Agape Family Hospice Inc.

“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 clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the bereavement assessment was completed as part of the comprehensive assessment as required by agency policy. AGENCY POLICY: “Bereavement (PC.130),” dated 09/01/2024 required in part, “...The hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment...A standardized bereavement assessment will be utilized to assess needs that must be addressed in the Bereavement POC (plan of care). They may include patient and family and/or caregiver prior loss issues; survivor needs; social, spiritual, and cultural beliefs which may impact grief; and risk factors and potential for pathological grief reactions including suicide.” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/20/2026. Clinical record review revealed no documented evidence that a bereavement assessment was completed. The Chaplain’s initial assessment dated 05/21/2026 contained the statement, “Daughter states bereavement services will not be needed,” and did not include an assessment of bereavement risk, coping status, support systems, or anticipated bereavement needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/12/2026. Clinical record review revealed no documented evidence that a bereavement assessment was completed. The Chaplain’s initial assessment dated 06/12/2026 included documentation that, “The MPOA (medical power of attorney) caregiver...has declined bereavement services. She stated she is spiritually prepared, and there will be no need...,” and did not include an assessment of bereavement risk, coping status, support systems, or anticipated bereavement needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/18/2025. Clinical record review revealed no documented evidence that a bereavement assessment was completed. The Social Work initial assessment conducted on 09/22/2025 documented, “Patient states that (he/she) will speak to (his/her) daughter about bereavement services...” and further noted that the patient’s son “...commented that he would be interested...” in bereavement services. However, the assessment did not include a documented bereavement risk evaluation. The Chaplain’s initial assessment, also completed on 09/22/2025, contained no bereavement assessment or bereavement risk evaluation. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/19/2025. Clinical record review revealed no documented evidence that a bereavement assessment was completed. The Social Work and Chaplain completed initial assessments, on 12/23/2025, and documented that bereavement services were declined due to an inability to obtain a response from the identified bereaved individual(s). However, neither discipline documented a bereavement risk assessment or evidence that the bereavement needs, coping status, support systems, or risk factors of the patient’s family and/or significant others were evaluated. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/23/2025. Clinical record review revealed no documented evidence that a bereavement assessment was completed. The Social Work initial assessment completed on 12/24/2025 included documentation that bereavement services were declined, “Patient is hard of hearing and was unable to provide a response related to bereavement services.” The Chaplain’s initial assessment completed on 12/26/2025 also documented that bereavement services were declined and noted, “Patient stated that (he/she) does not have anyone whom (he/she) would recommend receiving bereavement services. Patient has a son, who has been estranged from patient’s life for years.” The clinical record did not contain a documented bereavement risk assessment and did not demonstrate that the hospice evaluated the bereavement needs, support systems, or risk factors of the patient’s survivor(s). A joint clinical record review and interview were conducted on 07/31/2026 with the Administrator (RN) (Personnel Record 2), the Part-Owner/QAPI Coordinator (RN), and the Licensed Vocational Nurse serving as the Office Clinical Assistant. During the interview, agency representatives acknowledged they did not fully understand the requirements for completing and documenting an initial bereavement risk assessment in accordance with agency policy. They further stated that clinicians had been focusing on whether bereavement services were accepted or declined at admission; however, they had not been consistently conducting or documenting a comprehensive bereavement risk assessment to evaluate the identified survivor’s risk factors, support systems, coping abilities, and anticipated bereavement needs.