The Grove Care Centers of America

“It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This Condition of Participation was not met as evidenced by document review, review of clinical records, and interviews with the Administrator/Director of Nursing which revealed issues with the agency’s clinical records in the following areas: Failure to ensure the clinical record included documentation of whether the patient had executed an advance directive (HPFC.10.I/L503/418.52(a)(2)); Failure to ensure the patient was provided with information on who and how to voice grievances to the hospice, CHAP, or the state entity (HPFC.2.D/L505/418.52(b)(1)(iii)); and Failure to provide documentation that the patient was provided the right to choose his or her attending physician (HPFC.2.D/L515/418.52(c)(4)). The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.52: Patient’s Rights. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services per standard HCDT 5.I in this chapter. This standard was not met as evidenced by clinical record review, document review, interview, and personnel record review. The hospice did not ensure nursing services provided as part of the hospice’s core services was provided directly by hospice staff. During clinical record reviews, personnel record reviews, contract reviews, and an interview on 08/21/2026, the Administrator/Director of Nursing (Personnel Record 2) revealed the hospice routinely utilized contracted Registered Nurses to provide core nursing services. Clinical Record 14 received nursing services from a contracted Registered Nurse from 05/11/2025 through 11/22/2025. Clinical Record 2 received an admission visit from the Administrator/Director of Nursing on 05/13/2025, followed by nursing visits from a contracted Registered Nurse. Additionally, a contracted Registered Nurse visited Clinical Record 4 on 08/20/2026. Review of Registered Nurse contracts identified no end dates or evidence of short-term utilization. The contracted nurses primarily served patients that resided within the hospice’s licensed service area, but for patients located a significant distance from the hospice office. The Governing Body meeting minutes dated 06/10/2024 and 03/10/2025, and QAPI (Quality Assurance Performance Improvement) meeting documentation dated 02/21/2025, 04/15/2025, 09/09/2025, and 12/31/2025, revealed no documented discussion of the need for contracted nursing services, no evaluation of the routine use of contracted Registered Nurses, and no evidence of recruitment efforts to employ hospice nursing staff. During the interview, the Administrator/Director of Nursing stated she was not aware that contracted Registered Nurse services for core hospice nursing functions are limited to short-term, extraordinary, or non-routine circumstances.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Outcome measure data elements per regulation; Physician certification and recertification of terminal illness as required; Any advance directives; Copies of inpatient discharge summary, as applicable; and Physician orders. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This Condition of Participation was not met as evidenced by document review, review of clinical records, and interviews with the Administrator/Director of Nursing which revealed issues with the agency’s clinical records in the following areas: Failure to ensure the patient’s attending physician was sent a copy of the hospice discharge summary (HCDT.39.I/L683/418.104(e)(2)(i)); Failure to ensure the certification and recertifications of terminal illness were documented and included in the clinical record (HSIM.3.I/L676/418.104(a)(5)); Failure to ensure the clinical record included signed copies of the notice of patient rights (HSIM.3.I/L673/418.104(a)(2)); and Failure to ensure the patient’s medical record contained updated assessment data that was documented and available to the patient’s hospice physician and hospice staff (HSIM.3.I/L672/418.104(a)(1)). The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by document review, clinical record review, and interview. In 12 of 14 (86%) clinical records reviewed, the agency did not ensure the clinical record included documentation of whether the patient had executed an advance directive. Agency policy “Advance Directives,” dated 01/31/2015, required in part, “…The hospice will document on the Informed Consent whether or not the patient has executed an advance directive. The hospice will obtain a copy of the Advance Directive for the Clinical Record and “flag” the chart appropriately. The hospice will communicate verbally and/or in writing to the IDG…Interdisciplinary Group Meeting; Patient Demographic Page/Clinical Record…” CLINICAL RECORD 1: The patient elected the hospice benefit on 09/23/2023. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/13/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/14/2026. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/08/2026. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/01/2026. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/24/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/29/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 9: The patient elected the hospice benefit on 06/30/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/20/2026. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/28/2026. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/25/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/11/2025. The clinical record did not include documentation that indicated if the patient had executed an advanced directive as required by agency policy. The record lacked readily accessible evidence of the patient’s end-of-life treatment preferences. A joint clinical record review and interview with the Administrator/Director of Nursing (Personnel Record 2) was conducted on 08/21/2026. After also reviewing several patients’ charts, she demonstrated that there was no uniform process for documenting the patient’s code status, as she could not verify the patient’s specific healthcare wishes and could not see where it was noted that the patient was full code or had chosen to be DNR (Do Not Resuscitate).”

