacy services was requested for review. However, the contract was not provided to the site visitor for review by the requested submission time. No contract for pharmacy services was provided for review to determine if drugs and biologicals were made routinely available on a 24-hour basis, seven (7) days per week. CONTRACT 5: A contract for the agency’s Medical Director was requested for review. However, the contract was not provided to the site visitor for review by the requested submission time. No contract for physician services was provided for review to determine if physician services and drugs and biologicals were made routinely available on a 24-hour basis, seven (7) days per week. The Director of Nursing (DON) was interviewed on 09/10/2025 and stated, “I don’t have access to the personnel records or the contracts. The Administrator (Personnel Record 1) was then interviewed. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts were present in the contract binder. The Administrator stated, “The active contracts and personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025 at 2:30 p.m., no further documentation was provided for review.”

“It is required that a written agreement with another organization or individual to furnish hospice care or services includes the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice, care provided in a safe and effective manner and by qualified personnel that meet the human resources requirements of the hospice, and care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by document review and interview. In 4 of 5 (80%) written agreements requested for review, the agency did not ensure that arranged services were supported by written agreements that require that all services be authorized by the hospice. CONTRACT 1: A contract for inpatient/respite care was requested for review. However, the contract was not provided for review. No written agreement for inpatient/respite care was made available for review to determine compliance with this standard. CONTRACT 2: A contract for pharmacy services was requested for review. However, the contract was not provided for review. No written agreement for pharmacy services was made available for review to determine compliance with this standard. CONTRACT 3: A contract for durable medical equipment (DME) was requested for review. However, the contract was not provided for review. No written agreement for DME was made available for review to determine compliance with this standard. CONTRACT 5: A contract for the agency’s Medical Director was requested for review. However, the contract was not provided for review. No written agreement for Medical Director services was made available for review to determine compliance with this standard. The Director of Nursing (DON) was interviewed on 09/10/2025 and stated, “I don’t have access to the personnel records or the contracts. The Administrator (Personnel Record 1) was then interviewed. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts were present in the contract binder. The Administrator stated, “The active contracts and personnel records are in the old office and cannot be faxed, emailed, or sent to this office. Prior to the exit conference on 09/10/2025, at 2:30 p.m., no further documentation was provided for review.”

“It is required that a hospice may contract for medical director services with either a self-employed physician, or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) physician contracts requested for review, the agency did not ensure the contract for review. CONTRACT 5: A contract with a date of hire of 05/01/2025 for the agency’s Medical Director was requested for review. However, the contract was not provided to the site visitor for review by the requested submission time. No contract for physician services was provided for review to determine compliance with the standard. The Administrator (Personnel Record 1) was interviewed on 09/10/2025. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts provided by the Administrator were present in the contract binder. The Administrator stated, “The active contracts [and personnel records] are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025, at 2:30 p.m., no further documentation was provided for review.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed with patient live discharge, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/18/2025 and revoked hospice care on 08/29/2025. Clinical record review revealed a discharge summary was completed, however, there was no documented evidence that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/04/2025 and revoked hospice care on 09/05/2025. Clinical record review revealed a discharge summary was completed, however, there was no documented evidence that the discharge summary was sent to the patient’s attending physician. The Director of Nursing was interviewed on 09/10/2025 and stated, “The patients revoked hospice because they went to the hospital and wanted treatment. We didn’t send a physician a copy of the discharge summary.””

“It is required that a hospice may contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier that: meets the CMS DMEPOS Supplier Quality and Accreditation standards; has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) contract for durable medical equipment services (DME), the agency did not ensure that the DMEPOS supplier was accredited by a recognized accreditation organization. CONTRACT 3: A contract for Durable Medical Equipment was requested for review. However, the contract was not provided to the site visitor for review by the requested submission time. An evaluation for compliance with this standard could not be performed. There was no documented evidence that the agency contracted with a DME point-of-service (POS) supplier that was accredited by a recognized accreditation organization. The Administrator (Personnel Record 1) was interviewed on 09/10/2025. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts provided by the Administrator were present in the contract binder. The Administrator stated, “The active contracts [and personnel records] are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025 at 2:30 p.m., no further documentation was provided for review.”

