Every finding on record at Amare Hospice

Observed in Record Review. The organization failed to ensure the comprehensive assessment was accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The organization does not have any patients on service to be able to review compliance to standard.. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. The organization failed to ensure that the registered nurse supervised the hospice aide no less frequently that every 14 days. Organization does not have any patients on service to be able to review compliance. This observation was reviewed with the Administrator/DPCS.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for , 418.54, and 418.76 were met per policy as determined through observations and documentation. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to ensure the comprehensive assessment was accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. On review of RR#1 there was a 28 day gap in the RN update to the comprehensive assessment visit from the end of March to date in April 2026. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 4 patient records reviewed, The interdisciplinary group, in collaboration with the patient’s attending physician, if any, reviews and revises the plan of care (POC) as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. These reviews are documented. RR#1 lacked documentation that the IDG reviewed or revised the patient's POC for 28 days from the end of March to date in April 2026. This was discussed with the Administrator/DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, 1 active and 3 discharged patients who were provided aide services after the end of the last survey, the organization failed to ensure that the registered nurse supervised the hospice aide during an on-site visit to the patient's home no less frequently that every 14 days. On review of RR#1 it was noted the last supervisory visit was 23 days from the middle of March to the first week in April 2026. During D/CRR#1, D/CRR#2 and D/CRR#3 there were gaps of more than 14 days from the middle of March to the beginning of April 2026. These observations were reviewed with the Administrator/DPCS.

Observed in Document Review. The organization failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. On volunteer program review, there was no documentation of recruitment and retention efforts for volunteers since the end of the last survey. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Document Review. The organization failed to document the cost savings achieved through the use of volunteers since the last survey. The Administrator noted they had not recorded volunteer hours nor generated cost savings reports.

Observed in Document Review. The organization failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees and contract staff since the last survey. Upon discussion with the Administrator/DPCS the organization was not utilizing volunteers and not recording volunteer hours.

Observed in Document Review. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for , 418.54, 418.76, and 418.78 were met per policy as determined through observations, documentation, and staff interviews. This was discussed with the Administrator.

Observed in Emergency Management Session. the organization failed to evaluate all exercises and actual emergency or disaster incidents. On review of the emergency management program the organization had participated in the Great Shake however there was no documentation an after action report had been created to analyze the hospice's response and identify opportunities for improvement and recommendations to take to improve. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, for extended prognosis discharge, the organization failed to respect the patient's right to participate in decisions about their care, treatment, or services. On review of RRDC#1 and RRDC#4 with discharge for extended prognosis, the Notice of Medicare Non-Coverage was signed on the day of discharge and not at least two days prior as required. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, for active and bereavement records, the organization failed to ensure an initial bereavement assessment of the needs of the patient's family and other individuals focusing of the social, spiritual and cultural factors that may impact their ability to cope with the patient's death was performed on admission. On review of RRHV#2 there was no documentation an initial bereavement risk assessment was performed. In RRHV#3 there was no documentation of an initial bereavement risk assessment. There was also no documentation of a bereavement risk assessment for RRNHV#5. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, for active patient records, the organization failed to ensure the comprehensive assessment was accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. On review of RRHV#2 there was a 19 day gap in RN update to the comprehensive assessment visit in November and a 23 day gap between November and December. In review of RRHV#3 there was a 17 day gap from February to March in documentation of the RN update to the comprehensive assessment visit. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, for active patients, the organization failed to ensure the patient record was complete, promptly and accurately documented. In review of RRNHV#4 the LVN’s March documentation indicated that the patient reported no pain during the assessment and in the narrative; however, later in the same narrative, the patient’s pain was documented as 3/10. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 5 patient records reviewed, for active records, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable and time bound. On review of RRHV#1 there were goals that were not specific and measurable such as Patient will have elimination needs met at an acceptable level within 30 days. In RRHV#3 an example of a non-specific goal, not measurable goal was Patient needs will be met on a day to day basis as expressed through non-verbal cues for the next 2 weeks of hospice care. Review every IDG date and revise if needed. In RRNHV#4 another example of non-specific goal was Patient's strength and energy will improved in 30 days for functional activities. In RRNHV#5 there were goals that were not measurable and not specific such as Patient's blood sugar will be managed and will prevent hospitalization and within 30 days. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, for active patients, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#5 there was an order specifying Skilled nurse may perform blood glucose checking utilizing glucometer machine every visit and documenting results yet the order was incomplete as it or the plan of care failed to specify parameters for reporting results to the MD. Further, the documentation noted the patient had weakness and fatigue, unsteady gait and use of a walker yet the care plan on musculoskeletal/fall safety had been closed and did not address the current fall risk issue. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, The organization failed to ensure the interdisciplinary group review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently that every 15 days. On review of the documentation in RRHV#1 the current order for spiritual counseling was to assess at each recert yet the IDG documentation each IDG meeting noted that visit had been declined or placed on hold per family request and therefore no spiritual visits were documented after the request in November. In RRNHV#4 the plan of care was not updated to reflect the current orders for frequencies. The order noted the aide at 1 time a week yet clear documentation throughout the record noted that the aide services had been declined. There was an order for Skilled nursing (SN) at 1 time a week and another for LVN at 2 times a week. The LVN was going 2 times a week. The administrator noted the 1 time a week was in error yet the plan of care was not updated to reflect the current frequency. These observations were reviewed with the Administrator/DPCS.