“It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP (Community Health Accreditation Partner), or a state entity without fear of discrimination or reprisal. This standard was not met as evidenced by document review, clinical record review, and interview. In 14 of 14 (100%) clinical records reviewed, the agency did not ensure the patient was provided with information on who and how to voice grievances to the hospice, CHAP, or the state entity. Agency policy “Complaints,” dated 01/31/2015, required in part, “The hospice must protect and promote the patient’s right to voice grievances and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care. Prior to admission, the patient will be informed: They may file a complaint to the hospice Administrator, or {the states} Department of Aging and Disability services/Consumer Rights and Services Division, or the Joint Commission…Documentation of notifying the patient or representative on how to file a complaint will be on the Informed Consent and filed in the Clinical Record….” CLINICAL RECORD 1: The patient elected the hospice benefit on 09/23/2023. The Admission Consent and Contract for Hospice Services did not identify Community Health Accreditation Partner (CHAP) as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/13/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/14/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/08/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/30/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/01/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/24/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/29/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 9: The patient elected the hospice benefit on 06/30/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/20/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/03/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/28/2026. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/25/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/11/2025. The Admission Consent and Contract for Hospice Services did not identify CHAP as the agency’s accrediting organization. The consent and contract for hospice services did not include information to the patients or families with information on how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. On 08/21/2026, during an interview with the Administrator/Director of Nursing (Personnel Record 2) and after a review of a sample admission packet, patient hospice binders, and corresponding clinical records, it was confirmed that the Admission Consent and Contract for Hospice Services did not identify CHAP as the hospice’s accrediting organization. Additionally, the admission materials did not include information advising patients and families how to contact the hospice Administrator, the state reporting agency, or CHAP to file a grievance or complaint. The Administrator could not provide documentation showing that this information was communicated through other admission materials.”

“It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. 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 provide documentation that the patient was provided the right to choose his or her attending physician. Agency policy “Election of Hospice Care,” dated 01/13/2015, required in part that the “...Election Statement...will include...Identification of the attending physician that will provide care to the patient. The patient or representative must acknowledge that the identified attending physician was his or her choice. The Election Statement must include the Attending Physician’s NPI number...Documentation: NPI number of Attending Physician will be documented; The Election Statement will be filed in the clinical record.” CLINICAL RECORD 2: The Admission Consent and Contract for Hospice Services, signed by the patient’s sister on 05/12/2025, showed that the section designated for documenting the patient’s choice of attending physician was left blank. The clinical record contained no documentation demonstrating that the patient or legal representative was informed of, or offered, the option to choose an attending physician. CLINICAL RECORD 4: The Admission Consent and Contract for Hospice Services, signed by the patient on 06/08/2026, showed that the section designated for documenting the patient’s choice of attending physician was left blank. The clinical record contained no documentation demonstrating that the patient or legal representative was informed of, or offered, the option to choose an attending physician. CLINICAL RECORD 7: The Admission Consent and Contract for Hospice Services, signed by the patient’s representative on 10/24/2025, showed that the section designated for documenting the patient’s choice of attending physician was left blank. The clinical record contained no documentation demonstrating that the patient or legal representative was informed of, or offered, the option to choose an attending physician. CLINICAL RECORD 10: The Admission Consent and Contract for Hospice Services, signed by the patient’s representative on 04/20/2026, showed that the section designated for documenting the patient’s choice of attending physician was left blank. The clinical record contained no documentation demonstrating that the patient or legal representative was informed of, or offered, the option to choose an attending physician. CLINICAL RECORD 9: The Admission Consent and Contract for Hospice Services, signed by the patient on 06/30/2025, showed that the section designated for documenting the patient’s choice of attending physician was left blank. The clinical record contained no documentation demonstrating that the patient or legal representative was informed of, or offered, the option to choose an attending physician. During an interview on 08/21/2026, the findings were reviewed with the Administrator/Director of Nursing (Personnel Record 2). The Administrator acknowledged that the clinical record lacked documentation identifying the patient’s choice of attending physician and offered no explanation for the missing documentation. No additional records or supporting evidence were presented to demonstrate that the patient or legal representative had been informed of, or provided the opportunity to select, an attending physician.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 4/HOMR VISIT 1: The clinical record review conducted on 08/20/2026 at 1623 revealed that hospice services were elected on 06/08/2026. The medication profile, signed by the Registered Nurse (RN) and Medical Director (MD) on 06/08/2026, listed Ropinirole HCl 3 mg at bedtime for restless leg syndrome, Hydrocodone-Acetaminophen 5 mg/325 mg, two tablets every 6 hours as needed for pain, Amlodipine 5 mg daily for hypertension, Clonazepam 0.5 mg at bedtime for panic attack, Ondansetron HCl 8 mg every 8 hours as needed for nausea/vomiting, and Vitamin E 1000 units daily. During the home visit observation on 08/20/2026 with the Social Worker (SW) (Personnel Record 4), review of the patient’s hospice binder revealed the medication profile available in the home was dated 06/08/2026. The binder contained handwritten additions that were not signed, dated, or reflected on the hospice medication profile. These medications included Pramipexole twice daily, Fluticasone one spray in each nostril daily, Diphenoxylate/Atropine 2.5 mg/0.025 mg as needed, D3/K2 125 mcg/100 mcg daily, Vitamin C 1000 mg daily, Magnesium Complex 1000 mg daily, Hydrocortisone 10 mg, one tablet every morning and one-half tablet at 1500, and Fludrocortisone 0.1 mg daily. The hospice did not maintain an accurate, updated medication profile reflecting the patient’s current medication regimen. The home record included multiple medications not incorporated into the hospice medication profile and lacked documented review, reconciliation, dating, or authentication, showing the medication list had not been updated to reflect the patient’s current medications. This evidence did not support ongoing assessment of medication needs or ensure that the plan of care and medication profile accurately reflected the patient’s current clinical status and treatment regimen. On 08/21/2026, during an interview with the Administrator/Director of Nursing (Personnel Record 2), the findings related to the patient’s medication profile were reviewed. The Administrator could not provide documentation supporting timely updates to the patient’s medication profile and could not explain the lapse in clinical documentation. Additionally, the Administrator could not provide evidence reconciling discrepancies between the medication list documented in the home and the medication profile reflected on the hospice plan of care.”

