Every finding on record at Beaumont Ashn, LLC

Based on observation, interview and record review, the agency failed to provide written notice of rights and responsibilities, during the initial assessment visit, prior to furnishing services to 1 (P-1) of 6 patients observed during a home visit, from a total of 27 sampled records reviewed.  Findings include: --- Patient #1 (P-1) was admitted to hospice on 5/21/25.  The benefit period of review was 9/18/25 through 11/12/25 with a terminal diagnosis of Senile Degeneration of the Brain.  During the record review on 11/4/25, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Hospice Aide (HHa) and Medical Social Work (MSW) services to be provided.On 11/4/25 a scheduled survey home visit was conducted with the Medical Social Worker (MSW #1).  During the visit, a request was made to review P-1's admission/consent documents.  Upon review of the admission packet, there was no consent form available for review. MSW #1 asked the Group Home liaison of its whereabouts and was instructed to look in the patient's blue folder.  MSW #1 walked away to look in the blue folder as suggested.  Upon return, MSW #1 reported, "It's not in there."  The agency failed to ensure the patient was informed of her rights, verbally and in writing, prior to the provision of services.The Executive Director reviewed and acknowledged these findings during an interview on 11/7/25 at 9:15 a.m.

Based on record review and interview, the agency failed to ensure the physician was notified of severe drug interactions and took them into consideration when creating the patients' plan of care in 7 (P-7, P-9, P-12, P-21, P-23, P-24, and P-27) of 7 records with identified interactions, from a total of 27 sampled records reviewed, resulting in the potential for harm to the patients from adverse medication interactions. Findings include: --- Patient #21 (P-21) was admitted to this hospice agency on 1/10/25 with the terminal diagnosis of a malignant neoplasm of the stomach (stomach cancer). During record review on 11/7/25, it was determined the drug interaction report performed on 1/10/25 identified 1 severe medication interaction. There was no documented evidence the physician had been notified for resolution according to agency policy.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During record review on 11/7/25, it was determined the drug interaction report performed on 6/17/25 identified 1 severe medication interaction. It was documented “benefits outweigh risk” regarding the interaction, however, there was no documentation the physician was notified to determine this.Patient #24 (P-24) was admitted to this hospice agency on 10/22/25 with the terminal diagnoses of heart failure, atrial fibrillation, and chronic kidney disease. During record review on 11/6/25, it was determined the drug interaction report dated 10/23/25 identified 1 severe medication interaction. “DR AWARE” was documented regarding the interaction, however, there was no documentation of how the physician was made aware or of the resolution determined by the physician.Patient #27 (P-27) was admitted to this hospice agency on 9/5/25 with the terminal diagnoses of congestive heart failure and hypertension (high blood pressure). During record review on 11/4/25, it was determined the drug interaction report performed on 9/6/25 identified 1 severe medication interaction. It was documented “DR AWARE” regarding the interaction, however, there was no documentation of how the physician was made aware or of the resolution determined by the physician.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. Patient #12 (P-12) was admitted to hospice on 7/11/25 with terminal diagnoses that included malnutrition and dementia. On 11/06/25, a review of the agency's "Drug Interaction Report" was reviewed for P-12. This report noted 3 severe drugs to drug interactions, but additional review found no evidence that the physician had been notified. The findings were acknowledged by the Executive Director (ED #1) during an interview on 11/12/25 at 4:15 p.m. Policy: OP-085 HOS, Medication Management, 9/7/2022 stated, "All medications, including over the counter, herbal supplements, nutritional supplements, vitamins and minerals are to be included. Any discrepancy or contraindication will be reported to the physician for resolution."  Patient #7 (P-7) was admitted to hospice on 10/17/25 with terminal diagnoses that included Protein Calorie Malnutrition and Congestive Heart Failure.  During the record review on 11/12/25 at 8:55 a.m., the agency’s “Drug Interactions” report was reviewed.  The report revealed that severe drug to drug interactions had been identified. Upon further review, there was no documented evidence that the Physician had been notified.  The Executive Director (ED #1) reviewed and acknowledged these findings during an interview on 11/23/25 at 3:25 p.m.P-9 was admitted to hospice on 10/28/25 with a terminal diagnosis of Combined Chronic systolic/Diastolic Heart Failure.  On 11/12/25 at 12:05 p.m., the agency's "Drug Interactions" report was reviewed.  The report revealed that severe drug to drug interactions had been identified.  Upon further review, there was no documented evidence that the Physician had been notified.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:39 p.m.

