Every finding on record at Affinity Hospice LLC

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable goals anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 12: The patient elected the hospice benefit on 12/25/2025. The Registered Nurse documented on the admission assessment dated 12/25/2025, that the patient’s pain score was a 10/10, and the patient was unable to get comfortable in bed due to a constant, sharp, burning, and stinging pain at the location of the patient’s cancerous tumor. The hospice Medical Director ordered Morphine Sulfate Extended Release (MS ER) 15mg three times a day, Dexamethasone 2 mg daily, and Norco 7.5mg - 325 mg every 6 hours as needed for pain, and Morphine Sulfate Immediate Release Oral Concentrate (MS IR) 20mg/mL: 0.25–1.0 mL every 2 hours PRN (as needed) pain. The clinical record included documentation that on 12/26/2025, the patient’s pain remained 10/10, and Neurontin 100 mg three times a day was added to the patient’s medication profile. On 12/27/2025, the patient’s pain remained 10/10, and the nurse noted that the patient was not taking the pain medications correctly, and a medication planner was instituted. A physician’s order was received to increase the MS IR to 1-2 mL every 2 hours PRN. The nurse visited the next day and noted that the patient was still in pain. The Medical Director provided new orders for MS ER 30mg three times a day, increased the Dexamethasone from 2mg to 4 mg daily, and added Oxycodone 10mg every 4 hours PRN for pain. On 12/29/2025, the patient’s pain remained a 10/10 localized to the tumor site, and the patient presented with restlessness and crying. The caregiver could not report the last dosing of the prescribed pain medications, so the nurse administered MS ER with effective relief by the end of the visit, and a Fentanyl 50 mcg/hour patch was ordered. The plan of care for the benefit period from 12/25/2025 to 03/24/2026 included documentation that pain was a problem for the patient and listed the goal as “patient will maintain pain controlled at an acceptable level.” The goal on the plan of care did not include a patient-specific measurable pain goal for the patient. During a joint clinical record review with the Assistant Director of Nursing (ADON) (Personnel Record 5) on 01/23/2026, the ADON stated the nurse was a new case manager and noted it would be beneficial to document the patient's stated acceptable pain goal in the plan of care so that all nurses providing care understand the treatment target.

