Riverside Hospice Care

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to ensure that the volunteer assessment was completed as noted in the plan of care. {HCDT.21. I/L644/418.78(b)}; Failed to ensure ongoing volunteer recruitment and retention efforts/activities {HCDT.30.I/L645/418.78(c}; Failed to ensure documentation of cost savings achieved through the use of volunteers including the identification of each position occupied by volunteers, the time volunteers spent in those positions and estimates of the dollar costs the hospice would have incurred if paid employees had occupied those positions{HSLG.7.I/646/ 418.78(d)}; and Failed to ensure that that volunteers had provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers {HSLG.7.I/L647/418.78(e)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed revealed that the agency did not ensure that the comprehensive pain assessment included characteristics of the pain, including: location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/30/2026. The primary hospice diagnosis was Vascular parkinsonism. The skilled nurse (SN) hospice comprehensive assessment dated 04/30/2026 stated in part, “Hospice Initial Pain Assessment Pain Status: Patient has pain: no... Was the patient screened for pain: Yes... The patient’s pain severity was: mild... Is pain an active problem for the patient: Yes... Was a comprehensive pain assessment done: Yes... Comprehensive Pain Assessment - Included - 1 - Location, 2 - Severity, 3 - Character, 4 - Duration, 5 - Frequency, 6 - What relieves/worsens pain, 7 - Effect on function or quality of life... Encounter Notes: “Having worsening lower back pain making moving around even more difficult.” There was no documented evidence that the comprehensive pain assessment included the frequency and intensity of the pain. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/03/2026. The primary hospice diagnosis was amyotrophic lateral sclerosis. The SN hospice comprehensive assessment dated 04/03/2026 stated in part, “Hospice Initial Pain Assessment Pain Status: Patient has pain: no... Was the patient screened for pain: Yes... The patient’s pain severity was: mild... Is pain an active problem for the patient: Yes; Was a comprehensive pain assessment done: Yes... Comprehensive Pain Assessment - Included - 1 - Location, 2 - Severity, 3 - Character, 4 - Duration, 5 - Frequency, 6 - What relieves/worsens pain, 7 - Effect on function or quality of life... Encounter Notes: “Musculoskeletal/Amputations: Problems: joint pain.” There was no documented evidence that the comprehensive pain assessment included the pain’s location, severity, character, duration, frequency, management, and intensity. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the comprehensive pain assessments did not include characteristics of the pain, including location, severity, character, duration, frequency, management, and intensity.”

“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, 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, observation, and interview. In 2 of 23 (9%) clinical records reviewed and home visits, it was revealed that the agency did not ensure a medication reconciliation was completed and medications were updated and included on the medication profile. CLINICAL RECORD 7/HOME VISIT 5: The patient elected the hospice benefit on 03/22/2026 with the diagnosis of cancer of thoracic esophagus, and secondary diagnoses of squamous cell carcinoma esophagus, secondary malignant neoplasm of bronchopulmonary lymph node, metastasis to liver and peritoneal cavity, hypertension, protein calorie malnutrition, controlled diabetes mellitus, epigastric pain, anemia, GERD. The patient resided in a skilled nursing facility (SNF). The agency medication profile printed on 06/02/2026 revealed polyethylene glycol (PED 3350), take 17 g [grams] by mouth daily. During the home visit on 06/03/2026 with the certified nursing aide (Personnel Record 10), the medication at the facility revealed morphine (concentrate) solution 20 mg/ml, give 0.25 ml by mouth every one hour as needed for pain and/or dyspnea, dated 04/21/2026; and ondansetron HCl tab 4 mg, give one tab by mouth every 8 hours as needed for nausea/vomiting, dated 04/21/2026. The polyethylene glycol was not included on the facility’s medication list. The morphine and ondansetron were not included in the agency’s medication profile. There was no evidence that medication reconciliation occurred when a new medication was added or when changes were made to the existing medications. CLINICAL RECORD 17 /HOME VISIT 6: The patient elected the hospice benefit on 03/21/2026 with a diagnosis