Caregivers Hospice

“Based on staff (EMP) interview and document review, it was determined the hospice failed to ensure each patient was involved in developing their hospice plan of care. Specifically, the hospice failed to update the patient’s plan of care when the patient’s wishes regarding oral feeding changed and failed to visit the patient at the prescribed frequency in the plan of care in one (1) of five (5) records reviewed in the survey sample. Medical Record MR2. Findings:The medical record for MR2 was reviewed and indicated the patient was admitted to general inpatient level of care (in a contracted hospital) on January 29, 2026, with a terminal diagnosis of respiratory failure. MR2 contained documentation that the patient was awake and requesting to eat on January 31, 2026. The skilled nurse visited the patient and documented that the nurse was informed that the patient was asking for food and wanted to eat. The skilled nurse asked the patient if they wanted to eat, and the patient was not able to respond. The patient’s plan of care on admission indicated the patient was to receive nothing by mouth. The skilled nurse documented speaking with the hospice physician regarding the appropriateness of general inpatient level of care on January 31, 2026, but failed to document any information related to collaborating with the physician on the patient’s diet order and request for oral intake. An interview was conducted with the patient’s inpatient hospitalist (EMP9) on March 17, 2026, at 12:30 PM. EMP9 indicated the patient had a sudden change of condition on January 31, 2026, in which the patient woke up, was alert, and asked for food. EMP9 came to assess the patient and discussed the risks of eating with the patient and with the patient’s sister to include aspiration, sepsis, and death, but if the patient wished to eat, the patient could eat after understanding and discussing the risk. The patient’s sister and the patient agreed that the patient would want to try eating despite the risks.MR2’s hospice plan of care was never updated to include a new diet order. The care plan for MR2 indicated the patient should receive daily visits from the skilled nurse beginning on admission - January 29, 2026. The patient was not seen by the skilled nurse on February 01, 2026. The patient died on February 02, 2026. An interview was conducted with EMP1 on March 17, 2026, at 2:30 PM who confirmed that the patient did not receive a visit from the skilled nurse on February 01, 2026, as ordered and that there was no documentation in the medical record to indicate why the visit was not made. EMP1 also confirmed the patient’s diet order had not been changed from NPO for the duration of the patient’s admission. The hospice’s policy, “ Levels of Care - General Inpatient Care” (no revised date) was reviewed and reads in part, “...patients receiving the general inpatient level of care at a contracted facility receive a documented visit buy the RN Case Manager or designee daily. The nurse communicates any changes in the patient’s status to the attending or hospice physician and other members of the IDG as well as facility personnel involved in the patient’s care...”The hospice’s policy, “Missed Visit Policy” (effective February 21, 2026) was reviewed and reads in part, “...If unable to complete the visit, notify the supervisor or clinical manager as soon as possible...The missed visit must be documented in the patient’s medical record, including the date and time of the scheduled visit, reason for the missed visit, attempts to contact patient/caregiver, notifications made (supervisor, physician IDT), plan for followup or rescheduled visit...””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; 4. Consistent with the hospice aide training. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by review of clinical records and interviews with the Director of Clinical Services which revealed the agency failed to ensure that: 1. Hospice Aide care plans were complete or present in the clinical records (HCDT.15.I/L625); 2. Hospice Aides followed the plans of care with respect to visit frequencies and assigned tasks (HCDT.16.I/L626); and 3. Hospice Aide supervisory visits were conducted by a registered nurse no less frequently than every 14 days. The cumulative effect of these deficiencies could result in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.76 Hospice Aide and Homemaker Services. The deficient practice demonstrates systemic process failures demonstrating a lack of oversight and that have the potential to affect all patients cared for by the home health agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 7 of 19 (37%) clinical record reviews revealed the agency did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The clinical record lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 11/15/2025; the social work initial psychosocial assessment was completed on 11/28/2025 (13 days), and there was no evidence that the initial spiritual assessment was completed. CLINICAL RECORD 6: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 02/13/2025; the initial spiritual assessment was completed on 02/17/2025, and there was no evidence that the initial psychosocial assessment was completed. CLINICAL RECORD 8: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 10/18/2025; the initial spiritual assessment was completed on 10/31/2025 (13 days), and there was no evidence that the initial psychosocial services assessment was completed (psychosocial services were declined). CLINICAL RECORD 12: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 09/26/2025; the initial spiritual assessment was completed on 09/30/2025, and there was no evidence that the initial psychosocial assessment was completed. CLINICAL RECORD 16: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 01/31/2025; the initial spiritual assessment was completed on 02/05/2025, and there was no evidence that the initial psychosocial assessment was completed. CLINICAL RECORD 18: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 07/01/2025; the initial spiritual assessment was completed on 07/03/2025, and the initial psychosocial assessment was completed on 07/09/2025 (8 days). CLINICAL RECORD 19: The clinical record review lacked evidence that the initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. The initial nursing assessment was completed on 02/14/2025; there was no documentation of a spiritual or psychosocial initial assessment being completed. