Sunlight Hospice Company

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard is not met as evidenced by document review, clinical record review, and observation. The agency did not ensure the patients right to be involved in their care, when the information provided to the patient was unclear as to the hospice that was providing care to the patient. Review of the agency’s admission packet and paperwork that is provided to patients at the start of care revealed the Individualized Emergency Preparedness form included the name of another hospice company (Hospice 2). HOME VISIT 3: During the home visit observation on 07/29/2026 with the Hospice Aide (HA) (Personnel Record 12), the hospice aide was observed wearing the name badge for another hospice (Hospice 2) and not the name badge for the hospice providing care (Hospice 1). The Director of Nursing (Personnel Record 3) who also attended the home visit observation, was also observed wearing the name badge for Hospice 2 and not the hospice providing care to the patient. CLINICAL RECORD 13: Review of a bereavement letter that was sent to bereaved of clinical record 13 revealed the bereavement letter for the agency providing care (Hospice 1), included the address for Hospice 1 and included the documentation of two hospice agency’s name, “Again, (Hospice 2) and (Hospice 1) would like to express our deepest sympathy to you.” Another bereavement letter, undated, with a Hospice 2 address, included in part, “In Barbara Hills Lee Strang’s book, After Loss… Remember that (Hospice 2) team is here for you and are very much concerned about you and your well-being… please do not hesitate to call us at XXX-XXX-XXXX.” Another bereavement letter, undated, with a Hospice 1 address and phone number, included in part, “We are writing on behalf of (Hospice 2/Hospice 1) to express our compassion for your loved loss.” CLINICAL RECORD 14: Review of the bereavement letter sent to the bereaved of clinical record 14 revealed the bereavement letter, not dated, with Hospice 1 address, included the documentation, “Again, (Hospice 3) would like to express our deepest sympathy to you.” The agency did not ensure the patients’ right to be involved in their care, when the agency did not provide clear information related to the hospice agency that was providing care to the patient.”

“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 population 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, observation, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure a review of medications the patient was currently using was completed to identify any potential adverse effects and drug reactions. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 10/22/2024 with a diagnosis of heart disease. During the Home Visit on 07/29/2026 with the Home Health Aide (Personnel Record 12), the patient’s current medications were compared with the agency’s medication profile that was printed on 07/27/2026. The medication profile revealed Lantus Subcutaneous Solution 100 unit/ml 40 units daily, Baclofen Oral Tablet 5 mg take 3 tablets by mouth daily, Glipizide Oral Tablet 5 mg take 1 tablet by mouth daily, Gemtesa Oral Tablet 75 mg take 1 tablet by mouth daily, and Jardiance Oral Tablet 10 mg take one tablet by mouth daily. The patient’s home medications were amlodipine 10 mg tablet daily, with a start date of 11/14/2025; Solifenacin 10 mg tablet daily, with a start date of 05/11/2026; Linzess 145 mcg capsule daily, with a start date of 12/24/2025; atorvastatin 40 mg daily, with a start date of 05/25/2026; and Leflunomide 10 mg tablet daily, with a start date of 06/13/2026. The patient reported taking Lantus Subcutaneous Solution 100 unit/ml 30 units daily for about a year. The son stated that the patient had not taken the Baclofen, Jardiance, and Glipizide for about one month; and Gemtesa for about two months. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/17/2026 with a diagnosis of heart disease. The Registered Nurse initial comprehensive assessment dated 06/17/2026 documented that the patient was taking methadone 115 mg PO [by mouth] daily for right hip pain. The medication record was reviewed on 07/29/2026 and lacked documented evidence of the methadone. A discussion occurred, and the medication had been added to a written medication list on admission, but it was not added to the active medication record in the electronic record. During a joint record review and interview on 07/29/2026, the Director of Nursing confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications.”

“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 and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as part of the comprehensive assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/23/2026 with a diagnosis of senile degeneration of the brain. There was no documented evidence in the clinical record that an initial bereavement assessment was completed. During a joint clinical record review and interview on 07/29/2026, the Director of Nursing confirmed that the record lacked an initial bereavement assessment.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. 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 plan of care reflected problems identified in the patient’s assessments with planned interventions and patient-specific measurable goals for treatment. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/17/2026 with diagnoses of heart disease, hypertension, and edema. The Registered Nurse (RN) Initial Comprehensive Assessment dated 06/17/2026 included documentation, “that the patient had dyspnea with minimal exertion, a non-productive cough, diminished lung sounds,” and was classified as NYHA [New York Heart Association] 3; “summary/comments: becomes SOB (short of breath) with minimal exertion in (his/her) wheelchair from moving back and forth and requiring 2-3 min rest to recover. (He/she) reports a non-productive cough and the need to use multiple pillows while in bed to relieve orthopnea. Noted SOB with minimal exertion in wheelchair from moving back and forth O2 [oxygen] sats at 90% and at rest... Patient refuses O2... pain 5 on assessment PAINAD to right hip current medications - ache/dull, throbbing, Methadone 115 mg.” The medication record reviewed 07/29/2026 revealed Losartan Potassium (medication for treatment of hypertension) Oral tablet 25 mg, take one tablet by mouth daily. The IDT [Interdisciplinary Team] Meeting dated 07/02/2026 and the Plan of Care Order dated 06/17/2026 did not include problems, interventions, and goals for altered respiratory status, pain, and altered cardiovascular status. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/04/2026 with diagnoses of heart disease, hypertension, diabetes mellitus, chronic kidney disease, and COPD. The RN recertification comprehensive assessment dated 07/08/2026 stated in part, “Appetite fair; this month’s food consumption was less than last month’s food consumption by 40%.” The medication profile was reviewed on 07/29/2026 and revealed Lantus 100 unit/ml give 17 units SQ every morning and every night; and Humalog 100 unit/ml 199-200 = 2 units sliding scale 201-250 = 4 units SQ 251-300 = 6 units 301-350 = 8 units 352-400 = 10 units SQ. The Plan of Care dated 07/08/2026 did not include problems, interventions, and goals for hyper/hypoglycemia. During a joint review of the record and an interview on 07/29/2026, the Director of Nursing confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“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. 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 and interview. In 1 of 2 (50%) clinical records reviewed with a discharge due to death, the hospice did not ensure that bereavement services were provided to the bereaved. CLINICAL RECORD 14: The patient elected the Hospice benefit on 03/17/2026. The patient’s date of death was 04/01/2026. The Bereavement Plan of Care form listed Letters/Articles as an intervention, with blanks to fill in the number of months the letters will be sent, but they were not filled out. The bereavement letters that had been sent did not have dates, nor the corresponding month from the date of death. The Bereavement Plan of Care was created and signed by the physician, registered nurse, and chaplain, but was not dated. During a joint review of the record and an interview on 07/27/2026, the Administrator agreed there was no documented evidence that the months the letters were to be sent were not indicated and that the Plan of Care did not have dates of when the forms were created.”