of malignant neoplasm of ovary, secondary diagnoses of malignant ascites, acute heart failure with preserved EF, hypertension, atrial fibrillation, morbid obesity, history of falls, lower extremity pain, pressure injury, bilateral lower extremity edema, hypothyroidism. The patient resided in an assisted living facility (ALF). The agency medication profile printed on 06/02/2026 revealed Cinnamon 500 mg tablet, take 500 mg by mouth daily; Cranberry 500 mg capsule, take 500 mg by mouth daily; folic acid 400 mg mcg tablet, take 400 mcg by mouth daily; Magnesium Oxide 400 mg capsule, take 400 mg by mouth daily; Turmeric 500 mg capsule, take 500 mg by mouth two times a day; vitamin C 500 mg tablet, take 500 mg by mouth daily; and zinc sulfate 220 (50 Zn) mg capsule, take 220 mg by mouth daily. During the home visit on 06/03/2026 with the Masters Social Worker (Personnel Record 8), the medication profile at the facility included Metoprolol tartate 25 mg, take one tablet by mouth twice a day for hypertension, hold for SBP <110, DBP <65, or HR <55, started 03/03/2026; Bisacodyl suppository 10 mg, take one suppository rectally daily as needed for constipation, started 05/12/2026; ondansetron tablet 4 mg ODT, dissolve one tablet on the tongue every eight hours as needed for nausea or vomiting, started 05/18/2026; promethazine tablet 25 mg, take one tablet by mouth every 4 hours as needed for nausea or vomiting, started 05/07/2026; and Rolaids 675-135 mg chew DIOC, use as needed at bedside, started 05/08/2026. The facility Licensed Practical Nurse (LPN) verified that the Metoprolol, bisacodyl, ondansetron, promethazine, and Rolaids were active medications and the patient had been receiving them as prescribed. The LPN stated that the Cinnamon, Cranberry, folic acid, Magnesium Oxide, and turmeric were discontinued on 04/06/2026; and the vitamin C and zinc sulfate were discontinued on 05/18/2026. The Metoprolol, bisacodyl, ondansetron, promethazine, and Rolaids were not listed on the agency’s medications. The Cinnamon, Cranberry, folic acid, Magnesium Oxide, turmeric, vitamin C, and zinc sulfate were not on the facility medication profile. The record did not include evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 06/03/2026, the Regional Director of Home Care Operations (Personnel Record 2) confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment and updated to the medication profile.”

“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 2 of 23 (9%) clinical records reviewed it was revealed that the agency did not ensure the comprehensive assessment included 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. CLINICAL RECORD 14: The election of benefits form was dated 04/27/2026. There was no documented evidence of an initial bereavement assessment. CLINICAL RECORD 22: The election of benefit form was dated 04/04/2025. There was no documented evidence of an initial bereavement assessment. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare confirmed that the record did not include documentation of 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 3 of 23 (13%) clinical records reviewed it was revealed that the agency did not ensure the plans of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2: The election of benefit form was dated 04/30/2026. The primary diagnosis was Vascular Parkinsonism. The skilled nurse (SN) hospice comprehensive assessment dated 04/30/2026 stated in part, “Hospice Initial Pain Assessment Pain Status: Patient has pain: no... Was the patient screened for pain: Yes... The patient’s pain severity was: mild... Is pain an active problem for the patient: Yes... Was a comprehensive pain assessment done: Yes... Comprehensive Pain Assessment - Included - 1 - Location, 2 - Severity, 3 - Character, 4 - Duration, 5 - Frequency, 6 - What relieves/worsens pain, 7 - Effect on function or quality of life... Encounter Notes: “Having worsened lower back pain making moving around even more difficult.” The plan of care dated 04/30/2026 and the hospice POC updates dated 05/06/2026 and 05/20/2026 did not include problems, interventions, and goals for pain management. CLINICAL RECORD 4: The election of benefit form was dated 04/03/2026. The primary diagnosis was amyotrophic lateral sclerosis. The hospice comprehensive assessment dated 04/03/2026 documented that the patient had a PEG tube and was receiving Isosource 1.5 cal via tube feedings. The plan of care dated 04/03/2026 and the POC updates 04/08/2026 and 04/22/2026 did not include problems, interventions, and goals for the PEG tube and enteral feedings. CLINICAL RECORD 8: The election of benefit form was