“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, but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure an update to the comprehensive assessment was completed at least every 15 days. CLINICAL RECORD 4: On 08/20/2026 at 1623 (4:23 PM), a review of the clinical record showed the patient elected the hospice benefit on 06/08/2026. The record contained a Nursing (HOPE-Hospice Outcomes and Patient Evaluation) Initial Admission Assessment dated 06/08/2026 documented by the Registered Nurse (RN) and an RN HOPE Update Visit 1 dated 06/14/2026. The other interdisciplinary disciplines were declined; however, no additional nursing visits were documented. Initially, on 08/20/2026 at 1623, a review of the Plan of Care (POC)/Interdisciplinary Group (IDG) documentation identified only an entry dated 06/08/2026. The following day, 08/21/2026 at 1302 (1:02 PM), two additional documents had been added under the POC/IDG tab for 06/24/2026 and 07/08/2026. Despite the additional documentation identified on 08/21/2026 at 1302, the record reflected a forty-one (41) day interval from 07/09/2026 through 08/19/2026 with no documented update of the comprehensive assessment, which exceeded the minimum requirement of an update at least every fifteen (15) days. On 08/20/2026, the clinical record findings were reviewed with the Administrator/Director of Nursing (Personnel Record 2). During the interview, the Administrator confirmed that clinical documentation did not demonstrate timely updates to the patient’s comprehensive assessment. The Administrator did not explain the missing documentation and stated that “she would get it entered.””

“It is required that the hospice use quality indicator data, including patient care data and other relevant data, in the QAPI (Quality Assurance Performance Improvement) program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. This standard was not met as evidenced by document review and interview. The agency did not ensure the QAPI program included data elements abstracted and aggregated from comprehensive patient assessments. On 08/21/2026, a review of the Quality Assessment and Performance Improvement (QAPI) program documentation, in conjunction with an interview with the Administrator/Director of Nursing (Personnel Record 2), revealed that the hospice did not maintain comprehensive, organization-wide quality data to support an effective QAPI program. The Administrator presented handwritten “raw” data maintained on a yellow legal pad; however, the information had not been trended, analyzed, or evaluated to identify patterns, performance concerns, opportunities for improvement, or measurable outcomes. Additionally, no evidence was provided that demonstrated routine collection or monitoring of clinical quality indicators. On 08/21/2026, a review of the Quality Assessment and Performance Improvement (QAPI) program documentation, in conjunction with an interview with the Administrator/Director of Nursing (Personnel Record 2), revealed that the hospice did not maintain comprehensive, organization-wide quality data to support an effective QAPI program. The Administrator presented handwritten “raw” data maintained on a yellow legal pad; however, the information had not been trended, analyzed, or evaluated to identify patterns, performance concerns, opportunities for improvement, or measurable outcomes. Additionally, no evidence was provided demonstrating routine collection or monitoring of clinical quality indicators.”

“Each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized plan of care included patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4/HOME VISIT 1: On 08/20/2026, a review of the clinical record for a patient who elected the hospice benefit on 06/08/2026 revealed that the plan of care for the benefit period 06/08/2026 through 09/05/2026 identified the problem of “Cancer,” with the goal that the patient would receive hospice care for the terminal illness and the intervention to admit the patient to hospice. The Registered Nurse (RN) Initial Assessment dated 06/08/2026 documented additional clinical concerns that included poor appetite, constant nausea and vomiting, fatigue, shortness of breath with minimal exertion, confusion, and short-term memory loss. During the home visit observation with the Social Worker (SW) (Personnel Record 4) on 08/29/2026 at 11:00 AM, the patient verbalized experiencing pain, weakness, nausea and vomiting, and restless leg syndrome symptoms. Despite these documented and reported symptoms, the plan of care did not identify these conditions or include corresponding goals or interventions to manage them. On 08/21/2026, during an interview with the Administrator/Director of Nursing (Personnel Record 2), the findings related to the patient’s plan of care were reviewed. The Administrator confirmed that the plan of care did not include identified problems, goals, or interventions addressing the patient’s ongoing symptoms, including those documented in the clinical record and reported during the patient’s care. No additional documentation was provided to show that the patient’s nausea and vomiting, pain, weakness, restless leg syndrome, or other symptom management needs were incorporated into the plan of care.”