Based on observation, record review, and interview, the hospice failed to ensure the comprehensive assessment included an initial bereavement assessment in 20 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-12, P-13, P-14, P-20, P-22, P-23, P-24, P-25, P-26, and P-27) of 27 records that required a bereavement assessment, from a total sample of 27 sampled records reviewed, resulting in the potential for ineffective grieving and lack of bereavement support for the family members and caregivers upon the patient's death. Findings included: --- Patient #20 (P-20) was admitted to this hospice agency on 9/30/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 11/12/25, it was determined the initial bereavement assessment identified P-20’s daughter/caregiver as the only individual who would need bereavement services after P-20’s death. Upon further review of the record, it was noted the medical social work evaluation dated 10/2/25 indicated P-20 had 2 sons and 2 other daughters. There was no documentation regarding why P-20’s other children were not assessed.Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was determined the initial bereavement assessment identified P-22’s 2 sons as individuals who would need bereavement services after P-22’s death. Upon further review of the record it was noted the spiritual care noted dated 4/10/25 indicated a call was placed to P-22’s daughter to confirm a visit. There was no documentation regarding why P-22’s daughter was not assessed.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During record review on 11/7/25, it was determined P-23’s spouse and 1 son were identified as individuals who would need bereavement services after P-23’s death. Upon further review of the record, it was determined a pre-admission note dated 6/16/25 indicated another son and his wife would be present at the admission the following day. There was no documentation regarding why P-23’s son and wife were not assessed.Patient #24 (P-24) was admitted to this hospice agency on 10/22/25 with the terminal diagnoses of heart failure, atrial fibrillation, and chronic kidney disease. During record review on 11/6/25, it was determined P-24’s son was the only individual identified who would need bereavement services after P-24’s death. Upon further review of the record, it was noted the medical social work note dated 10/24/25 indicated P-24 had a daughter who was listed as the preferred person for communication. There was no documentation regarding why P-24’s daughter was not assessed.Patient #25 (P-25) was admitted to this hospice agency on 2/13/25 with the terminal diagnosis of metastatic melanoma with metastasis to the lungs (skin and lung cancer). During record review on 11/6/25, it was determined the initial bereavement assessment identified P-25’s spouse and 1 son as individuals who would need bereavement services after P-25’s death. Upon further review of the record, it was determined paperwork for power of attorney (POA) listed a daughter as a back up to P-25’s spouse. Additionally, the medical social work evaluation dated 2/20/25 indicated P-25 had 7 children (1 deceased). There was no documentation regarding why P-25’s other children were not assessed.Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During record review on 11/5/25, it was determined the initial bereavement identified P-26’s daughter (who was also her durable power of attorney) as the only individual who would need bereavement services after P-26’s death. Upon further review of the record, it was noted the medical social work evaluation dated 9/8/25 indicated P-26 had “2 adult dtrs and one adult son who lives out of state.” [sic] There was no documentation regarding why P-26’s other children were not assessed.Patient #27 (P-27) was admitted to this hospice agency on 9/5/25 with the terminal diagnoses of congestive heart failure, and hypertension (high blood pressure). During record review on 11/4/25, it was determined the initial bereavement assessment identified a son and daughter-in-law who would need bereavement services after P-27’s death. During a joint home visit with the chaplain on 11/4/25 at 1:30 PM, P-27 was talking about her family and indicated she had 6 children in total – 3 of her own and 3 step children who were close to her. In addition, P-27 spoke of a friend in her apartment building who came down regularly to take her to events in the building or to assist her with other tasks. There was no documentation in the record regarding why P-27’s other children or friend were not assessed.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. Patient #10 (P-10) was admitted to hospice on 11/3/25 with terminal diagnosis of ovarian cancer. On 11/04/25, the comprehensive assessment was reviewed, and it documented that a bereavement assessment had been completed. Upon review of the bereavement assessment dated 11/4/25, it was discovered that P-10's son was assessed for bereavement risks, but P-10's daughter and son-in-law were not. There was no documented explanation in the record as to why P-10's daughter and son-in-law were not assessed for bereavement risks.Patient #12 (P-12) was admitted to hospice on 8/8/25 with terminal diagnoses that included malnutrition and dementia. On 11/06/25, the comprehensive assessment was reviewed, and it documented that a bereavement assessment had been completed. Upon review of the bereavement assessment dated 11/4/25, it was discovered that only 1 of P-12's 2 daughters had been assessed for bereavement risks. There was no documented explanation in the record as to why only 1 of P-12's daughters were assessed for bereavement risks.Patient #13 (P-13) was admitted to hospice on 12/21/23 with terminal