Every finding on record at Amore Hospice Care

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served and includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences. This standard was not met as evidenced by document review and interview. The agency did not ensure development of hazard vulnerability assessment. During the review of the Emergency Preparedness Plan, it was identified that the current plan lacks a documented, hospice-specific and community-based Hazard Vulnerability Assessment (HVA) tailored to the unique geography, demographics, and risk profile of the population served by the agency. Following a joint review of the Emergency Management Plan and an interview with the Director of Clinical Services on 12/18/2025, it was confirmed that the agency does not maintain a current Hazard Vulnerability Assessment (HVA). The Director acknowledged this and agreed that the assessment has not been developed or updated as required. During the review of the Emergency Preparedness Plan, it was identified that the current plan lacks a documented, hospice-specific and community-based Hazard Vulnerability Assessment (HVA) tailored to the unique geography, demographics, and risk profile of the population served by the 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. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment was completed within the required five calendar days following election of hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/18/2025. The Social Worker completed the assessment on 10/25/2025 (7 days), which was outside the required five-day timeframe. There was no documentation provided to explain the delay. CLINICAL RECORD 11: The patient elected the benefit on 08/22/2025. The social worker completed the assessment on 08/31/2025 (9days), which was outside the required five-day timeframe. There was no documentation provided to explain the delay. During a joint record review and interview conducted on 12/17/2025 with the Director of Clinical Services, it was confirmed that the Social Worker did not complete the required assessment within five days of the patient’s election of hospice care. Additionally, there was no documentation provided to explain the delay.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the initial bereavement assessment was completed as required. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/04/2025. The review of the clinical record revealed that an initial bereavement assessment was not completed as required. The patient is currently receiving skilled nursing and chaplain services; however, documentation of the initial assessments indicated that neither discipline performed a pre-bereavement assessment. Following a joint record review and an interview with the Director of Clinical Services on 12/19/2025, she acknowledged that the pre-bereavement assessment had not been completed as required.

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. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the plan of care included all the interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/21/2025. At admission, the patient had a documented co-morbidity of seizures and was prescribed Keppra for seizure management; however, the plan of care dated 11/21/2025-01/19/2026 did not include a problem statement or interventions addressing seizure management. Additionally, wound care orders were initiated on 11/21/2025 for the coccyx and on 11/28/2025 for the right upper arm, yet the plan of care lacks a corresponding problem related to wounds/skin integrity and does not outline interventions for wound management. The patient has a left nephrostomy tube, and nursing documentation reflects multiple notes indicating dressing changes to the nephrostomy site and drainage of clear yellow urine. The plan of care did not include interventions related to dressing changes for the nephrostomy site. Following a joint review of records and an interview with the Director of Clinical Services on 12/18/2025, she confirmed that the problems identified in the comprehensive assessments were not reflected in the plan of care, and corresponding interventions to address these issues were absent.

It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview. The agency did not ensure the governing body appointed a person responsible for the QAPI program. Based on review of the agency’s QAPI program and interviews with administrative staff, it was determined that the Governing Body did not appoint an individual or individuals responsible for the development, implementation, oversight, and evaluation of the Quality Assessment and Performance Improvement (QAPI) program. The agency was unable to identify a designated QAPI coordinator or team, and documentation did not reflect assigned leadership, defined responsibilities, or active oversight by the Governing Body as required. Following document review and interview with the Director of Clinical Services and the Administrator both determined that the Governing Body did not officially appoint an individual/individuals responsible for QAPI. Based on review of the agency’s QAPI program and interviews with administrative staff, it was determined that the Governing Body failed to appoint an individual or individuals responsible for the development, implementation, oversight, and evaluation of the Quality Assessment and Performance Improvement (QAPI) program. The agency was unable to identify a designated QAPI coordinator or team, and documentation did not reflect assigned leadership, defined responsibilities, or active oversight by the Governing Body as required.

It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for deceased patients revealed that the agency did not ensure the development of a bereavement plan of care that specified the types of bereavement services to be provided and the frequency of service delivery. CLINICAL RECORD 19: The patient elected the hospice benefit on 05/06/2025 and died on 06/20/2025. The clinical record review revealed that although the bereavement coordinator-maintained contact with the bereaved party—including documented follow-up communications and mailings—there was no formal bereavement plan of care in place. The bereaved individual had been assessed as low risk. CLINICAL RECORD 18: The patient elected the hospice benefit on 05/16/2025 and died on 06/24/2025. The clinical record review revealed that although the bereavement coordinator-maintained contact with the bereaved party—including documented follow-up communications and mailings—there was no formal bereavement plan of care in place. The bereaved individual had been assessed as low risk. CLINICAL RECORD 17: The patient elected the hospice benefit on 08/27/2025 and died on 07/04/2025. The clinical record review revealed that although the bereavement coordinator-maintained contact with the bereaved party—including documented follow-up communications and mailings—there was no formal bereavement plan of care in place. The bereaved individual had been assessed as low risk During the joint record review and subsequent discussion with the Director of Clinical Services and the Administrator on 12/19/2025, both agreed that although the bereaved parties were being followed appropriately, there was no formal bereavement plan of care in place.

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 1 of 17 (6%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure the hospice aide plan of care included all required written instructions. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/31/2025. The patient was ordered oxygen at 2 liters via nasal cannula as needed for shortness of breath and uses it frequently. However, upon review of the hospice aide plan of care, there was no documentation regarding the oxygen or guidance on whether it could be removed during care. Following a joint record review and an interview with the Director of Clinical Services on 12/19/2025, she confirmed that the hospice aide plan of care did not include the required information related to oxygen therapy.