Observed in Data Session. the organization failed to analyze and compare internal data over time to identify levels of performance, patterns, trends and variations. On review of the QAPI program the organization was collecting data, analyzing and reporting on a quarterly basis yet failed to analyze and compare the data over time to identify patterns, trends, and variations. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to ensure that the Registered Nurse evaluate the following areas by observing a home health or hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: - Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. On review of the initial competency for the Hospice Aide all required tasks were documented to be assessed verbally and not by observation with a patient or pseudo-patient as part of a simulation. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, for active patient's with aide services, the organization failed to ensure written patient care instructions for the hospice aide were provided by the registered nurse. On review of RRHV#1 the patient had oxygen in the home yet no oxygen precautions noted on the record. The patient also had wounds to the coccyx and heel at varying time throughout the admissions yet there were no specific instruction on how the aide was to handle the wounds while providing care. In RRHV#2 the patient was also ordered oxygen yet oxygen precautions were not addressed in the aide plan of care. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 4 patient records reviewed, for active patient's with aide services, the organization failed to ensure the services were provided as per the aide assignment. On review of RRHV#2 the aide assignment ordered a bed bath yet in each visit the aide documented in the narrative that a shower was tolerated very well by the patient and therefore not following the bath assignment. In RRHV#3 the aide was assigned to provide a bed bath but documentation at each visit noted the aide provided a shower with shower chair and not a bed bath as assigned. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, for active patient's with aide services, the organization failed to ensure that the registered nurse supervise the hospice aide during an on-site visit to the patient's home no less frequently that every 14 days. On review of RRHV#2 there was a 43 day gap in aide supervisory visits documented between November and December of 2025. In review of RRHV#3 there was a 23 day gap from February to March (current) in the documentation of RN aide supervisory visits. These observations were reviewed with the Administrator/DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to ensure the registered nurse make an annual on-site visit to the location where the patient is receiving care in order to observe and assess the aide while performing care. On review of HR#4 for the hospice aide there was no documentation of an annual on-site visit to assess the aide while providing care. This observation was reviewed with the Administrator/DPCS.

Observed in Tracer Activities. The organization failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. On volunteer program review, there was no documentation of recruitment and retention efforts for volunteers. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Tracer Activities. the organization failed to document the cost savings achieved through the use of volunteers and the documentation was unavailable at time of survey. The Administrator noted they had not recorded volunteer hours nor generated cost savings reports.