diagnoses that included respiratory failure and congestive heart failure. On 11/06/25, the comprehensive assessment was reviewed, and it documented that a bereavement assessment had been completed. Upon review of the bereavement assessment note dated 11/4/25, it was discovered that only P-13's spouse had been assessed for bereavement risks. P-13's 3 adult children, daughter-in-law, and 4 grand children had been assessed for bereavement risks. There was no documented explanation in the record as to why P-13's 3 adult children, daughter-in-law, and 4 grand children had not been assessed for bereavement risks.Patient #14 (P-14) was admitted to hospice on 2/8/24 with terminal diagnosis of breast cancer. On 11/12/25, the comprehensive assessment was reviewed, and it documented that a bereavement assessment had been completed. Upon review of the bereavement assessment dated 4/9/25, it was discovered that P-14's mother was assessed for bereavement risks, but P-14's husband was not. There was no documented explanation in the record as to why P-14's husband was not assessed for bereavement risks.During an interview on 11/12/25 at 4:15 p.m., the Executive Director (ED #1) acknowledged the above findings.  Patient #1 (P-1:) was admitted to hospice on 5/21/25. The benefit period of review was 9/18/25 through 11/16/25 with a terminal diagnosis of Senile Degeneration of the Brain.  On 11/4/25 at 1:50 p.m., during a review of the Initial Bereavement Assessment (BA) dated 5/22/25, it was noted that the social worker only listed the patient’s daughter as the person who would be affected by the patient’s death.  On 11/4/25 during a scheduled survey home visit with the Medical Social worker (MSW #1), the patient and MSW #1 discussed additional family members which included the patient’s grandchildren, daughter-in-law and another daughter.  None of the above-mentioned family members were included in the Initial BA.  The Executive Director (ED #1) reviewed and acknowledged these findings during an interview on 11/7/25 at 9:15 a.m. P-2 was admitted to hospice on 5/19/23 with a terminal diagnosis of Alzheimer's Disease. On 11/5/25 at 9:00 a.m., during a review of the clinical record, the patient’s contacts listed a cousin, niece, sister and caregiver.  A clinical note dated 5/19/23 documented the patient had 2 sisters and 2 brothers.  The initial BA provided by ED #1, identified the patient’s sister as the only person who would be affected by the patient’s death. ED #1 reviewed and acknowledged these findings during an interview on 11/7/25 at 9:20 a.m. P-3 was admitted to hospice on 11/6/24 with a terminal diagnosis of Malignant Neoplasm of the Lung.  On 11/5/25 at 12:15 p.m., a referral dated 11/6/24 listed the patient’s common law spouse and 2 nieces. The BA only listed one of the patient’s nieces and the common law spouse.  The BA failed to include all who would be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/7/25 at 9:26 a.m. P-4 was admitted to hospice on 10/24/24 with terminal diagnoses that included Cirrhosis of the Liver, Ascites and Chronic Kidney Disease.  During the record review on 11/6/25, it was noted that the patient passed away on 11/4/24.  The BA dated 10/29/24 identified the patient’s husband as the bereaved.  The Discharge-Transfer summary Report dated 11/4/24 revealed the patient had one son, a daughter and a spouse.  The BA failed to include all who would be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/7/25 at 9:30 a.m. P-5 was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructive Pulmonary Disease.  During the record review on 11/7/25 at 11:05 a.m., it was noted that the patient passed away on 4/11/25.  During the review, it was noted that the patient had 2 daughters.  The BA only identified one of the patient’s daughters.  The BA failed to include all who would be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:12 p.m. P-6 was admitted to hospice on 10/23/24 with terminal diagnoses that included Stroke and Acute Respiratory Failure.  The patient’s contact list indicated the patient had 2 sons, 2 daughters and 1 granddaughter.  The BA failed to include one of the patient’s sons and daughter as persons who would be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:28 p.m. P-7 was admitted to hospice on 10/17/25 with terminal diagnoses that included Protein Calorie Malnutrition and congestive Heart Failure.  During the record review on 11/12/25 at 8:55 a.m. it was noted that the Medical Social Worker (MSW) initial assessment dated 10/20/25 stated, “Patient had 4 children.”  The BA dated 10/20/25 listed the patient’s girlfriend as the bereaved. The BA failed to indicate all parties who would be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:25 p.m. P-8 was admitted to hospice on 10/28/25 with terminal diagnoses that included Lung Cancer and Cancer of the Liver and Bile Duct.  During the record review on 11/12/25, it was noted that the patient’s contact list listed the patient’s son and 2 daughters-in-law.  A MSW note dated 11/7/25 documented, “Patient has 3 sons and 2 stepsons.” The BA dated 10/28/25 only identified one of the patient’s sons as the person to be affected by the patient’s death. ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:35 p.m. P-9 was admitted to hospice on 10/28/25 with a terminal diagnosis of Chronic Combined Systolic/Diastolic Heart Failure.  During the record review on 11/12/25 at 12:00 p.m., it was noted that the patient’s contact list revealed the patient had 2 daughters and a son.  The BA dated 11/4/25 only identified one of the patient’s daughters and his son as the persons to be affected by the patient’s death.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:39 p.m.