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 3 of 18 (17%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) provided patient specific care instructions to the Hospice Aide (HA). CLINICAL RECORD 4: The patient, who resided in a nursing facility (NF), elected the hospice benefit on 06/18/2025. The patient’s spouse signed the Hospice Election Statement, and the reason the patient couldn't sign was documented as the patient was incapacitated. The plan of care for the benefit period from 12/15/2025 to 02/12/2026 included an order for the HA to visit the patient three times a week. The Registered Nurse documented on the nursing visit note dated 12/16/2025, the patient was alert and oriented to person and place only and had a FAST (Functional Assessment Screening Tool) score of 6E (moderately severe dementia). The nurse also noted a non-healing stage IV pressure ulcer to the patient's sacral area. Treatment orders included cleansing the area with Dakin's Solution, patting dry, applying a 4 x 4 gauze, and covering with a 6 x 6 silicone bordered gauze. The HA plan of care assignment dated 12/15/2025 included a choice of bed bath or a shower every visit, and the sacral wound was noted, but there were no instructions to the HA on what to do if the dressing became loose, wet, or soiled. The HA plan of care sections labeled "Report to RN" and "Special Instructions" were left blank. As the patient resided in a NF and was deemed not appropriate to sign his/her hospice consents and had a documented FAST score of 6E, it would not be suitable for the patient to make decisions about his/her care. The patient’s primary caregiver was not present to make decisions, so a choice of bath should not have been included on the HA plan of care. CLINICAL RECORD 11: The patient, who resided in an assisted living facility (ALF), elected the hospice benefit on 06/14/2024. The patient's MPOA (Medical Power of Attorney) signed the Hospice Election Statement; however, no reason was given for why the patient did not sign. The patient's terminal diagnosis was documented as Alzheimer's disease, and the physician's certification of terminal illness for the benefit period from 10/07/2025 to 12/05/2025 included in part that the patient had a FAST score of 7F (severe dementia), was bedbound, nonverbal, unable to follow commands with a palliative performance scale of 30% (bed bound/total care), and experienced dysphagia (difficulty swallowing). The plans of care for the benefit periods from 10/07/2025 to 12/05/2025 and 12/06/2025 to 02/03/2026 included orders for the HA to visit the patient three times a week. The HA plan of care dated 10/07/2025 and 12/06/2025 assigned the aide to provide at every visit both a shower and a bed bath, and combing/brushing and shampooing hair "as tolerated by the patient." The plan of care section labeled "Special Instructions" was left blank. Another section labeled, "Report to RN," included instructions to notify the nurse of signs and symptoms of pain, nausea/vomiting, increased fatigue, increased weakness, and shortness of breath. As the patient resided in an ALF and was deemed not appropriate to sign the hospice consents, had a FAST of 7F, was nonverbal, and unable to follow commands, it would not be suitable for the patient to make decisions about his/her care and the MPOA was not present to make decisions, so a choice of bath or whether or not to have hair shampooed should not have been included on the HA plan of care assignment. CLINICAL RECORD 19: The patient, who resided in a NF, elected the hospice benefit on 06/12/2024 and died on hospice services on 04/17/2025. The patient’s granddaughter signed the Hospice Election Statement, but no reason was given for why the patient did not sign. One of the patient's co-morbid conditions was senile degeneration of the brain. The physician's certification of terminal illness for the benefit period from 02/08/2025 to 04/08/2025 included in part that the “Patient with increased confusion and forgetfulness...with a behavioral episode requiring medical assistance to control..." The RN documented on the nursing visit note dated 03/06/2025, that the patient had unspecified dementia with agitation and was only oriented to person and place. A review of the patient's plans of care for the benefit periods from 02/08/2025 to 04/08/2025 and 04/09/2025 to 06/07/2025 included orders for the HA to visit the patient three times a week. The HA plan of care assignment dated 02/08/2025 and 04/09/2025 included at every visit both a shower and a bed bath, and the statement "as tolerated by the patient." The plan of care section labeled "Special Instructions" was left blank. Another section labeled, "Report to RN," included instructions to notify the nurse of signs and symptoms of pain, nausea/vomiting, increased fatigue, increased weakness, and shortness of breath. As the patient resided in a NF and was deemed not appropriate to sign the hospice consents, not oriented to person, place, and time, with increased confusion, it would not be suitable for the patient to make decisions about his/her care and the primary caregiver (the granddaughter) was not present to make decisions, so a choice of bath should not have been included on the HA plan of care assignment. During a joint clinical record review and interview with the Director of Nursing (DON) (Personnel Record 4) on 01/22/2026, the DON confirmed that the hospice aide plans of care did include a choice for what type of bath the patient would receive without an alert and oriented person or an available caregiver who could direct care.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure documentation that the discharge summary was provided to the patient's attending physician. CLINICAL RECORD 15: The patient elected the hospice benefit on 10/15/2024 and revoked hospice services on 12/01/2025. The discharge summary dated 12/01/2025 included documentation that the patient revoked to seek aggressive treatment at the hospital on 12/01/2025 and included documentation "Notified physician patient is leaving the program and agency patient is referred to (blank) ...on hospice services with a terminal diagnosis of Atherosclerotic Heart Disease...recent decline of increased weakness and fatigue. Patient becoming unable to walk without assistance...had a reported assisted fall...caregivers wanted patient to be sent to ER for evaluation and treatment..." However, there was no documented evidence in the clinical record that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 16: The patient elected the hospice benefit on 02/13/2025 and was discharged on 09/07/2025 due to an extended prognosis. The discharge summary dated 09/07/2025 included documentation that the patient was discharged due to an extended prognosis and included the documentation "Notified physician patient is leaving the program and agency patient is referred to (blank) … instructions given to patient and/or caregiver for continuity of care … Discharge of care to facility physician due to extended prognosis. Pt is agreeable with discharge." However, there was no documented evidence in the clinical record that the discharge summary was sent to the patient’s attending physician. During a joint clinical record review and interview on 01/22/2026, the Director of Nursing (DON) (Personnel Record 4) stated nurses are instructed to send the plan of care, medication list, and physician orders to the receiving physician. The agency uses a paper checklist to prompt nurses to complete discharge documentation; however, the DON acknowledged that there was no documentation to verify that the discharge summary had been sent to the receiving physician.