dated 04/26/2026. The primary diagnosis was subdural hematoma. The hospice comprehensive assessment dated 04/26/2026 documented, “Pt was recently hospitalized 04/15/2026 and was noted to have chronic right-sided subdural hematoma, no initial CT head. MRI brain notable for subacute right hemispheric subdural hematoma measuring up to 10 mm in thickness. Mild 3 mm leftward midline shift noted. He was evaluated by Neurology and Neurosurgery. Discussed with Dr. Neurosurgery, (physician) and patient/(patient’s) daughters - they do not want to pursue surgical intervention for SDH. Pt returned home and was sent back a few days later for left side weakness of both upper and lower extremities. There was concern for CVA [cerebrovascular accident] or TIA [transient ischemic attack]. It was likely seizure related and pt was started on Vimpat. (seizure medication)” The plan of care dated 04/26/2026 and the Hospice Plan of Care Updates dated 05/01/2026 and 05/15/2026 did not include documented evidence of problems, interventions, and goals for seizure precautions. During a joint review of the record and an interview on 06/05/2026, the RN Clinical Reviewer Homecare 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 the hospice develops, implements, and maintains 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: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract or arrangement; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and is evaluated annually. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. This standard was not met as evidenced by document review and interview. During a review of the agency’s quality assurance and performance improvement (QAPI) program, multiple requests for documentation were made daily. The agency did not ensure that the governing body evaluated the QAPI program annually. The agency did not provide documentation for the QAPI program since the last survey June 2023. During the exit conference on 06/05/2026, the Regional Director Home Health (Personnel Record 2) acknowledged that the agency did not provide the requested documentation for the QAPI Program. During a review of the agency’s quality assurance and performance improvement (QAPI) program, requests were made on days 1, 2, 3, 4, and 5 of the site visit for documents. The agency did not provide documentation for the QAPI program.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, observation, document review and interview. In 2 of 6 (33%) home visits it was revealed that the agency did not ensure that infection control policies were followed to prevent the transmission of infections. DOCUMENT 1: Agency Policy: Hand Hygiene Policy and Procedure Policy #DIV-916, last reviewed 04/2026, stated in part, “Perform hand hygiene using an alcohol-based hygiene product (when the hands are not visibly soiled) or antimicrobial soap and water. Immediately before having direct contact with patient. Before donning PPE. Before performing an aseptic task (e.g., performing wound care or inserting an invasive medical device). Before moving from a soiled-body site (e.g. perineal area) to a clean body site (e.g. patient’s face) on the same patient during patient care. After contact with a patient. After contact with the patient’s immediate environment... Immediately after removing gloves.” DOCUMENT 3: Agency Policy: Dressing Change - Hydrocolloid, Foam, and Absorption Policy # CP-211, last reviewed 01/2026, stated in part, “Perform hand hygiene and don PPE [personal protective equipment]. Set up all supplies needed for dressing change on clean surface. Ensure disposable bag nearby to discard of old dressing. Explain procedure to patient. Assist the patient to a comfortable position, expose wound site and drape patient. Remove old dressing by slowly pulling back across the wound in the direction of hair growth. (If dressing requires adhesive remover to loosen the dressing edges, ensure the adhesive remover does not contact the wound). Dispose of soiled dressing in disposable bag. Remove gloves, discard and perform hand hygiene. Open and prepare the dressing supplies using aseptic technique. Perform hand hygiene and don gloves. Cleanse the wound using sterile normal saline (NS) or prescribed wound cleanser. Pat the wound surface to dry with 4x4 gauze pads. Dry the surrounding skin with another dry gauze pad. Assess wound for tissue type, color, odor and drainage. Measure the length, width, and depth. Apply a skin barrier film or cream to the peri wound skin as ordered. Apply dressing per the manufacturer’s directions... Foam dressings: select correct size foam dressing for wound size. (Ensure that foam portion extends