Based on record review and interview, the Hospice failed to ensure the plan of care was clear, current, accurate and addressed the individualized needs of the patients for 10 (P-7, P-8, P-9, P-19, P-20, P-22, P-23, P-24, P-26, P-27) of 27 records reviewed, resulting the potential for unidentified, untreated health concerns, unmet care needs and poor patient outcomes.  Findings include: --- Patient #19 (P-19) was admitted to this hospice agency on 9/29/25 with the terminal diagnoses of a malignant neoplasm of the lung and a secondary malignant neoplasm of the brain (lung and brain cancer). During record review on 11/12/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.Patient #20 (P-20) was admitted to this hospice agency on 9/30/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 11/12/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care. Additionally, the plan of care ordered 2 liters of oxygen PRN (as necessary), however, failed to include oxygen under safety precautions.Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During record review on 11/7/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.Patient #24 (P-24) was admitted to this hospice agency on 10/22/25 with the terminal diagnoses of heart failure, atrial fibrillation, and chronic kidney disease. During record review on 11/6/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During record review on 11/5/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.Patient #27 (P-27) was admitted to this hospice agency on 9/5/25 with the terminal diagnoses of congestive heart failure, and hypertension (high blood pressure). During record review on 11/4/25, it was determined all items under “Orders of Discipline and Treatments” were written in past tense as if they had already occurred/been completed. There were no active interventions for needs going forward included on the plan of care.  Additionally, the plan of care ordered 4 liters of oxygen continuously, however, failed to include oxygen under safety precautions.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. Patient #7 (P-7) was admitted to hospice on 10/17/25 with terminal diagnoses that included Protein Calorie Malnutrition and Congestive Heart Failure. During the clinical record review on 11/12/25 at 8:55 a.m., it was noted that the Plan of Care (POC) listed the patient’s 9 diagnoses as having exacerbated on the same date of admission to hospice (10/17/25).  Additionally, all the hospice interventions listed under “Orders of Discipline and Treatments” were written in past tense as if they (interventions) had already been completed, such as, “educated on the role of the hospice nurse.”  There were no current interventions that instructed the disciplines on the needs of the patient going forward. The Executive Director (ED #1) reviewed and acknowledged these findings during an interview on 11/12/25 at 3:25 p.m.P-8 was admitted to hospice on 10/28/25 with terminal diagnoses that included Lung Cancer and Cancer of the Liver and Bile Duct.  During the clinical record review on 11/12/25, it was noted that the POC reflected that all 11 of the patient’s diagnoses exacerbated on the date of admission (10/28/25).  Additionally, all the hospice interventions listed under “Orders of Discipline and Treatments” were written in past tense as if they had already been completed, such as, “educated patient and caregiver on the role of bereavement services…, reviewed routine level of care services with patient and caregiver….” There were no current interventions that instructed staff on the needs of the patient going forward. ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:35 p.m.P-9 was admitted to hospice on 10/28/25 with a terminal diagnosis of Chronic combined Systolic/Diastolic Heart Failure.  During the record review on 11/12/25 at 12:00 p.m., it was noted that the POC indicated that all 7 of the patient’s diagnoses exacerbated on the same date of admission to hospice (10/28/25).  Further, all the hospice interventions listed under “Orders of Discipline and Treatments” were written in past tense as if the tasks had already been completed, such as, “educated patient and caregiver on the role of bereavement services, hospice aide plan of care was established…”   There were no current interventions that instructed staff on the needs of the patient going forward. ED #1 reviewed and acknowledged the above findings during an interview on 11/12/25 3:39 p.m.

Based on record review and interview, the hospice failed to develop a patient centered plan of care that included specific interventions for pain and symptom management for 3 (P-7, P-8, P-9) of 3 records reviewed for appropriate pain and symptom management, from a total of 27 sampled records reviewed, resulting in the potential for unrelieved pain and poor symptom management.  Findings include: --- Patient #7 (P-7) was admitted to hospice on 10/17/25 with terminal diagnoses that included Protein Calorie Malnutrition and Congestive Heart Failure. The Plan of Care (POC) ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided.  During the record review on 11/12/25 at 8:55 a.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, that included alternative interventions to manage pain and symptomology during the end of life. The Executive Director (ED #1) reviewed and acknowledged these findings during an interview on 11/12/25 at 3:25 p.m.P-8 was admitted to hospice on 10/28/25 with terminal diagnoses that included Lung Cancer and Cancer of the Liver and Bile duct.  The POC ordered SN, HHa, SC and MSW services to be provided.  During the record review on 11/12/25, it was noted that the POC was void of interventions to monitor, assess and treat pain, that included alternative interventions to manage pain and other symptomology during the end of life. ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:35 p.m.P-9 was admitted to hospice on 10/28/25 with a terminal diagnosis of Chronic Combined Systolic/Diastolic Heart Failure.  During the clinical record review on 11/12/25 at 12:00 p.m., it was noted that the POC was void of interventions to monitor, assess and treat pain, that included alternative interventions to manage pain and other symptomology during the end of life. ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:39 p.m.