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that she does not know why or how initial comprehensive assessments were not completed in a timely manner.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: 1. The hospice IDG in collaboration with the attending physician (if any); 2. The patient or patient representative if any of them so desire; 3. The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical record reviews revealed the agency did not ensure nursing services were provided as ordered on the patients’ plans of care. CLINICAL RECORD 2: The clinical record lacked evidence that nursing services were provided as ordered on the plan of care. The plan of care dated 01/28/2025 to 04/27/2025, ordered the nursing visit frequency at one time per week. The patient was admitted and seen by nursing on 01/28/2025. The next documented nursing visit was 02/07/2025 (10 days). There was no documented nursing visit during the week of 02/02/2025 to 02/08/2025. CLINICAL RECORD 8: The clinical record lacked evidence that spiritual counseling was provided in accordance with the plan of care dated 10/18/2025 to 01/15/2026. There was no spiritual care visit frequency on the plan of care. Spiritual care visits were documented on 11/11/2025, 12/11/2025, and 01/06/2026. The clinical record only included visit frequency orders for skilled nursing; no other discipline orders were found. CLINICAL RECORD 11: The clinical record lacked evidence that nursing services were provided as ordered on the plan of care. The plan of care dated 12/02/2025 to 03/01/2026 ordered the nursing visit frequency at two times per week. The patient was admitted and seen by nursing on 12/02/2025, then again on 12/04/2025 (2 times this week), then 12/12/2025 and 12/17/2025 (2 times this week). There were no subsequent documented nursing visits as of the date of review, 01/09/2026 (23 days). There were no documented missed visits during this time frame. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026 she stated that they did have a nurse who resigned during that time and the patient was being seen by someone else but she did not know why the documentation was not in the electronic medical record. Additionally, she stated that there are many orders that were not updated or reentered into the new electronic medical record (EMR) during the transition in November 2025. She also stated that information was entered by the EMR personnel, and they are now reviewing all data to update frequency and orders as needed.”

“It is required that each patient’s individualized written plan of care: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. 1 of 19 (5%) clinical record reviews revealed that the agency did not ensure the patient’s individualized written plan of care included problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 7: The clinical record lacked evidence of an individualized plan of care that included problems identified in updated comprehensive assessments. The patient elected the hospice benefit on 04/17/2025 with a diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The nursing assessment on 12/15/2025 documented that the patient was receiving Glucerna via pump tube feeding and had a large sacral decubitus. The nursing assessment, completed on 12/30/2025, documented the suprapubic catheter was draining well, the g-tube site had no redness, and (the patient) had a pressure sore to the sacrum and left back. The plan of care dated 12/13/2025 to 02/13/2026 does not address any of the problem areas identified; no integumentary, urinary, or gastrointestinal problems were documented in the patient’s plan of care. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that they have transitioned to a new electronic medical record and are still learning about the available features and how to customize them.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure that the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plans no less frequently than every 15 calendar days. CLINICAL RECORD 5: The clinical record lacked evidence that the IDG reviewed, revised, and documented the individualized care plan. During the benefit period dated 09/12/2025 to 11/10/2025; the IDG meetings for the dates 09/17/2025, 10/01/2025, 10/15/2025, and 10/29/2025 were reviewed. Updated plans of care for these dates did not contain any information, problems, medications, or a summary of care provided or to be provided. CLINICAL RECORD 6: The clinical record lacked evidence that the IDG reviewed, revised, and documented the individualized care plan. During the benefit period 10/11/2025 to 12/09/2025 the IDG meetings for the dates 10/15/2025 and 10/29/2025 were reviewed. Updated plans of care for these dates did not contain any information, problems, medications, or a summary of care provided or to be provided. CLINICAL RECORD 8: The clinical record lacked evidence that the IDG reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. During the benefit period 10/18/2025 to 01/15/2026 the IDG documented meetings on 10/22/2025 then 11/19/2025 (28 days), 12/03/2025, 12/17/2025, 12/31/2025. CLINICAL RECORD 10: The clinical record lacked evidence that the IDG reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days,. During the benefit period 09/28/2025 to 11/26/2025 the IDG documented meetings on 10/29/2025, then 11/26/2025 (28 days), 12/10/2025, 12/24/2025, and 01/07/2026. CLINICAL RECORD 16: The clinical record lacked evidence that the IDG reviewed, revised, and documented the individualized care plan. During the benefit period 01/31/2025 to 02/06/2025 the IDG meetings were reviewed for the following dates: 02/05/2025 and 02/12/2025. The updated plan of care for the meeting on 02/05/2025 did not contain problems, medications, or a summary of care to be provided, During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that they have transitioned to a new electronic medical record (EMR) due to compliance issues in the old EMR. She stated that they do have a paper copy of the IDG agenda and attendance sheet, but do not have evidence of an updated plan of care if not in the EMR.”