beyond the wound edge onto peri wound skin to achieve adequate seal). Do not cut bordered foam dressings. Apply the foam dressing over the wound smoothly without wrinkles. Apply a secondary dressing as needed... Discard supplies, remove PPE, and perform hand hygiene. DOCUMENT 4: Agency Policy: Bladder Irrigation by opening a closed system Policy # CP-222, last reviewed 01/2026, stated in part, “Perform hand hygiene and don PPE. Unfold the under pad and place it under the connection between the catheter tube and the drainage bag. Open the irrigation tray and pour irrigant into the sterile container. Place the syringe in the container. Draw 30 to 60 ml of irrigant into the syringe. Cleanse the site where the catheter tubing and the drainage bag tubing connect with an alcohol swab. Disconnect the catheter from the drainage tube. Use the plastic tip protector (provided in the tray) to cover the end of the tubing. Place drainage basin under catheter. Cleanse the catheter with alcohol wipe and then connect the syringe to the catheter. Instill the irrigant into the catheter with a gentle but firm pressure. Avoid forceful instillation to prevent irritation, spasms, or hemorrhage... Remove the syringe and place the end of the catheter over the drainage basin, allowing the returning fluid to drain into the basin...Repeat irrigation as ordered by physician... Cleanse the ends with alcohol before reconnecting the catheter and tubing. Discard supplies appropriately, remove PPE, and perform hand hygiene.” CLINICAL RECORD 15/HOME VISIT 2: During the home visit on 06/02/2026 with the Licensed Practical Nurse (LPN) (Personnel Record 6), the LPN was observed donning gloves and assisting the patient’s spouse in turning the patient. The wound care supplies had been assembled by the spouse prior to the visit. The LPN removed the wound dressing and changed the gloves. The LPN cleaned the wound with a wound cleanser and 4x4 gauze, then placed the gauze in the trash. The LPN changed the gloves and repeated the wound cleaning with wound cleanser and 4x4 gauze, then placed the gauze in the trash. The gloves were removed, and alcohol was used to decontaminate the hands. The LPN removed more gloves from the nursing bag and placed them on the table. The LPN measured the wound and used a cotton-tip applicator to measure the tunneling. The LPN packed the wound, applied skin prep around the wound area, applied hydrogel to the foam dressing, and applied the dressing to the wound. The LPN removed the gloves, picked up the trash bag, threw it away, and then used alcohol. The LPN prepared supplies for bladder irrigation. The LPN donned gloves drew up normal saline into the syringe and removed the catheter tubing from the drainage bag. The LPN cleaned the catheter with alcohol, inserted the syringe into the catheter, irrigated it, and reconnected the tubing to the catheter bag. The LPN changed the gloves. The irrigation syringe, normal saline bottle, and irrigation container fell on the floor. The LPN picked up the container and syringe, placed the syringe in the irrigation bottle, returned the tray, and placed them on the over-the-bed table (OBT). The items were left on the OBT. The LPN did not perform hand hygiene after removing the wound dressing and gloves. The LPN did not clean the site where the catheter tubing and the drainage bag tubing connected with alcohol before disconnecting. The LPN did not cover the end of the drainage bag tubing. The LPN did not clean the ends with alcohol before reconnecting the catheter and tubing. The LPN did not discard the supplies, after they fell to the floor. CLINICAL RECORD 7/HOME VISIT 5: During the home visit on 06/03/2025 with the certified nurse aide (CNA) (Personnel Record 10), the CNA was observed donning gloves, filling one basin with water, and placing it on the over-the-bed table. The CNA removed the sheets while placing a dry bath towel on the patient. The CNA washed the patient’s face and discarded the washcloth. The CNA used a washcloth to wash the torso and arms, laid it on the side of the basin, and used a second washcloth to rinse the areas. The CNA picked up the washcloth from the side of the basin, added soap, and added water from the basin before washing the legs. The CNA laid the washcloth on the side of the basin and used the second washcloth to rinse the legs. The CNA picked up the washcloth from the side of the basin, added soap, and added water from the basin before washing the perineal area. The CNA laid the washcloth on the side of the basin, picked up the second washcloth from the water, and rinsed the area. The CNA prepared the bed to change the