Based on record review and interview, the agency failed to ensure the plan of care included necessary medical supplies to meet the needs of the patient for 2 (P-19 and P-23) of 27 records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient #19 (P-19) was admitted to this hospice agency on 9/29/25 with the terminal diagnoses of a malignant neoplasm of the lung and a secondary malignant neoplasm of the brain (lung and brain cancer). During record review on 11/12/25, it was noted the plan of care indicated P-19 “HAS AND IS USING OXYGEN PER ORDERS, OXYGEN PRECAUTIONS.” [sic] However, it was the determined the “DME and Supplies” section of the plan of care failed to include oxygen supplies.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During record review on 11/7/25, it was noted the “DME and Supplies” section on the plan of care noted the following:“DME-BED/CHAIR ALARM; DME-BINDER; DME-BRODA CHAIR; DME-CANE; DME-COMMODE; DME-CRUTCHES; DME-DIALYSIS SUPPLIES; DME-FALL MATS; DME-GLUCOMTER; DME-HOSPITAL BED; DME-INCENTIVE SPIROMETER; DME-LIFT; DME-LOW VISION SUPPLIES; DME-ORTHOTICS; DME-OXYGEN SUPPLIES; DME-PODIS BOOT; DME-PUMP/MONITORS; DME-QUAD CANE; DME-RAILS/GRAB BARS; DME-RESPIRATORY SUPPLIES; DME-ROHO W/C CUSHION; DME-SCOOTER; DME-SHOWER/TUB EQUIPMENT; DME-SUCITON; DME-SUPPORT SURFACES; DME-SUPPORT BRACES; DME-TABLE/CHAIR; DME-TENS UNIT; DME-TRANSFER BENCH; DME-TRAPEPZE; DME-VITAL SIGNS EQUIPMENT; DME-WALKER; DME-WALKER-HEMI; DME-WALKER-ROLLING; DME-WHEELCHAIR; DME-WHEELCHAIR-POWERED; DRESSING FOAM; EMPLOYEE SUPPLIES/PPE; GLOVES; INCONTINENT CARE DISPOSABLE; PERSONAL CARE/OTHER; PERSONAL PROTECTION; RESPIRATORY SUPPLIES; SKIN CARE.”According to the information in the initial comprehensive assessment, P-23 was a full assist with a hoyer lift (a mechanical lift used to lift patients who cannot assist), therefore, he would not need the mobility equipment. P-23 was also not on dialysis and was not diabetic, therefore would not need the glucometer or dialysis supplies. Additionally, it was noted the plan of care included continuous oxygen at 3 liters, however, the supplies section failed to include oxygen equipment. During an interview with ED #1 on 11/12/25 at 1:45 PM, ED #1 was asked about the documentation above regarding P-23. ED #1 stated it appears that was documented in error as she agreed the patient would not need all the supplies listed. ED #1 acknowledged the findings at the time of interview.

Based on observation, record review and interview, the agency failed to ensure accepted infection control standards of practice for 2 (P-5 and P-26) of 7 patients, from a total of 27 sampled records reviewed and 6 home visits, resulting in the potential for the development and spread of infection.  Findings include: --- A review of agency policy titled “Hand Hygiene” (last reviewed 9/22/25) revealed staff will “…regularly wash their hands per the most recent published CDC regulations and guidelines for hand hygiene in healthcare settings. This includes, but is not limited to:…Before entering the clean section of the visit bag (if applicable).”Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During a joint home visit with the licensed practical nurse (LPN #1) on 11/5/25 at 11:00 AM, LPN #1 was observed touching the patient during assessment then entering the clean section of her bag to retrieve additional equipment 3 times without performing hand hygiene first. Additionally, LPN #1 was observed using her “dirty” hands to retrieve a pen and paper from her pocket to record vitals, returning the pen and paper to her pocket, then continuing to assess the patient 2 times without performing hand hygiene.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. Policy: QA-043 Standard Precautions, 9/7/22 stated, "All Clinical Agency Staff are responsible for knowing and adhering to this policy.  Agency personnel will adhere to the following precautions and will instruct patient and families/caregivers in infection control precautions as appropriate to the patient's care needs.  