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, by CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 13 (8%) clinical records reviewed, revealed that the agency did not ensure that the social worker completed the initial social work assessment within 5 days after admission. Record 9: The patient elected the hospice benefit on 11/7/2023. The initial Social Work Assessment was completed on 11/17/2023 - 10 days after admission. There was no note as to why the visit was delayed past the 5-day regulatory window. During an interview with the Director of Nursing on 3/23/2023, it was confirmed that the initial social work assessment did occur after the required 5-day timeline due to a scheduling error by the social worker. No further documentation was provided by the end of the site visit.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); The patient or patient representative; The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 13 (8%) clinical records reviewed, revealed that the hospice did not ensure that the patient's Plan of Care (POC) was followed for the frequency of weekly nursing visits. Record 12: The patient elected the hospice benefit on 8/4/2022. The initial frequency of nursing visits was set at 2 times a week in an order dated 8/4/2022. Nursing visits occurred only 1 time a week during the period of review from 2/5/2023 to 3/18/2023 with visits made on 2/6/2023, 2/13/2023, 2/20/2023, 2/27/2023, 3/6/2023, and 3/13/2023. During an interview on 3/23/2023 with the Director of Nursing (DON), it was confirmed that in the patient's initial POC, the frequency order for the nurse was 2 times a week, and that order had not been updated from admission.

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. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 13 (23%) clinical records reviewed, revealed that the agency did not ensure that the interdisciplinary group meeting documentation reflected the patient decline or changes as noted in the comprehensive assessments and did not reflect updates in the plan of care including updating goals and progress towards goals. Record 1: The patient elected the hospice benefit on 5/24/2022. The Plan of Care (POC) effective 3/8/2023 lacked updates to the problems, progress toward the outcomes, and goals as documented in the updated comprehensive assessment, for the identified problems of pain, musculo/skeletal, neuro/mental/emotional, and skin integrity/vascular access. Record 3: The patient elected the hospice benefit on 11/4/2022. The Plan of Care effective date 3/8/2023, lacked updates to the problems, progress toward the outcomes, and goals as documented in the updated comprehensive assessment, for the identified problems of pain, musculo/skeletal, neuro/mental/emotional, family adaption, cardiopulmonary, and nutrition/hydration. Record 12: The patient elected the hospice benefit on 8/4/2022. The Plan of Care effective 2/22/2023 lacked updates to the problems, progress toward the outcomes, and goals as documented in the updated comprehensive assessment, for the identified problems of pain, musculo/skeletal, neuro/mental/emotional, and cardiopulmonary. During an interview on 3/23/2023 with the QAPI Manager/Alternate Supervising Nurse, it was confirmed that these updates to the patients' Plan of Care and follow-up and progress toward goals were not documented as the agency would expect.