“It is required that the Interdisciplinary Group (IDG), 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. 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 that the patient’s plan of care was updated at least every 15 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/13/2025. Clinical record review revealed an eighty-two (82) day interval from 02/04/2026 through 04/27/2026 with no documented IDG review or plan of care update. Although the IDG Binder contained signed attendance records for meetings held on 02/18/2026, 03/04/2026, 03/18/2026, 04/01/2026, and 04/15/2026, the documentation did not identify the patients reviewed during the meetings. The clinical record also reflected a twenty-eight (28) day gap from 06/24/2026 through 07/22/2026 and an additional twenty-eight (28) day gap from 07/22/2026 through 08/19/2026 without documented IDG review or plan-of-care updates. While the IDG Binder included evidence of meetings conducted on 07/08/2026 and 08/05/2026, with patient review lists indicating this patient was discussed, the clinical record contained no corresponding documentation demonstrating review, revision, or update of the patient’s plan of care. CLINICAL RECORD 4: On 08/20/2026 at 1623 (4:23 PM), a review of the clinical record for a patient who elected the hospice benefit on 06/08/2026 revealed a Plan of Care/Plan of Care Order documented on 06/08/2026 with no subsequent Interdisciplinary Group (IDG) updates present in the clinical record at the time of review. Following the initial record review, additional IDG documentation dated 06/24/2026 and 07/08/2026 was entered into the clinical record on 08/21/2026 at 1302 (1:02 PM). Despite the late entry of these records, the clinical record did not include a documented IDG review or plan-of-care update from 07/09/2026 through 08/19/2026. Review of the IDG Binder identified signed attendance records and patient review lists for IDG meetings conducted on 07/22/2026, 08/05/2026, and 08/19/2026, which indicated the patient was reviewed; however, the patient’s clinical record reflected no corresponding updates, revisions, or documentation. On 08/21/2026, a review of findings that included the missing Interdisciplinary Group (IDG) documentation was completed with the Administrator/Director of Nursing (Personnel Record 2). During the review and interview, the Administrator could not explain the absence of IDG reviews and plan of care updates in the clinical record during the identified timeframes. Although the IDG binder was produced and supported that the IDG met, the documentation did not reflect complete and timely updates in the patient’s clinical record, including evidence of plan of care updates and progress toward goals.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. The agency did not ensure performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive measures. On 08/21/2026, a review of the hospice’s QAPI (Quality Assurance Performance Improvement) program documentation was conducted in conjunction with an interview with the Administrator/Director of Nursing (Personnel Record 2). During the review, the Administrator presented handwritten data collection records maintained on a yellow legal pad, kept outside the organization’s QAPI binder and supporting QAPI documentation. The data reflected information collected by the hospice; however, no evidence was provided that the data had been analyzed, trended, evaluated, or incorporated into the hospice’s QAPI activities. During the interview, the Administrator/Director of Nursing acknowledged the data collection process but could not produce documented evidence of analysis of the collected data, identification of performance improvement opportunities, or actions taken based on the information gathered. The absence of documented analysis prevented verification that the hospice systematically monitored, measured, and evaluated performance indicators to identify areas requiring improvement. The agency could not produce documentation showing that the hospice collected and analyzed data to monitor the effectiveness and safety of services and use that information to identify opportunities for performance improvement and sustain quality outcomes. The available evidence reflected data collection without documented analysis to support an effective, data-driven QAPI program. On 08/21/2026, a review of the hospice’s QAPI program documentation was conducted in conjunction with an interview with the Administrator/Director of Nursing (Personnel Record 2). During the review, the Administrator presented handwritten data collection records maintained on a yellow legal pad, kept outside the organization’s QAPI binder and supporting QAPI documentation. The data reflected information collected by the hospice; however, no evidence was provided that the data had been analyzed, trended, evaluated, or incorporated into the hospice’s QAPI activities. During the interview, the Administrator/Director of Nursing acknowledged the data collection process but could not produce documentation evidencing analysis of the collected data, identification of performance improvement opportunities, or actions taken based on the information gathered. The absence of documented analysis prevented verification that the hospice systematically monitored, measured, and evaluated performance indicators to identify areas requiring improvement. The agency could not produce documentation showing that the hospice collected and analyzed data to monitor the effectiveness and safety of services and use that information to identify opportunities for performance improvement and sustain quality outcomes. The available evidence reflected data collection without documented analysis to support an effective, data-driven QAPI program.”