“It is required that the supervising registered nurse assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: following the patient’s plan of care for completion of tasks assigned by the RN (Registered Nurse); creating successful interpersonal relationships with the patient and family; demonstrating competency with assigned tasks; complying with infection control policies and procedures; and reporting changes in the patient’s condition. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of hospice aides reviewed, the agency did not ensure that a competency evaluation was completed prior to the aide performing care independently and annually. PERSONNEL RECORD 12: The Home Health Aide date of hire was 10/05/2023. The Hospice Aide Skills Competency Checklist form dated 10/05/2023 stated in part, “III. Other Bath [All Required] A. Sponge B. Tub C. Shower... IV. Shampoo [All Required] A. Sink B. Tub C. Bed... VIII. Safe Transfer Techniques and Ambulation Appropriate use of Hoyer Lift... and X. Adequate nutrition and fluid intake.” The documentation included Sponge for Other Bath circled completed on 10/16/2023 and Bed for Shampoo circled completed on 10/16/2023. The form lacked documented evidence for completing the tub and shower baths, the sink and tub shampooing, the safe transfer techniques and ambulation, and adequate nutrition and fluid intake. The Hospice Aide Skills Competency Checklist form dated 09/24/2024 stated in part, “III. Other Bath [All Required] A. Sponge B. Tub C. Shower... IV. Shampoo [All Required] A. Sink B. Tub C. Bed... and X. Adequate nutrition and fluid intake.” The documentation included Shower for Other Bath circled completed on 09/24/2024 and Tub for Shampoo circled completed on 10/16/2023. The form lacked documented evidence for completing the sponge and tub baths, the sink and bed shampooing, and adequate nutrition and fluid intake. The Hospice Aide Skills Competency Checklist form dated 7/29/2025 lacked documented evidence of the types of baths and shampoo that were completed during the annual evaluation. During a joint personnel record review and an interview on 07/28/2026, the Administrator agreed that there was no documented evidence that a hospice aide’s skills competency was completed for all types of baths and shampooing for the initial and annual competency and performance for 2023, 2024, and 2025.”

“It is required that a patient clinical record containing past and current findings be maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the organization did not ensure correct and accurate clinical notes. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/16/2026. The IDT (Interdisciplinary Team) Meeting dated 03/26/2026 stated in part, “Summary/Comments: IDG meeting held today to discuss the patients of (another hospice agency’s name, Hospice 2).” CLINICAL RECORD 7: The patient elected the hospice benefit on 03/04/2026. The IDT Meeting dated 03/12/2026 and 03/26/2026 stated in part, “Summary/Comments: IDG meeting held today to discuss the patients of (another hospice agency’s name, Hospice 2).” CLINICAL RECORD 9: The patient elected the hospice benefit on 03/13/2026. The IDT Meeting dated 03/26/2026 stated in part, “Summary/Comments: IDG meeting held today to discuss the patients of (another hospice agency’s name, Hospice 2).” CLINICAL RECORD 10: The patient elected the hospice benefit on 03/19/2026. The IDT Meeting dated 03/26/2026 stated in part, “Summary/Comments: IDG meeting held today to discuss the patients of (another hospice agency’s name, Hospice 2).” During a joint record review and an interview on 07/29/2026, the Director of Nursing (Personnel Record 3) confirmed that another hospice agency’s name was on the summary in the IDT Meeting documents listed above.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of discharged patients, the agency did not ensure the discharge summary, inclusive of all required elements, was forwarded to a facility receiving a hospice patient for care, or to the patient’s community attending physician upon hospice discharge. CLINICAL RECORD 11: The patient elected the Hospice benefit on 04/23/2026. The date of discharge was 05/29/2026. The clinical record did not have documented evidence that a discharge summary was created and sent to the facility receiving the hospice patient for care. CLINICAL RECORD 12: The patient elected the Hospice benefit on 02/19/2026. The date of the discharge was 04/19/2026. The clinical record did not have documented evidence that a discharge summary was created and sent to the community attending physician. During a joint record review and interview on 07/29/2026, the Director of Nursing confirmed that the records lacked evidence of a completed discharge summary.”