linens, chux, and brief. The patient assisted with turning. The CNA took the washcloth from the basin, added soap and water, and washed the back and buttocks. The CNA rinsed the area with the second washcloth. The CNA changed the linens, chux, and brief. The CNA removed lotion from the patient’s dresser drawer and applied it to the back. The CNA did not change gloves and perform hand hygiene when moving from a soiled body site (e.g., the perineal area) to a clean body site (e.g., the patient’s face) during patient care, after contact with a patient, or after contact with the patient’s immediate environment. During a document review and interview on 06/03/2026, the Regional Director of Homecare Operations (Personnel Record 2) confirmed that the LPN did not follow the wound-care and bladder-irrigation guidelines or hand hygiene policy.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed it was revealed that the agency did not ensure that nursing care and services were provided as ordered on the plan of care. CLINICAL RECORD 15: The election of benefits form was dated 04/01/2023. The physician’s order dated 04/19/2026 for skilled nursing, stated 2 visits every week for 8 weeks. The missed visit note dated 5/14/2026 stated, “This nurse reached back out to patient’s wife (name), apologized that I have to move his visit back even more now due to a PRN(as needed) visit that came through. (Wife) offered to cancel his nurse visit today if this nurse needs to. This nurse thanked (wife) and let her know I am sorry; we will cancel his visit today. She understood. Denied needing any meds or supplies at this time. Reinforced 24 hour hospice number.” There was no documented evidence that an additional attempt was made to make the visit during the week of 05/10/2026 to 05/16/2026. The record only had one visit documented for the week of 05/10/2026 to 05/16/2026. During a joint record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the nursing care and services were not provided per the patient’s plan of care.”

“It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 2 of 21 (10%) clinical records reviewed it was revealed that the agency did not ensure that medical social work services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of the services. CLINICAL RECORD 3: The election of benefits form was dated 10/30/2025. The physician’s orders dated 11/17/2025 documented “MSW Visit Sets 1 visit every 2 weeks for 11 weeks,” and the orders dated 12/08/2025 documented “MSW Visit Sets 1 visit every 2 weeks for 8 weeks.” There were MSW missed visit notes dated 12/01/2025 and 12/31/2025 that documented “MSW was unable to connect with patient to complete the visit. MSW will resume visits with patient next week.” There was no documented evidence of additional attempts to visit the patient between 11/23/2025 and 12/06/2025, or between 12/28/2025 and 01/03/2026. CLINICAL RECORD 4: The election of benefits form was dated 04/03/2026. The physician’s orders dated 04/19/2026 documented “MSW Visit Sets 1 visit every 2 weeks for 10 weeks.” There was an MSW missed visit note dated 04/30/2026 that documented “MSW was unable to connect with patient to complete the visit. MSW will resume visits with patient next week.” There was no documented evidence of additional attempts to make a visit between 04/19/2026 and 05/02/2026. During a joint record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) agreed that there was no documented evidence that social work services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of services.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed of patients receiving hospice aide services it was revealed that the agency did not ensure written patient care instructions for the hospice aide were prepared by an RN who was responsible for the supervision of the hospice aide. CLINICAL RECORD 8: The election of benefits form was dated 04/26/2026. The primary diagnosis was subdural hematoma. The SN hospice comprehensive assessment dated 04/26/2026 documented, “Pt was recently hospitalized 04/15/2026 and was noted to have chronic right-sided subdural hematoma (SDH), no initial CT head. MRI brain notable for subacute right hemispheric subdural hematoma measuring up to 10 millimeters (mm) in thickness. Mild 3 mm leftward midline shift noted. He was evaluated by Neurology and Neurosurgery specialists. Discussed with Dr. Neurosurgery, (physician) and patient/his daughters - they do not want to pursue surgical intervention for SDH. Patient returned home and was sent back a few days later for left side weakness of both upper and lower extremities. There was concern for CVA or TIA. It was likely seizure related and patient was started on Vimpat (seizure medication).” The plan of care for aide services dated 04/26/2026 did not include seizure precautions. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the record did not include evidence that the registered nurse prepared the written patient care instructions to include seizure precautions.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical record review with hospice aide services it was revealed that the agency did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. CLINICAL RECORD 3: The patient’s date of election was 10/30/2025. The plan of care dated 10/30/2025 ordered the hospice aide frequency to be once a week. The hospice aide visit dated 05/06/20206 was documented as non-billable and was not performed. One hospice aide visit was not made for the week of 05/03/2026-05/09/2026. CLINICAL RECORD 7/HOME VISIT 5: The plan of care for hospice aide services, dated 03/22/2026, revealed patient has the following precautions: fall risk/fall and aspiration precautions. On 04/15/2026, assist with ambulation/transfers using walker. Document refusal of gait belt; assist with repositioning patient; assist patient with dressing; assist patient with hair care (combing, curling, etc.); assist patient with oral care; assist patient with shampooing hair; shaving: razor; aide to do a complete: shower; inspect skin for signs of pressure or irritation. Report any observed or patient reported concerns to primary nurse. Apply lotion sacrum/buttocks for redness or protection; perform filing/cleaning of nails; inspect skin of pressure or irritation. Report any observed or patient-reported concerns to the primary nurse. Apply lotion sacrum/buttocks for redness or protection; aide change incontinent briefs/diapers; assist patient to bathroom; assist patient with urinal; change bed linens; and aide to clean patient area was added to the plan of care for hospice aide services. On 06/02/2026, change incontinent briefs/diapers to the plan of care for hospice aide services. The hospice aide visit notes dated 05/12/2026, 05/26/2026, 05/29/2026, and 06/03/2026 documented that the patient received a shower. The hospice aide visit note dated 5/16/2026 documented that the shower was “verbally declined by patient. He had stated that he was washed up yesterday and had no desire for another bath today.” During the home visit on 06/03/2025 with the Certified Nurse Aide (CNA) (Personnel Record 10), the CNA was observed donning gloves, filling one basin with water, and placing it on the over-the-bed table. The CNA removed the sheets while placing a dry bath towel on the patient. The CNA washed the patient’s face. The CNA assisted the patient’s shirt, which the patient removed fairly well. The CNA washed the torso and arms, the legs, the perineal area, the back, and the buttocks. The CNA changed the linens, chux, and brief. The patient assisted with turning in the bed. The CNA removed lotion from the patient’s dresser drawer and applied it to the back. Bed bath was not included in the hospice aide’s plan of care. When reviewing the aide visit note, the CNA had documented giving a shower. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the hospice aide did not provide services included in the plan of care.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical record review with hospice aide services it was revealed that the agency did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. CLINICAL RECORD 3: The patient’s date of election was 10/30/2025. The plan of care dated 10/30/2025 ordered the hospice aide frequency to be once a week. The hospice aide visit dated 05/06/20206 was documented as non-billable and was not performed. One hospice aide visit was not made for the week of 05/03/2026-05/09/2026. CLINICAL RECORD 7/HOME VISIT 5: The plan of care for hospice aide services, dated 03/22/2026, revealed patient has the following precautions: fall risk/fall and aspiration precautions. On 04/15/2026, assist with ambulation/transfers using walker. Document refusal of gait belt; assist with repositioning patient; assist patient with dressing; assist patient with hair care (combing, curling, etc.); assist patient with oral care; assist patient with shampooing hair; shaving: razor; aide to do a complete: shower; inspect skin for signs of pressure or irritation. Report any observed or patient reported concerns to primary nurse. Apply lotion sacrum/buttocks for redness or protection; perform filing/cleaning of nails; inspect skin of pressure or irritation. Report any observed or patient-reported concerns to the primary nurse. Apply lotion