“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 needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse documented supervision of the Hospice Aide at least every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/13/2025. The patient’s plans of care for the benefit periods from 03/09/2026 to 05/07/2026, 05/08/2026 to 07/06/2026, and 07/07/2026 to 09/14/2026 included orders for the Hospice Aide (HA) to provide visits to the patient three times a week. There was no documented evidence in the clinical record that the Registered Nurse (RN) had completed supervisory assessments of the HA. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/29/2025 and was discharged on 03/01/2026. The patient’s plans of care for the benefit periods from 12/28/2025 to 02/25/2026 and 02/26/2026 to 03/01/2026 included orders for the Hospice Aide to provide visits to the patient five times a week. Clinical record review revealed that the Registered Nurse last documented an aide supervisory visit on 12/15/2025. CLINICAL RECORD 11: The patient elected the hospice benefit on 5/03/2025 and died on 03/15/2026. The patient’s plans of care for the benefit periods from 12/29/2025 to 02/26/2026 and 02/27/2026 to 03/15/2026 included orders for the Hospice Aide to provide visits to the patient five times a week. The RN documented an aide supervisory visit on 07/10/2025. The next aide supervisory visit was documented on 07/31/2025, a total of 21 days and 7 days outstanding. On 08/21/2026, a joint clinical record review and interview was conducted with the Administrator/Director of Nursing (Personnel Record 2). During the review, the identified findings were reviewed and compared to the requirements for clinical record content and oversight. The Administrator acknowledged the identified issues without dispute. No additional documentation or evidence was presented to demonstrate compliance with the Hospice Aide Supervisory visits.”

“It is required that orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, personnel record review, and interview. In 3 of 8 (38%) personnel records reviewed, the agency did not ensure that employees received orientation to hospice philosophy. Agency policy “Contract,” dated 06/15/2015, required in part, “...Leadership Responsibility: Hospice Administrator...will approve contractual agreements...Monitor contracted services...A hospice is not required to maintain a personnel record for independent contractors or personnel who provide services under arrangement with another hospice or organization. Upon request by [the state], a hospice will provide documentation at the site of a survey within eight working hours of the request to demonstrate that independent contractors or staff under arrangement meet the hospice’s written job qualifications for the position and duties performed...” PERSONNEL RECORD 1: Review of the personnel record for the contracted Medical Director, whose contract was effective 03/14/2024, revealed no documentation of hospice orientation. The record did not contain an orientation checklist, attendance record, signed acknowledgment, or other evidence demonstrating orientation to hospice-specific policies, procedures, responsibilities, or services. PERSONNEL RECORD 7: Review of the personnel record for the contracted Registered Nurse, whose contract was effective 02/03/2025, revealed no documentation of hospice orientation. The record did not contain an orientation checklist, attendance record, signed acknowledgment, or other evidence demonstrating orientation to hospice-specific policies, procedures, responsibilities, or services. PERSONNEL RECORD 9: Review of the personnel record for the contracted Registered Nurse, whose contract was effective 08/20/2026, revealed no documentation of hospice orientation. The record did not contain an orientation checklist, attendance record, signed acknowledgment, or other evidence demonstrating orientation to hospice-specific policies, procedures, responsibilities, or services. This nurse visited a hospice patient on 08/20/2026. On 08/21/2026, during an interview, policy review, and joint personnel record review, the Administrator/Director of Nursing (Personnel Record 2) confirmed that while the hospice was not required to maintain a complete personnel file for contracted staff, required documentation must be available upon request. The review identified no documentation demonstrating that the contracted Medical Director or two contracted nurses received orientation to the hospice philosophy of care or the needs and concerns of patients and families coping with terminal illness.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 9 (22%) personnel records reviewed, the agency did not ensure the skills and competencies of contracted Registered Nurses were verified prior to providing care to the hospice’s patients. Agency policy “Contract,” dated 06/15/2015, required in part, “...Independent contractors: If a hospice uses independent contractors...The contract will be enforced by the hospice and clearly designate...The necessity of the contractor to conform to all applicable hospice policies, including personnel qualifications...” PERSONNEL RECORD 7: Registered Nurse contracted on 02/03/2025. The personnel record did not include a Hospice Nurse Competency Skills Evaluation or other documentation that demonstrated competency validation for hospice nursing duties. No evidence was present to verify that the Registered Nurse’s clinical knowledge, skills, and abilities were assessed and found appropriate to provide hospice services. PERSONNEL RECORD 9: Registered Nurse contracted on 08/20/2026. The personnel record did not include a Hospice Nurse Competency Skills Evaluation or other documentation that demonstrated competency validation for hospice nursing duties. No evidence was present to verify that the Registered Nurse’s clinical knowledge, skills, and abilities were assessed and found appropriate to provide hospice services before the contracted nurse’s visit on 08/20/2026. On 08/21/2026, during an interview regarding personnel record requirements, the Administrator/Director of Nursing (Personnel Record 2) stated that she did not understand that personnel documentation was required to ensure all personnel, including contracted staff, are qualified and competent to perform assigned duties.”