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. 2 of 9 (22%) clinical records reviewed in which hospice aide services were accepted, revealed that the hospice did not ensure that the aide plan of care was developed by the RN. Record 8: The patient elected the hospice benefit on 2/15/2023 with the hospice diagnosis of Senile Degeneration of the Brain. The patient resided in a SNF. The aide care plan found in the "Hospice Aide Visit Assignment" dated 2/15/2023 included, "Bath: shower, bed - as tolerated by the patient." "Hair Care: Comb/brush; Shampoo - as tolerated by the patient." Record 12: The patient elected the hospice benefit on 8/4/2022 with the hospice diagnosis of heart disease. The nurse documented in the 1/30/2023 "Nurse Progress Note Comprehensive Assessment: Summary of Visit" that, the "patient-oriented to self only." The "Hospice Aide Visit Assignment" dated 1/31/2023 included "Bath: shower, bed - per pt request." During an interview conducted with the QAPI Manager/Alternate Supervising Nurse and the Director of Nursing on 3/23/2023, it was confirmed that the aide care plans should not include "patient choice" for those patients with dementia or "as tolerated" as it is outside the hospice aide's scope of practice to assess a patient.

It is required if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40. I, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed in which a transfer to a Medicare/Medicaid facility occurred, revealed that the hospice did not ensure that the discharge summary was sent to the receiving facility. Record 6: The patient elected the hospice benefit on 2/24/2023. The patient signed a revocation from hospice on 3/5/2023. The Transfer Summary dated 3/5/2023 stated, "The patient revoked hospice services due to being admitted for dx of AFIB RVR and Anemia. Notified office/team members of change of status. Revocation/Transfer signed by patient or representative on 3/5/2023. The patient was exhibiting signs of hypotension. The caregiver contacted hospice, and a nurse on call advised them to contact the physician. The patient was admitted to the hospital for AFIB RVR and Anemia. The patient was aware of hospice discharge and signed revocation papers. The clinical record contained no evidence that the transfer summary was sent to the receiving facility. During an interview with the Director of Nursing and the QAPI Manager/Alternate Supervising Nurse on 3/23/2023, it was confirmed that the transfer summary for the transferred patient reviewed was not sent to the receiving facility.

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. 1 of 1 (100%) clinical record reviewed in which a live discharge for extended prognosis from hospice occurred, revealed that the hospice did not ensure that the discharge summary was sent to the patient's physician. Record 10: The patient elected the hospice benefit on 2/16/2022. The patient was discharged for an extended prognosis on 10/13/2022. There was no documented evidence that the discharge summary was sent to the patient's physician. During an interview with the Director of Nursing and the QAPI Manager/Alternate Supervising Nurse on 3/23/2023, it was confirmed that the discharge summary for the live discharge reviewed did not contain evidence that the summary was sent to the physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient or 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. 2 of 2 (100%) clinical records reviewed in which a live discharge from hospice occurred, revealed that the hospice did not ensure that the discharge summaries included the required information to assist with continuity of care post-discharge. Record 6: The patient elected the hospice benefit on 2/24/2023. The patient signed a revocation from hospice on 3/5/2023. The Transfer/Discharge/Death Summary dated 3/5/2023 stated, "The patient revoked hospice services to be admitted to [facility] for dx of AFIB RVR and Anemia. The patient was aware of hospice discharge and has signed revocation papers." The discharge summary did not include a summary of the patient's hospice stay, nor did it include the patient's last plan of care, physician orders, medications, symptoms management, or treatments. Record 10: The patient elected the hospice benefit on 2/16/2022. The patient was discharged for an extended prognosis on 10/13/2022. The Discharge Summary dated 10/13/2022 stated, "Status: Discharge - Pt discharged due to stable condition with no declines for certification period 3, 8/15/2022 - 10/13/2022. Instructions given to patient and/or caregiver for continuity of care. Completed Clinical Transfer/Discharge Summary Forms." The discharge summary did not include a summary of the patient's hospice stay, nor did it include the patient's last plan of care, physician orders, medications, symptoms management, or treatments. During an interview with the Director of Nursing and the QAPI Manager/Alternate Supervising Nurse on 3/23/2023, it was confirmed that the discharge summaries for the 2 live discharges reviewed did not contain a summary of the patient's hospice stays, any information about their plans of care, medications, or any other physician orders.