“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. 1 of 3 (33%) clinical records reviewed that were bereavement records, revealed that the agency did not ensure bereavement services were provided and delivered. CLINICAL RECORD 17: The patient elected the hospice benefit on 11/19/2025 and died on 11/20/2025. The clinical record lacked evidence that bereavement services were provided to the bereaved. Nursing documentation on 11/20/2025 stated, “Bereavement risk moderate, coordinator to reach out to family.” A bereavement plan of care was present in the record and contained the following information: “Goal: Bereaved will set limits when appropriate, resolved date 11/26/2025; resolved reason stated as “goal met, not interventions”. There was no other bereavement documentation in the EMR (electronic medical record) clinical record. During an interview with the Bereavement Coordinator (Personnel Record 6) on 01/08/2026, she stated that her log shows that the family declined bereavement services, and stated that she does not know why it was not documented.”

“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 a 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 2 of 16 (12%) clinical record review of patients with hospice aide services revealed that the registered nurse did not provide all patient care instructions for the hospice aide. CLINICAL RECORD 7: The clinical record lacked evidence that the registered nurse provided written care instructions to the hospice aide regarding the Foley catheter and g-tube. This is evidenced by the hospice aide plan of care dated 12/13/2025. CLINICAL RECORD 10: The clinical record lacked evidence that the registered nurse provided any written care instructions to the hospice aide. This was evidenced by a review of the clinical record for the benefit period dated 11/27/2025 to 01/25/2026. No hospice aide plan of care was found in the clinical record, but hospice aide services were ordered and provided twice a week with first visit of the benefit period being on 12/02/2025. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that many orders were not updated or reentered into the new electronic medical records (EMR) during the transition in November 2025.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical record review of patients who elected hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 1: The clinical record lacked evidence that the hospice aide provided services as ordered on the plan of care dated 11/15/2025 to 02/12/2026. The ordered hospice aide visit frequency was 3 times a week on the plan of care for the benefit period starting 11/15/2025. There was a physician order documenting a hospice aide visit frequency of 3w14, start on 11/15/2025, end 02/12/2026. The actual hospice aide visit frequency provided was 11/18/2025 and 11/21/2025 (2 x per week), then 3 x week, then, on the following dates: 12/1/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/05/2025 (5 x week). Missed visits were documented on 12/08/2025 and 12/12/2025; the patient was then seen on 12/09/2025, 12/10/2025, 12/11/2025 (5 x week), then 3 x week, then 12/22/2025, 12/23/2025, 12/24/2025, 12/25/2025 and 12/26/2025 missed visits (5 x week), missed visits were documented on 12/30/2025, 12/31/2025, and 01/01/2026; the patient was seen on 12/29/2025 and 01/02/2026 (5 x week). The hospice aide plan of care dated 11/15/2025 was present and reviewed in the clinical record. The hospice aide visit on 12/02/2025 documented vital signs “not addressed”. The following tasks were documented as “completed” but were not assigned on the aide plan of care: bathing/dressing shower documented as completed; activity documented as completed: assist with ambulation, assist with transfer documented as completed; dangle on side of bed documented as completed; hoyer lift documented as completed; turn and position documented as completed; active ROM documented as completed; passive ROM documented as completed; clean dentures documented as completed; comb hair, lotion, nails clean/file documented as completed; and oral care, shampoo, and back rub documented as completed. CLINICAL RECORD 5: The clinical record lacked evidence that the hospice aide provided services as ordered on the plan of care for the benefit period 09/12/2025 to 11/10/2025. The ordered hospice aide visit frequency was 3 times a week on the plan of care dated 09/12/2025 to 11/10/2025. The patient was seen by the hospice aide on 10/27/2025 and 10/29/2025 (2 x week), with no documentation of a missed visit or any additional visit frequency orders. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that many orders were not updated or reentered into the new electronic medical record (EMR) during the transition in November 2025.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. 5 of 16 (31%) clinical records reviewed of patients who accepted hospice aide services revealed the agency did not ensure the hospice aides were supervised by a registered nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 1: The patient’s election of hospice care was dated 11/15/2025. A review of the plan of care dated 11/15/2025 to 01/13/2026 included an order for the hospice aide three times a week (3xw). The first hospice aide visit was dated 11/18/2025 The RN’s first supervisory visit was dated 12/10/2025, 21 days since the first hospice aide visit. There was no documented evidence that the aide was supervised every 14 days. CLINICAL RECORD 5: The patient’s election of hospice care was dated 03/16/2025. A review of the plan of care dated 11/11/2025 to 01/09/2026 included an order for the hospice aide at a visit frequency of three times a week (3xw). The first hospice aide visit was dated. 