“It is required that each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the patient’s medical record contained updated assessment data that was documented and available to the patient’s hospice physician and hospice staff. Agency policy “Clinical Record,” dated 01/31/2015, required in part, “The hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information...The hospice will...Document all hospice services provided to a patient’s family in the clinical record...which must be written the day service is rendered and incorporated into the client record within 14 working days...Ensure that entries are...complete, current, accurate...Each clinical record will include the following...Advance Directives; Assessments...Bereavement, Comprehensive Nursing, Eligibility, Initial, Psychosocial, Safety, Spiritual, Volunteer...” CLINICAL RECORD 4: The patient elected the hospice benefit on 06/08/2026 with diagnosis of malignant neoplasm of left kidney. The clinical record was reviewed on 08/20/2026 at 1623 (4:23 PM). The record contained documentation of the Registered Nurse (RN) Initial Admission Assessment (HOPE) dated 06/08/2026 and an RN HOPE Update Visit 1 dated 06/14/2026. All other Interdisciplinary disciplines were declined, and no additional nursing visits were documented. During the record review on 08/20/2026 at 1623, the Plan of Care (POC)/Interdisciplinary Group (IDG) documentation identified one entry dated 06/08/2026. The following day, on 08/21/2026 at 1302 (1:02 PM), two additional documents had been added to the clinical record under the POC/IDG tab. The documents were dated 06/24/2026 and 07/08/2026. On 08/20/2026, the clinical record findings were reviewed with the Administrator/Director of Nursing (Personnel Record 2). During the interview, the Administrator confirmed that no clinical documentation demonstrated timely updates to the patient’s comprehensive assessment. The Administrator did not explain the missing documentation and stated that “she would get it entered.” The Administrator’s acknowledgment of the missing documentation confirmed that the patient’s clinical record did not contain assessment information available for all the IDG team, nor did it comply with the agency’s policy requiring hospice services to be documented the day of service and incorporated into the record within 14 working days.”

“It is required that each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 home visit observations, the agency did not ensure the clinical record included signed copies of the notice of patient rights. CLINICAL RECORD 1/HOME VISIT 2: The patient elected the hospice benefit on 09/23/2023 with diagnoses heart failure and hypertension. The Admission Consent and Contract for Hospice Services, signed 08/08/2023, listed the wrong hospice name and was signed and dated by the patient on 08/08/2023, which did not match the start of care date. On page 2, the consents included the statement that, “I acknowledge that I have received information in writing regarding the topics listed below: *Complaint Process, How to file a grievance with the Hospice and appropriate governing bodies, Abuse, Neglect, and Exploitation...Mental Health Rights...Information on Hospice’s policy for drug testing...Management and disposal of controlled substances.” The policies/information included in the acknowledgment statement were not present in the sample admission documentation provided for review, nor were they included in the patient’s home binder reviewed during home visit observation on 08/20/2026 with the Registered Nurse (RN) (Personnel Record 2). CLINICAL RECORD 4/HOME VISIT 1: The patient elected the hospice benefit on 06/08/2026 with diagnosis of malignant neoplasm of left kidney. The Admission Consent and Contract for Hospice Services, signed and dated by the patient on 06/06/2026, included on page 2 the statement that, “I acknowledge that I have received information in writing regarding the topics listed below: *Complaint Process, How to file a grievance with the Hospice and appropriate governing bodies, Abuse, Neglect, and Exploitation...Mental Health Rights...Information on Hospice’s policy for drug testing...Management and disposal of controlled substances.” The policies/information included in the acknowledgment statement were not present in the sample admission documentation provided for review, nor were they included in the patient’s home binder reviewed during home visit observation on 08/20/2026 with the Social Worker (SW) (Personnel Record 4). On 08/21/2026, the findings were reviewed during an interview with the Administrator/Director of Nursing (Personnel Record 2). The Administrator acknowledged that the sample admission documentation provided for review did not contain the policies/information listed in the evidence as having been provided to and acknowledged by the patients.”