3. Sharps: Needles, Syringes and Sharps: After use, needles and other sharps will be placed directly into a puncture-proof container. Needles must not be recapped, bent, broken or clipped." Patient #5 (P-5) was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructive Pulmonary Disease.  The Plan of Care (POC) ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided.  The clinical record was reviewed on 11/7/25 at 11:05 a.m.  A "Coordination Note" dated 3/8/25 documented, "03/08/2025 HOSPICE TRIAGE ONCALL (Nurse's Name) RN, TRIAGE - HOSPICE Active Last Update Last Updated By Note CALLER NAME/RELATION:  DAUGHTER PATIENT IDENTIFIERS PROVIDED (LIST TWO): NAME/DOB SITUATION: 1105 - P-5's DAUGHTER STATES SHE GAVE MORPHINE LAST NIGHT TO P-5 AND SHE DID REALLY WELL WITH IT, SHE ONLY HAS 2 SYRINGES TO DRAW MORPHINE UP AND WANTS TO KNOW IF THOSE CAN BE REUSED. TRIAGE NURSE ADVICE: I DID LET HER KNOW SHE CAN REUSE THOSE, RECOMMENDED THAT SHE JUST RINSE AND DRY IT BETWEEN USES AND ASKED HER TO LET HER RNCM (Registered Nurse Case Manager) KNOW IF SHE WOULD LIKE HER TO ORDER A FEW MORE AT NEXT VISIT. PLAN: NO ADDITIONAL NEEDS AT THIS TIME. NURSE VISIT REQUIRED: NO.” [sic]The Executive Director reviewed and acknowledged the above findings during an interview on 11/12/25 at 3:12 p.m. and responded, "This is not acceptable. We should have sent a nurse out to the home with syringes to draw up some new ones."

Based on record review and interview, the agency failed to ensure the Registered Nurse followed up on patient care concerns and performed assessments in a timely manner for 1 (P-5) of 1 patient who voiced concerns during the end of life, from a total of 27 sampled records reviewed.  Findings include: --- Patient #5 (P-5) was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructive Pulmonary disease.  A review of the clinical record on 11/7/25 at 11:05 a.m., revealed the following: Coordination note 4/8/25: stated, patient’s daughter is “asking for a call back as the spots on mom’s forehead that you took a picture of doesn’t look good.”Coordination note 4/8/25: patient “keeps throwing up and daughter doesn’t know what to do…”Coordination note 4/8/25: Triage nurse stated, “Spoke with daughter on multiple occasions today…, patient with increased anxiety today.”Coordination note 4/9/25: “Patient states she is having severe back pain. Triage nurse advised give pain meds.”Coordination note 4/9/25: “Patient states she is still having severe pain in her back despite medication.” Coordination note 4/9/25: Nurse visit made. On 11/12/25 at 3:12 p.m., during an interview, the Executive Director (ED #1) was queried about the timeliness of responding to the patient’s care concerns and reported, “I remember this because we couldn’t get ahold of our midnight nurse. She wasn’t answering her phone, so I had to call her personal phone. She (nurse) ended up going. There was a nurse follow-up on 4/9/25 but that was not appropriate. We should have dispatched a nurse to the patient’s home on the 8th when she (patient) called 3 times.”  The nurse failed to follow up on patient care concerns in a timely manner.ED #1 reviewed and acknowledged the above findings during the above interview.

Based on record review and interview, the agency failed to ensure medical social work services provided timely follow-up in 1 (P-22) of 27 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: --- Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was noted a coordination note documented that somebody from adult protective services (APS) called on 4/22/25 and requested to speak with the social worker regarding the patient. Upon further review of the record, it was determined the social worker did not return the call from APS until 5/2/25 - 10 days after the phone call was made. The agency failed to ensure social work provided timely follow-up for a potentially negative situation for this patient.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.