11/12/2025 The first RN supervisory visit was dated 11/17/2025; the next RN supervisory visit was dated 12/26/2025 (39 days from the previous supervisory visit). There was no documented evidence that the aide was supervised every 14 days. CLINICAL RECORD 10: The patient’s election of hospice care was dated 04/01/2025. A review of the plan of care dated 11/27/2025 to 01/25/2026 included an order for the hospice aide at a visit frequency of two times a week (2xw). The first hospice aide visit of this benefit period was dated 12/02/2025 The first RN supervisory visit was dated 12/19/2025 (17 days from the first hospice aide visit of the benefit period). There was no documented evidence that the aide was supervised every 14 days. CLINICAL RECORD 11: The patient’s election of hospice care was dated 12/02/2025. A review of the plan of care dated 12/02/2025 to 01/25/2026 included an order for the hospice aide at a visit frequency of two times a week (2xw). The first hospice aide visit was dated 12/03/2025 The first RN supervisory visit has not been completed since the first hospice aide visit as of the date of review, 01/09/2026 (37 days from the first hospice aide visit). There was no documented evidence that the aide was supervised every 14 days. CLINICAL RECORD 12: The patient’s election of hospice care was dated 09/26/2024. A review of the plan of care dated 11/20/2025 to 01/18/2026 included an order for the hospice aide at a visit frequency of two times a week (2xw). The first hospice aide visit of the benefit period was dated 11/21/2025. The RN documented supervisory visits on 11/21/2025, and 11/25/2025, then no other supervisory visits were documented as of the date of review, 01/09/2026 (45 days from the last documented supervisory visit). There was no documented evidence that the aide was supervised every 14 days. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that she does not know why aide supervisory visits were not completed timely.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) clinical records reviewed of patients with a recertification of terminal illness revealed the agency did not ensure that a written, signed recertification was informed by the review of the patient’s clinical information. CLINICAL RECORD 5: A review of the clinical record lacked evidence that a written and signed recertification of terminal illness for the benefit period dated 11/11/2025 to 01/09/2026. The certification of terminal illness (CTI) present in the clinical record was missing a signature for “I recertify that this patient is under my care, and to the best of my medical knowledge given the data available, has a life expectancy of six (6) months or less if the terminal illness runs its normal course”. Additionally the CTI was missing a signature for the Face to Face Encounter visit details and the physician attestation section. CLINICAL RECORD 12: A review of the clinical record lacked evidence that the recertification of terminal illness for benefit period 11/20/2025 to 01/18/2026 was informed by the review of the patient’s clinical information The CTI present in the clinical record was blank, with no clinical documentation and no physician signature. During an interview with the Director of Clinical Services (personnel record 7) on 01/09/2026, she stated that they have transitioned to a new electronic medical record (EMR) due to compliance issues in the old EMR. She also stated that she has no real answer as to why recertifications are incomplete or missing signatures.”

“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. 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 review of clinical records and interview. 2 of 11 (18%) clinical records reviewed of patients requiring a recertification of terminal illness revealed the agency did not ensure that recertifications of the patients’ terminal illness were present in the clinical record. CLINICAL RECORD 12: A review of the clinical record lacked evidence that the recertification of terminal illness for benefit period 11/20/2025 to 01/18/2026 was present in the record. The certification of terminal illness (CTI) present in the clinical record was blank, with no clinical documentation and no physician signature. CLINICAL RECORD 13: A review of the clinical record lacked evidence that the recertification of terminal illness for benefit period 12/16/2025 to 03/09/2026 was present in the record. The clinical record did not have a documented CTI for the current benefit period in the clinical record. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated that they have transitioned to a new electronic medical record (EMR) due to compliance issues in the old EMR. She also stated that she has no real answer as to why recertifications are incomplete.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical record reviews of the patients’ discharge from hospice services revealed that the agency did not ensure the patients’ attending physician(s) received a copy of the hospice discharge summaries. CLINICAL RECORD 18: The patient elected the hospice benefit on 07/01/2025 and was discharged on 7/23/2025 after going to a non-contracted hospital. The clinical record was absent evidence that the discharge summary was sent to the patient’s attending physician. The discharge summary, dated 07/23/2025, included the question, “Patient attending physician notified”; the documented answer was “No”. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/14/2025 and was discharged from hospice services due to transfer to another hospice on 02/27/2025. The clinical record was absent evidence that the discharge summary was sent to the patient’s attending physician. The discharge summary dated 02/27/2025 included the question “Patient attending physician notified”; the documented answer was “No”. During an interview with the Director of Clinical Services (Personnel Record 7) on 01/09/2026, she stated she did not know why it was answered “No”, but that was one of the reasons could be that they changed to a new electronic medical record.”