Observed in Tracer Activities. the organization failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees and contract staff. Upon discussion with the Administrator/DPCS the organization was not utilizing volunteers and not recording volunteer hours.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.116, 418.54, 418.76, and 418.78 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On home observation for RRHV#1 during medication reconciliation there were Latanoprost and Brimonidine eye drops noted in the home and caregiver stated the patient had been taking them for a long time yet the medications were not included on the plan of care or medication profile. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, where patients were discharged to a facility, the organization failed to provide the receiving facility with a copy of the hospice discharge summary and if requested a copy of the patient's clinical record. In review of RRDC#2 and RRDC#3 where the patient revoked seeking aggressive treatment and transferred to a medical facility, there was no documentation that the discharge summary was sent to the receiving facility. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 2 of 4 patient records reviewed, for live discharges, the organization failed to provide the patient's attending physician with a copy of the hospice discharge. On Review of RRDC#2, and RRDC#3 there was no documentation that the discharge summary was sent to the attending physician nor did it include all required elements as it only contained information on the reason for discharge and did not include a summary of the care and services provided. This observation was reviewed with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 5 of 5 patient records reviewed, for active patients, the organization failed to provide care, treatment or services in accordance with licensure requirements, law, and rules and regulations. On review of the clinical record there was no indication that the patient/caregiver was informed of their right to the Patient Notification of Non-Covered items, supplies and drugs addendum. On discussion with the Administrator/DPCS there was no clear process the organization was following to know whether the patient had elected or declined the addendum.

Observed in Record Review. In 1 of 3 patient records reviewed, the Surveyor noted the patient had not had a comprehensive nursing visit in 35 days. All visits had been performed by an LVN. This was validated by the Director of Nursing.

Observed in Record Review. In 1 of 3 patient records reviewed, the Surveyor noted the patient Plan of Care (POC) had not been followed as ordered. In RR #3, the POC had the Hospice Aide frequency of 2 times per week. No visit had been documented for 2 weeks for a total of 4 missed visits. There had been no documented communication between the HA and the IDG related to the missed visits. This was validated with the Director Of Nursing.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient had Hospice Aide Services, the supervisory visits had not been completed every 14 days. In RR #2, the patient had not had a HA supervisory visit in 35 days. This was validated with the Director of Nursing.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, of which HSRR#2 was the only discharge for extended prognosis for which the patient no longer met the criteria for hospice coverage. There was no documentation that Notice of Medicare Provider Noncoverage was given as required by the agency's policy No. 1-003 Financial Responsibility and Medicare Written Notices.

Observed in Leadership Session. The hospice interdisciplinary group (IDG) did not establish and approve policies governing the day-to-day provision of hospice care and services. Policies were established, reviewed, and approved by the Administrator/Director of Patient Care Services/RN, Medical Director, Alternate Director of Patient Care Services, and Human Resources Director. The social worker and counseling services were not represented. The agency's policy No 4-013 Development of Policies and Procedures clarified the role and involvement of the IDG.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the organization did not develop individualized, specific and measurable goals for patients: HVs 1-3 and RRs 1-8. The following goals without further definition were written in the plans of care: optimal bowel movement, optimal mobility, minimize complications, have urinary elimination needs met at an acceptable level, sore will heal to maximum potential, optimal peripheral circulation, BP will be stable, comfort will be promoted, optional functional activities, sleep will be improved, and optimal level of oxygen.

Observed in Individual Tracer. In 5 of 11 patient records reviewed, the organization did not update the plan of care when changes in care were made. For example, during HV2 the LVN stated that the patient was on 2.5 l/min continuous. During record review the surveyor noted the oxygen was ordered at 2 liters as needed. During review of RR1 the care plan was not updated with new wounds, when aide services were added 10/28 and when continuous care was started. For RR3 the plan of care was not updated when continuous care was started 8/6. For RR4 the plan of care was not updated when continuous care was started 7/16. And lastly for RR7 the plan of care was not updated when continuous care was started 3/19.