“It is required that each patient’s record includes, at a minimum physician certification and recertification of terminal illness as required. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the certification and recertifications of terminal illness were documented and included in the clinical record. Agency policy “Clinical Record,” dated 01/31/2015, required in part, “The hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information...The hospice will...Document all hospice services provided to a patient’s family in the clinical record...which must be written the day service is rendered and incorporated into the client record within 14 working days...Ensure that entries are...complete, current, accurate...Each clinical record will include the following...Advance Directives; Assessments...Bereavement, Comprehensive Nursing, Eligibility, Initial, Psychosocial, Safety, Spiritual, Volunteer...” CLINICAL RECORD 1: The patient elected the hospice benefit on 09/23/2023. Clinical record review revealed that, for the benefit period of 07/20/2026 through 09/17/2026, no verbal or written physician recertification of terminal illness was documented. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/13/2025. Clinical record review revealed that, for the benefit period of 05/08/2026 through 07/06/2026, a verbal certification of terminal illness was documented on 04/25/2026; however, the clinical record did not include a written physician recertification of terminal illness. For the subsequent benefit period of 07/07/2026 through 09/04/2026, a verbal recertification of terminal illness was documented on 06/24/2026, however the written recertification was not signed by the physician. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/24/2025. Clinical record review revealed that for the benefit period of 10/24/2025 through 01/21/2026, a verbal certification of terminal illness was documented on 10/24/2025; however, the physician did not sign the written certification of terminal illness. For the subsequent benefit period of 01/22/2026 through 04/21/2026, a verbal recertification of terminal illness was documented on 01/07/2026; however, no written physician recertification of terminal illness was present in the clinical record. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/29/2025. Clinical record review revealed that for the benefit period of 02/26/2026 through 04/26/2026, a verbal certification of terminal illness was documented on 02/18/2026; however, no written physician recertification of terminal illness was present in the clinical record. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/11/2025. Clinical record review revealed that for the benefit period of 05/11/2025 through 08/08/2025, a verbal certification of terminal illness was documented on 05/11/2025; however, the clinical record did not include a written physician certification of terminal illness. For the benefit period of 08/09/2025 through 11/06/2025, a verbal recertification of terminal illness was documented on 07/25/2025; however, no written physician recertification of terminal illness was documented. For the benefit period of 11/07/2025 through 01/05/2026, a verbal certification of terminal illness was documented on 10/20/2025, and a written physician recertification containing the required narrative was present; however, the recertification was not signed by the physician. On 08/21/2026, a joint clinical record review was conducted with the Administrator/Director of Nursing (Personnel Record 2). During the review, the incomplete certification and recertification documentation identified in multiple clinical records was brought to her attention. The Administrator did not explain the missing and incomplete physician certification and recertification records.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed with live discharge, the agency did not ensure the patient’s attending physician was sent a copy of the hospice discharge summary. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/30/2026. The patient was discharged on 06/27/2026. The Registered Nurse documented a live discharge to home/self-care in stable condition and noted, “The patient has improved and is no longer hospice appropriate and life expectancy is more than 6 months. (The patient) is being referred to Home Health.” Review of the clinical record, including scanned documents and communication notes, identified no evidence that a discharge summary or other clinical record information was forwarded to the patient’s attending physician upon discharge from hospice services. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/01/2026. The patient was discharged on 06/08/2026. The Registered Nurse documented a live discharge to home/self-care in stable condition and indicated that the patient was no longer terminally ill. The discharge note included documentation that the patient’s condition had improved following hospice interventions, including initiation of medication for depression and oxygen therapy, and that the patient was no longer appropriate for hospice services. Review of the post-discharge IDG meeting dated 06/10/2026, scanned documents, and communication notes identified no evidence that a discharge summary or any portion of the clinical record was provided to the patient’s physician upon discharge. During a review of the discharge record findings, the regulatory requirement, and an interview on 08/21/2026, the Administrator/Director of Nursing (Personnel Record 2) could not provide documentation showing that the discharge summaries or other pertinent clinical record information were forwarded to the physicians of patients discharged from hospice services. No communication notes, fax confirmations, scanned documents, or other evidence were presented to verify physician notification or transmission of discharge information.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, observation, and interview. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure the agency’s policy for the management and disposal of controlled substances was provided to the patient and discussed with the patient or caregiver. CLINICAL RECORD 1/HOME VISIT 2: During the home visit observation on 08/20/2026 with the Registered Nurse (RN) (Personnel Record 2), review of the patient’s home hospice folder revealed the hospice’s policy for the management and disposal of controlled substances was not present. The plans of care for the benefit periods 05/21/2026 through 07/19/2026 and 07/20/2026 through 09/17/2026 included orders for prescribed controlled medications, including Hydrocodone-Acetaminophen 10 mg/325 mg, one tablet twice daily, and Lorazepam 1 mg twice daily. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education with the patient or caregiver on the safe management and disposal of these medications. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/08/2026. The plan of care for the benefit period from 06/08/2026 to 09/05/2026 included orders for prescribed controlled medications, including Hydrocodone-Acetaminophen 5 mg/325 mg, one tablet every six hours PRN (as needed) for pain, and Clonazepam 0.5mg at bedtime for anxiety. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education with the patient or caregiver on the safe management and disposal of these medications. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/29/2025. The plans of care for the benefit periods from 12/28/2025 to 02/25/2026 and 02/26/2026 to 03/01/2026 included orders for prescribed controlled medications, including Tramadol 50 mg three times daily for pain and Hydrocodone-Acetaminophen 5mg/325mg every six hours PRN (as needed) for pain. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education on the safe management and disposal of these medications. CLINICAL RECORD 9: The patient elected the hospice benefit on 06/30/2025. The plan of care for the benefit period from 02/25/2026 to 03/24/2026 included orders for prescribed controlled medications, including Morphine Sulfate 20mg/mL: 0.25mL every four hours PRN (as needed) for pain or shortness of breath and Lorazepam 0.5mg every four hours PRN for anxiety. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education on the safe management and disposal of these medications. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/03/2025. The plans of care for the benefit periods from 12/29/2025 to 02/26/2026 and 02/27/2026 to 03/15/2026 included orders for prescribed controlled medications, including ABH (1mg/25mg/1mg): one mL PRN (as needed) every six hours for anxiety, Lorazepam 2mg/mL: 0.5mL every six hours PRN anxiety, Morphine Sulfate 20mg/mL: 0.25 - 0.5mL every six hours PRN pain or shortness of breath, and Dilaudid 1mg/mL: 0.25-0.5mL every hour PRN for pain. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education on the safe management and disposal of these medications. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/28/2026. The plan of care for the benefit period from 01/28/2026 to 02/14/2026 included orders for prescribed controlled medications, including ABH (1mg/25mg/1mg): one mL PRN (as needed) every six hours for anxiety; Lorazepam 0.5mg every eight hours PRN for anxiety; Morphine Sulfate 20mg/mL: 0.25- 0.5 mL every four hours PRN for pain or shortness of breath. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education on the safe management and disposal of these medications. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/25/2025. The plans of care for the benefit periods from 07/25/2025 to 10/02/2025 and 10/03/2025 to 12/12/2025 included orders for prescribed controlled medications, including ABH (1mg/25mg/1mg): one mL PRN (as needed) every six hours for anxiety; Lorazepam 0.5mg every eight hours PRN for anxiety; Morphine Sulfate 20mg/mL: 0.25- 0.5 mL every four hours PRN for pain or shortness of breath. There was no documented evidence in the clinical record that the patient or caregiver received the hospice’s written policy on the management and disposal of controlled substances, and the record did not include documentation of a verbal review or education on the safe management and disposal of these medications. A joint review of the hospice’s sample admission packet, clinical records, and applicable CHAP standards and hospice regulations on 08/21/2026 was conducted with the Administrator/Director of Nursing (Personnel Record 2). The review confirmed no documentation showing that patients, families, or caregivers received education on managing and disposing of controlled substances. The Administrator acknowledged the findings and could not produce clinical documentation, admission records, or other evidence verifying that these discussions occurred. She stated that she was updating the admission materials but had not completed the process.”

“It is required that hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review, contract review, and interview. In 4 of 9 (44%) hospice contracts reviewed, the hospice did not ensure contracts contained language that required criminal background checks for anyone who has access to hospice patients or their records. Agency policy “Contract,” dated 06/15/2015, required in part, “...Independent contractors: If a hospice uses independent contractors...The contract will be enforced by the hospice and clearly designate...The necessity of the contractor to conform to all applicable hospice policies, including personnel qualifications...Leadership Responsibility: Hospice Administrator...will approve contractual agreements...Monitor contracted services...A hospice is not required to maintain a personnel record for independent contractors or personnel who provide services under arrangement with another hospice or organization. Upon request by [the state], a hospice will provide documentation at the site of a survey within eight working hours of the request to demonstrate that independent contractors or staff under arrangement meet the hospice’s written job qualifications for the position and duties performed...” Agency policy “Criminal Background Checks,” dated 02/11/2016, required in part, “The hospice must obtain a criminal background check on all hospice personnel (including volunteers) who have direct patient contact or access to patient records. Hospice contracts must require that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records...” CONTRACT 1: The contract for the Medical Director, effective 03/15/2024, does not include the requirement that all contracted employees with direct patient contact or access to patient records must obtain criminal background checks. CONTRACT 2: The contract for the Alternate Medical Director, effective 08/07/2026, does not include the requirement that all contracted employees with direct patient contact or access to patient records must obtain criminal background checks. CONTRACT 8: The contract for laboratory services, effective 09/02/2025, does not include the requirement that all contracted employees with direct patient contact or access to patient records must obtain criminal background checks. CONTRACT 9: The contract for staffing services, effective 02/03/2025, does not include the requirement that all contracted employees with direct patient contact or access to patient records must obtain criminal background checks. On 08/21/2026, the contract evidence was reviewed with the Administrator/Director of Nursing (Personnel Record 2) during an interview. The Administrator acknowledged that, during the initial site, she remembered another hospice contract that also lacked the required language related to criminal background checks and needed to be amended. During the discussion, the Administrator could not provide evidence that a comprehensive audit of all hospice contracts had been conducted to verify compliance with criminal background check requirements.”