Based on record review and interview, the hospice failed to make bereavement services available to all of the bereaved family members who would be affected by the patient's death, and failed to complete a bereavement plan of care that reflected the needs of each bereaved family member, the kind of bereavement services to be offered and the frequency of service delivery in 3 (BRV #13, 14, 15) of 4 bereavement records reviewed, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: --- Bereavement Record #13 (BRV #13): BRV #13 was admitted to hospice on 12/21/23 with a terminal diagnosis of failure to thrive. A review of the clinical record on 11/7/25, revealed the patient expired on 12/24/23. A Bereavement note dated 1/29/24, conducted by the bereavement counselor (BC #1), revealed that BRV #13 was survived by "Husband, 3 adult children, and 4 grandchildren." There were no Bereavement Care Plans documented in the record for BRV #13's 3 adult children or 4 grandchildren. The hospice failed to ensure a Bereavement Plan of Care was developed for BRV #13's 3 adult children and 4 grandchildren that reflected and addressed their individualized bereavement needs.Bereavement Record #14 (BRV #14): BRV #14 was admitted to hospice on 2/8/24 with a terminal diagnosis of breast cancer. A review of the clinical record on 11/5/25, revealed the patient expired on 2/8/24. A Bereavement note dated 2/28/24, conducted by the bereavement counselor (BC #1), revealed that BRV #14 was survived by "Husband and mother." There was no Bereavement Care Plan documented in the record for BRV #14's husband. The hospice failed to ensure a Bereavement Plan of Care was developed for BRV #14's husband that reflected and addressed his individualized bereavement needs.Bereavement Record #15 (BRV #15): BRV #15 was admitted to hospice on 4/8/25 with a terminal diagnosis of colon cancer. A review of the clinical record on 11/6/25, revealed the patient expired on 4/17/25. A Bereavement note dated 7/12/25, conducted by the bereavement counselor (BC #1), revealed that BRV #15 was survived by "Wife, 3 adult children, and 2 grandchildren." There were no Bereavement Care Plans documented in the record for BRV #14's 3 adult children or 2 grandchildren. The hospice failed to ensure a Bereavement Plan of Care was developed for BRV #15's 3 adult children and 2 grandchildren that reflected and addressed their individualized bereavement needs.The Executive Director (ED #1) reviewed and acknowledged the above findings during an interview on 11/12/25 at 4:15 p.m.

Based on record review and interview, the Hospice failed to ensure that individuals who furnished Hospice Aide services on its behalf, only did so after successfully completing a competency evaluation by a Registered Nurse (L615); failed to ensure its hospice aides received at least 12 hours of annual in-service training (L620); failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient and included patient care equipment and safety precautions (L625); failed to ensure the hospice aide provided care and services as ordered in the plan of care (L626); the hospice aide failed to communicate missed visits and changes in patient condition to the Nurse Manager (L628); failed to ensure the Registered Nurse made on-site visits to the patient's home no less than every 14 days to assess the adequacy of aide services and failed to identify who was being supervised during supervisory visits (L629); failed to provide documented evidence to ensure the skilled discipline made an annual onsite visit to the patient's residence to observe the care being provided by the hospice aide (L632). --- .

Based on record review and interview, the Hospice failed to ensure that individuals who furnished Hospice Aide services on its behalf, only did so after successfully completing a competency evaluation by a Registered Nurse for 3 (HHa #1, HHa #2, HHa #3) of 3 hospice aides, resulting in the potential for the rendering of substandard care, unmet care needs and poor patient outcomes.  Findings include: --- On 11/6/25 at 9:30 a.m., the Executive Director (ED #1) was asked for permission to review the initial competency evaluations for 3 hospice aides (HHa #1, HHa #2, HHa #3) whose files were selected for review.  ED #1 was unable to provide the requested documentation.  The agency failed to ensure its hospice aides were deemed competent prior to the provision of care and services.  ED #1 acknowledged the above findings at the time of discovery.

Based on record review and interview, the hospice failed to ensure its hospice aides received at least 12 hours of annual in-service training for 3 (HHa #1, HHa #2, HHa #3) of 3 aides employed by the agency, resulting in the lack of education pertinent to hospice aide services and the needs of the patients.  Findings include: --- On 11/6/25 at 9:30 a.m., the Executive Director (ED #1) was asked for permission to review the personnel files for 3 hospice aides (HHa #1, HHa #2, HHa #3).  ED #1 provided a typed document titled "HHA INSERVICE EDUCATION 2025."  No information was provided for previous years.  The document reflected a list of hospice aides.  Further, the document was void of content and exact dates in which in-services were reported to have been provided.  Additionally, the document was void of staff signatures and void of a Registered Nurse's signature that verified oversight.  There was no way to ascertain which, if any of the listed in-services had actually been provided.  ED #1 reviewed and confirmed these findings during the above interview.