Observed in Individual Tracer. In 8 of 11 patient records reviewed, there was no evidence of interdisciplinary group meetings at least every 15 days as evidences in the following records: RR1 there was an interdisciplinary group meeting (IDG) after admission and no further documentation of meetings. There was two missed meetings after that before the patient expired. RR2 the record did not reflect meetings after 8/13/21, the patient expired 9/6/21 without any further documentation of meetings. RR3 there was no IDG after 5/12 through discharge 8/6. RR4 there was no IDG 6/10 after through discharge 7/16. RR5 there was no IDG after 4/19/22 through discharge 6/17/22. RR6 there was no IDG after 2/4/22 through discharge 3/29/22. RR7 there was an IDG at admission and no IDG when patient expired two weeks later, And lastly RR8 there was no IDG after 12/21 through patient's expiration 1/17/23.

Observed in Data Tracer. The organization leaders did not establish performance improvement priorities and describe in a written plan for 2021, 2022, and 2023 that included the following: - The defined process(es) needing improvement, along with any stakeholder (for example, patient, staff, regulatory) requirements, project goals, and improvement activities - Method(s) for measuring performance of the process(es) identified for improvement - Analysis method(s) for identifying causes of variation and poor performance in the process(es) - Methods implemented to address process deficiencies and improve performance - Methods for monitoring and sustaining the improved process(es). (

Observed in Leadership Session. There was no documentation to demonstrate that the organization used the results of data analysis to identify improvement opportunities for 2021 and 2022.

Observed in Leadership Session. During review of the governing body minutes for 2021, 2022, and as of survey 2023 it was determined that the governing body did not approve the 2021, 2022, and 2023 QAPI and IC plans including the frequency and detail of the data collection.

Observed in Data Session. The organization did not conduct any performance improvement projects based on the patients’ needs and internal organization needs for 2021 and 2022.

Observed in Leadership Session. During review of the governing body minutes that was no documentation that the leadership reviewed the plan for addressing performance improvement priorities at least annually in 2021 and 2022 and did not update the plan to reflect any changes in strategic priorities and in response to changes in the internal or external environment. Observed in Leadership Session. The organization did not conduct an annual program evaluation for 2021 or 2022. This was verified by the Administrator/DPCS.

Observed in Infection Control System Tracer. The organization did not evaluate the effectiveness of its planned infection prevention and control activities annually for 2020, 2021, and 2022 and whenever risks changed.

Observed in Infection Control System Tracer. The organization's written infection prevention and control goals for 2021, 2022, and 2023 did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals for 2021, 2022, and 2023 did not include the following: Limiting unprotected exposure to pathogens. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals for 2021, 2022, and 2023 did not include the following: Limiting the spread of infections associated with procedures. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals for 2021, 2022, and 2023 did not include the following: Addressing its prioritized risks.

Observed in HR File Review. CORE services were not routinely provided directly by hospice employees. Nursing, social work, and counseling provided by the spiritual counselor and bereavement counselor were not employees but contracted staff.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the surveyor noted that the spiritual counselor documented several issues related to spiritual distress and concern for two patients: RR7 and RR8. The issues were concerns about afterlife, pain and suffering, loss of independence, anxiety, unfinished business, and fear. The spiritual counselor did not develop a plan of care to address these concerns. During the interview with the spiritual counselor it was shared with the surveyor that the philosophy of the agency was for the spiritual counselor was to make the initial assessment and then visit as needed as determined by the Director Patient Care/RN. Further communication with the Director/RN revealed that the patients did not need visits from the spiritual counselor as determined by her. However, the Director/RN was not a qualified spiritual counselor.

Observed in HR File Review. the RN did not have a competency evaluation since 2019. The agency's policy was that competency would be assessed every three years.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, tthe organization did not give information about the care, treatment, or services provided to the patient to other service providers who would provide the patient with care, treatment, or services. The patient, HSRR#5 revoked to seek treatment and there was no documentation that the discharge summary and other information was sent to the next provider of care. The patient , HSRR#2, was referred to home health. There was no documentation that the discharge summary and other information was sent to the next provider of care.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, , RR6, did not include summary of the patient's stay including treatments, symptoms, and pain management