“It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care; it includes at a minimum: the hospice provides a copy of the patient’s plan care to the inpatient provider and specifies the inpatient services to be provided. This standard was not met as evidenced by document review and interview. The agency did not ensure that a written agreement with a facility to provide short-term inpatient care for pain control, symptom management, and respite purposes was available for review. Compliance with this standard could not be evaluated. A written agreement for short-term inpatient care for pain control, symptom management, and respite purposes was requested for review. However, the written agreement was not provided to the site visitor for review by the requested submission time. An evaluation for compliance with this standard could not be performed. The Director of Nursing (DON) was interviewed on 09/10/2025 and stated, “I don’t have access to the personnel records or the contracts. The Administrator (Personnel Record 1) was then interviewed. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts were present in the contract binder. The Administrator stated, “The active contracts and personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025 at 2:30 p.m., no further documentation was provided for review.”

“It is required that the hospice and SNF/NF or ICF/IID have a written agreement that specifies the provision of hospice services in the facility. This standard was not met as evidenced by document review and interview. The agency did not ensure that a written agreement was in place that specified the provision of hospice services in the facility. No written agreement for hospice services in a SNF/NF was made available for review to determine compliance with this standard. A written agreement for the provision of hospice services in the SNF/NF was requested for review. However, the written agreement was not provided to the site visitor for review. No written agreement for hospice services in a SNF/NF was made available for review to determine compliance with this standard. The Administrator (Personnel Record 1) was interviewed on 09/10/2025. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts provided by the Administrator were present in the contract binder. The Administrator stated, “The active contracts [and personnel records] are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025, at 2:30 p.m., no further documentation was provided for review.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation, act only within the scope of their state license or state certification or registration and keep their qualifications current at all times. Personnel qualifications for certain disciplines must be met for Physician, Hospice Aide, Social Worker, Speech Language Pathologist, Occupational Therapist, Occupational Therapy Assistant, Physical Therapist, Physical Therapist Assistant, Registered Nurse, Licensed Practical Nurse, Marriage and Family Therapist, and Mental Health Counselor. This standard was not met as evidenced by personnel record review and interview. In 2 of 10 (20%) personnel records requested for review, the agency did not ensure documentation that employees were legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. PERSONNEL RECORD 5: Registered Nurse, date of hire 05/01/2025. The personnel record was requested for review; however, the record was not provided for review. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard. PERSONNEL RECORD 6: Hospice Aide, date of hire 05/01/2025. The personnel record was requested for review; however, the record was not provided for review. The site visitor was unable to review the personnel record to evaluate the agency’s compliance with this standard. During an interview on 09/10/2025, the Director of Nursing stated, “I don’t have access to the personnel records.” The Administrator was then interviewed and the Administrator stated, “The personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.””

“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. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 10 (20%) personnel records requested for review, the agency did not ensure that a criminal background check were obtained for all employees with direct access to patient records and direct patient contact as per state regulation. The state administrative code stated in part, “a hospice must conduct a criminal history check on all hospice employees and volunteers with direct client contact or access to client records to verify each employee’s or volunteer’s criminal history report does not include a conviction that bars employment under ...§250.006, or a conviction that the hospice determines is a contraindication to employment.” PERSONNEL RECORD 5: The employee record for the Registered Nurse (RN) (DOH 05/01/2025) was requested for review. The agency did not provide the record within the requested time frame, and it was not reviewed during the site visit. The record could not be evaluated for compliance with this standard. PERSONNEL RECORD 6: The employee record for the Hospice Aide (HA) (DOH 05/01/2025) was requested for review. The agency did not provide the record within the requested time frame, and it was not reviewed during the site visit. The record could not be evaluated for compliance with this standard. The Director of Nursing (DON) was interviewed on 09/10/2025 and stated, “I don’t have access to the personnel records or the contracts. The Administrator (Personnel Record 1) was then interviewed. The Administrator provided a binder of agency contracts. However, none of the contracts included on the written list of active contracts were present in the contract binder. The Administrator stated, “The active contracts and personnel records are in the old office and cannot be faxed, emailed, or sent to this office. I could pick them up, but I wouldn’t be back until later this afternoon.” Prior to the exit conference on 09/10/2025 at 2:30 p.m., no further documentation was provided for review.”