sacrum/buttocks for redness or protection; aide change incontinent briefs/diapers; assist patient to bathroom; assist patient with urinal; change bed linens; and aide to clean patient area was added to the plan of care for hospice aide services. On 06/02/2026, change incontinent briefs/diapers to the plan of care for hospice aide services. The hospice aide visit notes dated 05/12/2026, 05/26/2026, 05/29/2026, and 06/03/2026 documented that the patient received a shower. The hospice aide visit note dated 5/16/2026 documented that the shower was “verbally declined by patient. He had stated that he was washed up yesterday and had no desire for another bath today.” During the home visit on 06/03/2025 with the Certified Nurse Aide (CNA) (Personnel Record 10), the CNA was observed donning gloves, filling one basin with water, and placing it on the over-the-bed table. The CNA removed the sheets while placing a dry bath towel on the patient. The CNA washed the patient’s face. The CNA assisted the patient’s shirt, which the patient removed fairly well. The CNA washed the torso and arms, the legs, the perineal area, the back, and the buttocks. The CNA changed the linens, chux, and brief. The patient assisted with turning in the bed. The CNA removed lotion from the patient’s dresser drawer and applied it to the back. Bed bath was not included in the hospice aide’s plan of care. When reviewing the aide visit note, the CNA had documented giving a shower. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the hospice aide did not provide services included in the plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 17 (6%) clinical records reviewed of patients that received aide services it was revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s needs. HOME VISIT 5: During the home visit on 06/03/2025 with the Certified Nurse Aide (CNA) (Personnel Record 10), the CNA was observed donning gloves, filling one basin with water, and placing it on the over-the-bed table. The CNA removed the sheets while placing a dry bath towel on the patient. The CNA washed the patient’s face. The CNA assisted the patient with the shirt, which the patient removed fairly well. The CNA washed the torso and arms, the legs, the perineal area, the back, and the buttocks. The CNA changed the linens, chux, and brief. The CNA assisted the patient with turning in the bed. The CNA removed lotion from the patient’s dresser drawer and applied it to the back. The bed bath was not included in the hospice aide plan of care. When reviewing the aide visit note, the CNA documented a shower was performed. There was no documented evidence that the aide reported giving the bed bath to the patient. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the hospice aide’s documentation did not include notification to the registered nurse of changes to the patient’s needs”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of a patient that received volunteer services it was revealed that the agency did not ensure that the volunteer assessment was completed, as noted in the plan of care. CLINICAL RECORD 9: The election of benefit form was dated 04/15/2026. There was a physician’s order stating, “Volunteer assessment 04/29/2026 to 05/02/2026 - 1 visit every week for 1 week.” The record lacked documented evidence that the volunteer assessment was completed and there was no physician’s order discontinuing the assessment. During a joint clinical record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare (Interview 3) confirmed that the volunteer assessment had not been completed, as noted in the plan of care.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During review of the volunteer program, it was revealed that the hospice did not ensure ongoing volunteer recruitment and retention efforts/activities. During document review and interview on 06/03/2026, the Volunteer Coordinator confirmed that there was no documented evidence of efforts to recruit and retain volunteers.. During a document review and interview on 06/03/2026, the Executive Director confirmed that documented evidence was not provided. Upon reviewing the volunteer program for alternate delivery site (ADS) 1, the documentation lacked evidence of efforts to recruit and retain volunteers from January 2024 through October 2025. Requests were made on days 1, 2, 3, 4, & 5 for evidence of efforts to recruit and retain volunteers for the parent and ADS 2.