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 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. In 1 of 15 (7%) clinical records reviewed that had aide services ordered it was revealed that the agency did not ensure that there were hospice aide supervisory visits completed as required at least every 14 days. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/25/2025. A review of the clinical record revealed that the patient was authorized to receive hospice aide services five times per week. However, as of the date of the record review on 12/18/2025, there has been no documented hospice aide supervisory visit since 09/30/2025 (79 days). During a joint record review and interview with the Director of Clinical Services, on 12/18/2025, it was identified that a transition occurred in the assigned Registered Nurse Case Manager. The newly assigned case manager did not complete the required supervisory visits in accordance with agency policy and regulatory expectations.

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. This standard was not met as evidenced by interview and personnel record review. In 5 of 11 (45%) personnel records reviewed it was revealed that the agency did not ensure that initial competencies were completed for newly hired employees. PERSONNEL RECORD 2: The review of the personnel record for the Registered Nurse Case Manager, hired on 09/12/2025, revealed that the agency did not document the required initial competency assessments. The record contained no documented evidence of completed skills validation, competency checklists, or orientation-related clinical evaluations demonstrating the employee’s ability to perform assigned duties. PERSONNEL RECORD 5: The review of the personnel record for the Chaplain/Bereavement Coordinator, hired on 06/23/2025, revealed that the agency did not document the required initial competency assessments. The record contained no documented evidence of completed competency checklists, skills validation, or orientation-related evaluations demonstrating the Chaplain’s ability to perform assigned duties. There was also no documented evidence of competency evaluation related to regulatory requirements for bereavement services PERSONNEL RECORD 7: The review of the personnel record for the Registered Nurse Case Manager, hired on 12/18/2024, revealed that the agency did not document the required initial competency assessments. The record contained no documented evidence of completed skills validation, competency checklists, or orientation-related clinical evaluations demonstrating the employee’s ability to perform assigned duties. PERSONNEL RECORD 10: The review of the personnel record for Licensed Medical Social Worker, hired on 01/06/2023, revealed that the agency did not document the required initial competency assessments. The record contained no documented evidence of completed skills validation, competency checklists, or orientation-related clinical evaluations demonstrating the employee’s ability to perform assigned duties. There were also no competencies noted for 2024. PERSONNEL RECORD 11: The review of the personnel record for a volunteer who completed training on 01/20/2023 revealed that the agency did not document initial competency assessments or any competency assessments for 2024. During the interview with the Director of Clinical Services, on 12/19/2025, it was confirmed that required competency assessments were not completed at the time of hire for several staff members, and that some staff did not have any documented competencies for 2024. The Director acknowledged that the agency did not have a consistent process in place to ensure completion, tracking, and annual updating of competency validation as required. The Director of Clinical Services did state that she had a competency fair for all staff last month. This was verified onsite.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients discharged due to revocation or extended prognosis revealed that the agency did not ensure the discharge summaries contained all required information. CLINICAL RECORD 15: The patient elected the hospice benefit on 05/01/2025 and was discharged due to revocation on 08/28/2025. Review of the clinical record revealed that the discharge summary did not contain the required elements, including a summary of the patient’s hospice course, treatments provided, symptom management, pain management interventions, the plan of care, or the most recent physician orders. The only notation documented on the discharge summary was, ‘patient and family going to Mexico.’ During the joint record review and interview with the Director of Clinical Services on 12/19/2025, she acknowledged that the discharge summary was incomplete and did not contain the required information.

It is required that a hospice aide provides services: (L626) ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) clinical records in which aide services were accepted revealed that the agency did not ensure the hospice aide provided services according to the Interdisciplinary Group Plan of Care. Clinical Record 3: the patient elected hospice care on 1/24/2021. The Plan of Care dated 1/24/2023 ordered Aide services to take vital signs every visit. The aide visits on 1/27/23, 1/30/23, 2/3/23, 2/6/23, 2/10/23, 2/13/23, 2/17/23 and 2/20/23 did not include vital signs and lacked documentation of why the vital signs were not taken as ordered. There was no documentation that the RN or Physician was notified. The Director of Nursing was interviewed during joint review of the clinical record on 2/20/23 and confirmed that the agency did not have documentation of missed vital signs by the aide or why they were not completed.

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. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) record reviewed where hospice aide services were accepted revealed the agency did not ensure the hospice aide reported changes in the patient's nursing needs. Clinical Record 3: the patient elected hospice care on 1/24/23. The Plan of Care dated 1/24/23 ordered aide to provide a shower twice weekly. Missed showers were identified on 1/30/23 and 2/6/23 due to patient's refusal. The record lacked documentation that the RN or Physician was notified. The Director of Nursing was interviewed during joint review of the clinical record on 2/20/23 and confirmed that the agency did not have documentation that the RN was notified.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) clinical record reviewed revealed the agency did not ensure a copy of the controlled medication disposal policy was provided to the patient, family or legal representative when a controlled medication was first ordered. The agency's policy on medication management stated that when a controlled medications was ordered the nurse will provide to the patient the agency's policy on the disposal of the controlled medication. Clinical Record 1: the patient was admitted to hospice on 12/31/22. The controlled medication oxycodone was ordered for the patient. The agency's drug disposal policy was not provided to the patient when the medication was started on 12/31/22. Clinical Record 2: the patient was admitted to hospice on 12/16/22. The controlled medication roxanol was ordered for the patient. The agency's drug disposal policy was not provided to the patient on admission or when the medication was started on 12/16/22. The Director of Nursing and administrator were interviewed during joint review of the clinical record on 2/20/23. They confirmed that the agency did not have evidence that the agency's policy on controlled drug disposal was provided to patients. During the interview the administrator stated that she was not aware that the agency's policy needed to be provided to the patients.