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the patient’s initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/24/2026 with a terminal diagnosis of alcoholic cirrhosis of the liver. The nurse documented on the nursing visit note dated 04/15/2026 the patient reported right leg pain and generalized pain that reached 10/10 at times yet declined prescribed pain medications. The note also included documentation of refusal of oxygen therapy despite worsening respiratory symptoms, including shortness of breath, crackles in the lung bases, orthopnea, and activity intolerance. The plan of care dated 03/24/2026 through 06/21/2026 did not include planned interventions based on the patient’s nonadherence to prescribed oxygen therapy and pain management regimen. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/16/2025 with a terminal diagnosis of chronic obstructive pulmonary disease and secondary conditions of heart failure. The nurse documented on the nursing visit note dated 07/09/2026 that the Registered Nurse (RN) found the patient smoking in bed with an oxygen saturation of 86% while refusing oxygen therapy because the patient wanted to finish smoking a cigarette. The nurse observed ashes on the patient’s neck and chest and provided education regarding the use of a fire blanket to reduce the risk of injury associated with smoking in bed. The patient reportedly agreed to switch to vaping products due to increasing weakness and difficulty holding cigarettes. During the Nurse Practitioner (NP) visit on 07/14/2026, the patient was noted to experience dyspnea with minimal exertion and oxygen saturation levels that decreased into the mid-80 percent range on room air. The plans of care dated 06/11/2026 through 08/09/2026 did not include planned interventions based on the patient’s significant safety risks associated with smoking in bed, heavy tobacco use, and repeated refusal of oxygen therapy were identified. A joint clinical record review and interview were conducted on 07/31/2026 with the Administrator (RN) (Personnel Record 2), the Director of Nursing (Personnel Record 3), the Part-Owner/QAPI Coordinator (RN), and the Licensed Vocational Nurse serving as the Clinical Office Assistant. During the review, agency leadership acknowledged that the plans of care did not consistently reflect all ongoing patient problems, symptoms, and care needs identified in the clinical record.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes or goals. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/12/2026 with a terminal diagnosis of severe vascular dementia with behavioral disturbance and comorbid conditions including insomnia due to mental disorder, anxiety disorder, and panic episodes. The plan of care dated 06/12/2026 through 09/09/2026 included the goal for the patient to achieve optimal sleep by the end of the benefit period, the goal was not measurable when it did not describe what optimal sleep would be for the patient. The pain management goal on the plan of care included that the patient would achieve an “optimal” level of pain control; however, the goal did not describe or define what an optimal level of pain would be for the patient. Respiratory, anxiety, behavioral, and psychosocial symptoms were addressed with goals that the patient would receive “optimal” support, achieve a “decrease” in anxiety, and have agitation “controlled.” However, the goals were not measurable when they did not describe what optimal support, decrease anxiety, and controlled agitation would be for the patient. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/18/2025 with a terminal diagnosis of unspecified severe protein-calorie malnutrition and comorbid conditions of weakness and constipation. The plans of care dated 05/16/2026 through 07/14/2026 and 07/15/2026 through 09/12/2026 included documentation that pain was identified as an active problem for the patient. The pain goal listed on the plan of care was to maintain pain at a “comfortable” level. The pain goal did not include patient specific parameters to describe what “comfortable” would mean to the patient. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/24/2026 with the terminal diagnosis of alcoholic cirrhosis of the liver. The plans of care dated 03/24/2026 to 06/21/2026 and 06/22/2026 to 09/19/2026 were reviewed. A goal on the plans of care for the patient’s respiratory problem was for the patient to achieve an optimal breathing pattern, airway patency, and comfort by the end of the benefit period. This goal did not address the patient’s specific respiratory symptoms or identify a specific measurable goal. The plans of care included the goal for the patient to have pain at a “comfortable’ level by the end of the benefit period. The goal on the plan of care did not define what a “Comfortable” pain level would be for the patient. A joint clinical record review and interview were conducted on 07/31/2026 with the Administrator (RN) (Personnel Record 2), the Director of Nursing (Personnel Record 3), the Part-Owner/QAPI Coordinator (RN), and the Licensed Vocational Nurse serving as the Clinical Office Assistant. During the review, agency leadership acknowledged that the goals documented within the patients’ plans of care were not consistently measurable and did not reflect the patient-specific goals, symptom thresholds, or desired outcomes.”