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Review of the agency Volunteer Program activities revealed the agency did ensure documentation of cost savings achieved through the use of volunteers including the identification of each position occupied by volunteers, the time volunteers spent in those positions and estimates of the dollar costs the hospice would have incurred if paid employees had occupied those positions. During a document review and interview on 06/05/2026, the Executive Director (Personnel Record 2) acknowledged that the agency had not provided the documentation for positions occupied by volunteers, the time volunteers spent in those positions and estimates of the dollar costs the hospice would have incurred if paid employees had occupied those positions During a review of the agency’s volunteer program, requests were made on days 1, 2, 3, 4, and 5 of the site visit for documents. The agency did not provide documentation for positions occupied by volunteers, the time volunteers spent in those positions, and estimates of the dollar costs the hospice would have incurred if paid employees had occupied those positions.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Review of agency Volunteer Program documents revealed the agency did not ensure that volunteers had provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers. No records of volunteer positions and time worked was provided. During a joint review of the volunteer program records and an interview on 06/05/2026, the Executive Director (Personnel Record 2) acknowledged that the agency had not provided the documentation for hospice volunteers to provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers. During a review of the agency’s volunteer program, requests were made on days 1, 2, 3, 4, and 5 of the site visit for documents. The agency did not provide documentation for hospice volunteers to provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers.”

“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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 1 of 16 (6%) personnel records reviewed it was revealed that the agency did not ensure all employees were assessed for skills and competencies. PERSONNEL RECORD 16: The volunteer’s date of hire was 11/03/2025. A review of the personnel record revealed no documented evidence of an initial competency. During a joint personnel record review and interview on 06/05/2026, the Executive Director (Personnel Record 1) confirmed that the record contained no evidence that the volunteer had been assessed for skills and competencies.”

“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, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical record review revealed the agency did not ensure there were physician orders for the wound care. CLINICAL RECORD 5: The patient’s date of election was 07/22/2025. The skilled nurse PRN hospice visit note dated 12/15/2025 stated, “Appears to have boil? To left side beside breast draining yellowish/bloody scant amount to drainage. It is tender about quarter size. Asked (physician’s name) to place an order for cleanse with wound cleanser, apply calcium alginate, with bordered dressing daily. Just really for the drainage and someone to pay attention to it daily.” There were no documented evidence for physicians’ orders for the wound care in the record. In a joint record review and interview on 06/05/2026, the RN Clinical Reviewer Homecare confirmed that the records did not include evidence of the physician’s orders for wound care.”

“It is required that a hospice may contract for durable medical equipment services with a with a Medicare-certified DME point-of-service supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards and has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview which revealed the agency’s did not have a current contract for durable medical equipment services with a Medicare-certified DME point-of-service supplier. The agency provided a letter indicating the transfer/sale of the previous DME supplier to the current DME supplier. The agency did provide the current DME supplier’s accreditation certificate. During a document review and interview on 06/05/2026, the Executive Director (Personnel Record 1) acknowledged that the agency had not provided the documentation for the current contract with a Medicare-certified DME point-of-service (POS) supplier. During a review of the agency’s contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier, requests were made on days 1, 2, 3, 4, and 5 of the site visit. The agency provided a letter indicating the transfer/sale of the previous DME supplier to the current DME supplier. The agency did not provide a contract for the current with a Medicare-certified DME point-of-service (POS) supplier. The agency did provide the current DME supplier’s accreditation certificate.”