“It is required that the hospice develop, implement, and maintain an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Includes defined data detail and frequency of collection and approves such. This standard was not met as evidenced by document review and interview. The hospice did not ensure implementation of a defined, measurable, and consistently applied data collection process for its Quality Assessment and Performance Improvement (QAPI) program. AGENCY POLICY, “Performance Improvement Process: Data Collection (QAPI 15),” dated 09/01/2024, required hospice leadership to establish measurement criteria, data collection tools, and defined frequencies for data collection. The related “Performance Improvement Process: Data Collection - Addendum (QAPI 15),” dated 04/14/2023, required analysis of representative samples of active and closed clinical records, including verification that services were provided in accordance with the individualized plan of care. AGENCY POLICY, “Quality Assessment Performance Improvement Program (QAPI.5),” dated 09/01/2024, required identification of performance measures, data collection methodologies, and Governing Body approval of the frequency and scope of data collection activities. Review of QAPI Committee Meeting Minutes dated 01/09/2026 documented discussion of quality indicators, service effectiveness, patient safety, and whether services were provided in accordance with the plan of care. The record contained no documented evidence of supporting audit data, measurement criteria, sample review results, or data collection methodology. The Governing Body Meeting Minutes dated 01/10/2025 and 01/09/2026 reflected approval of the Quality Improvement Plan and annual agency evaluation, but there was no documented evidence the Governing Body reviewed or approved the frequency or scope of data collection activities related to monitoring whether hospice services were delivered in accordance with individualized plans of care. During an interview on 07/31/2026, the Director of Nursing (DON) (Personnel Record 3) and the Administrator (RN) (Personnel Record 2) stated that quality data was being collected; however, they were unable to produce documentation identifying the specific measures being monitored, the methodology used for collection, or the established frequency of audits. Based on review of the hospice’s QAPI policies, QAPI Committee Meeting Minutes, Governing Body Meeting Minutes, quality oversight records, and interview findings, the hospice did not demonstrate implementation of a defined, measurable, and consistently applied data collection process for its Quality Assessment and Performance Improvement (QAPI) program. Agency policy, “Performance Improvement Process: Data Collection (QAPI 15),” dated 09/01/2024, required hospice leadership to establish measurement criteria, data collection tools, and defined frequencies for data collection. The related “Performance Improvement Process: Data Collection - Addendum (QAPI 15),” dated 04/14/2023, required analysis of representative samples of active and closed clinical records, including verification that services were provided in accordance with the individualized plan of care. Additionally, the policy “Quality Assessment Performance Improvement Program (QAPI.5),” dated 09/01/2024, required identification of performance measures, data collection methodologies, and Governing Body approval of the frequency and scope of data collection activities. Review of QAPI Committee Meeting Minutes dated 01/09/2026 documented discussion of quality indicators, service effectiveness, patient safety, and whether services were provided in accordance with the plan of care. However, the record contained no supporting audit data, measurement criteria, sample review results, or data collection methodology. Similarly, review of QAPI Committee Meeting Minutes dated 01/24/2025 revealed a statement of the overall plan of data collection, defined with the frequency of the data collection. Although Governing Body Meeting Minutes dated 01/10/2025 and 01/09/2026 reflected approval of the Quality Improvement Plan and annual agency evaluation, there was no evidence the Governing Body reviewed or approved the frequency or scope of data collection activities related to monitoring whether hospice services were delivered in accordance with individualized plans of care. During an interview on 07/31/2026, the Director of Nursing (DON) (Personnel Record 3) and the Administrator (RN) (Personnel Record 2) stated that quality data was being collected; however, they were unable to produce documentation identifying the specific measures being monitored, the methodology used for collection, or the established frequency of audits.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) bereavement records reviewed, the agency did not ensure bereavement services were provided as required by agency policy. AGENCY POLICY: “Bereavement (PC.130),” dated 09/01/2024 required in part, “...After the death of the patient: The bereavement coordinator will complete a follow-up assessment and develop a bereavement POC (plan of care) for bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. The Bereavement POC will be discussed at the next IDG/IDT meeting...” CLINICAL RECORD 13: The patient elected the hospice benefit on 12/15/2025 and died while receiving hospice services on 01/03/2026. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no evidence that the patient’s death was reviewed or discussed during a post-death Interdisciplinary Group (IDG) meeting as required by the agency’s policy. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/23/2025 and died while receiving hospice services on 03/24/2026. Clinical record review revealed no documented evidence of a post-death bereavement assessment and no evidence that the patient’s death was reviewed or discussed during a post-death IDG meeting. A joint clinical record review and interview were conducted on 07/31/2026 with the Administrator (RN) (Personnel Record 2), the Bereavement Coordinator (BC) (Personnel Record 4), and the QAPI Coordinator/Part-Owner (RN). During the interview, agency leadership confirmed that the organization’s current bereavement process did not include completion of a post-death bereavement assessment following a patient’s death and did not include discussion of bereavement needs or outcomes at the first Interdisciplinary Group meeting after death.”