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned hospice aide provided specific guidance and care instructions on the needs of the patient and included patient care equipment and safety precautions for 13 (P-1, P-2, P-5, P-7, P-9, P-12, P-19, P-20, P-22, P-23, P-24, P-26, P-27) of 13 records with hospice aide services ordered, from a total of 27 sampled records reviewed, resulting in the provision of substandard care, patient injury and unmet care needs.  Findings include: --- Patient #19 (P-19) was admitted to this hospice agency on 9/29/25 with the terminal diagnoses of a malignant neoplasm of the lung and a secondary malignant neoplasm of the brain (lung and brain cancer). During record review of the plan of care on 11/6/25, it was noted P-19 used oxygen and was on "complete bedrest." Upon further review of the record, it was determined the aide care plan failed to include the use of oxygen or any safety precautions regarding oxygen or the patient being on bedrest. Additionally, it was noted the aide care plan included interventions for “routine catheter care” and to “empty urinary drainage bag” for the catheter every visit. Upon further review of hospice aide notes dated 10/23/25, 1030/25, 11/3/25, and 11/6/25, it was noted catheter care was not performed as the patient no longer had a catheter according to the documentation. The agency failed to ensure the hospice aide plan of care was up to date and specific to this patient.Patient #20 (P-20) was admitted to this hospice agency on 9/30/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During review of the plan of care on 11/12/25, it was noted P-20 used oxygen, used a walker and a wheelchair, and was under fall precautions. Upon further review of the record, it was determined the aide care plan failed to include the use of oxygen, the use of any mobility equipment, or any safety precautions regarding oxygen or falls.Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During review of the plan of care on 11/7/25, it was noted P-22 used oxygen, had pets in the home, and was under fall precautions. Upon further review of the record, it was determined the aide care plan failed to include use of oxygen or safety precautions regarding oxygen use, pets in the home, or falls.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During review of the plan of care on 11/7/25, it was noted P-23 used oxygen, was under fall precautions, and had a wide variety of mobility equipment. During further review of the record, it was determined the aide care plan failed to include use of oxygen, use of mobility equipment, or safety precautions regarding oxygen use or falls.Patient #24 (P-24) was admitted to this hospice agency on 10/22/25 with the terminal diagnoses of heart failure, atrial fibrillation, and chronic kidney disease. During review of the plan of care on 11/6/25, it was noted P-24 used oxygen. Upon further review of the record, it was determined the aide care plan failed to include safety precautions for oxygen use.Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During review of the plan of care on 11/5/25, it was noted P-26 was on complete bed rest and was not allowed to ingest anything by mouth (NPO). Upon further review of the record, it was determined the aide are plan failed to include safety precautions regarding bed rest or the NPO order.Patient #27 (P-27) was admitted to this hospice agency on 9/5/25 with the terminal diagnoses of congestive heart failure, and hypertension (high blood pressure). During review of the plan of care on 11/4/25, it was noted P-27 used oxygen, used a walker or wheelchair, and was under fall precautions. Upon further review of the record, it was determined the aide care plan failed to include use of oxygen, use of equipment, or safety precautions regarding oxygen or falls.The executive director (ED #1) reviewed the findings and acknowledged there is no place on the aide care plan to document safety precautions, use of equipment, or additional care instructions during an interview on 11/12/25 at 1:45 PM.  Patient #12 (P-12): The start of care (SOC) date was 8/8/25, with diagnoses of malnutrition, gastroesophageal reflux disease, and dementia. During record review on 11/6/25, it was discovered that the plan of care (POC) ordered oxygen therapy and home health aide services. The aide care plan dated 8/8/25 failed to include oxygen precautions. During an interview on 11/12/25 at 4:15 p.m., the Executive Director (ED #1) acknowledged the above findings. Patient #1 (P-1) was admitted to hospice on 5/21/25 with a terminal diagnosis of Senile Degeneration of the Brain.  During the clinical record review on 11/4/25 at 1:50 p.m., it was noted that the plan of care (POC) order hospice aide services to be provided at a frequency of 1x/wk. x 9 wks.  The recertification plan of care revealed the patient used oxygen, required a wheelchair and ambulated with the assistance of a walker.  The aide care plan was void of the above medical equipment, oxygen use and any additional safety precautions.  The Executive Director (ED #1) reviewed and acknowledged the above findings during an interview on 11/7/25 at 9:15 a.m. P-2 was admitted to hospice on 5/19/23. The benefit period of review began 10/5/25 with a terminal diagnosis of Alzheimer’s Disease. During the record review on 11/5/25 at 9:00 a.m., it was noted that the POC ordered hospice aide services to be provided at a frequency of 2x/wk. x 12 wks., 1x/wk. x 1 wk.  The POC dated 10/5/25 revealed the patient had a hospital bed, oxygen and wound care supplies, on fall precautions and required supervision to promote safety awareness.  The aide care plan was void of any of the aforementioned medical equipment and safety precautions.  ED #1 reviewed and acknowledged these findings during an interview on 11/7/25 at 9:20 a.m. P-5 was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructive Pulmonary Disease.  During the record review on 11/7/25 at 11:05 a.m., it was noted that the POC ordered hospice aide services to be provided at a frequency of 1x/wk. x 14 wks. The POC revealed the patient had fall precautions and required the use of oxygen.  The aide care plan did not include oxygen or fall precautions.  ED #1 reviewed and acknowledged the above findings during an interview on 11/12/25 at 3:12 p.m. P-7 was admitted to hospice on 10/17/25 with terminal diagnoses that included Protein Calorie Malnutrition and Congestive Heart Failure. The record review conducted on 11/12/25 at 8:55 a.m. revealed that hospice aide services were to be provided at a frequency of 1x/wk. x 13 wks.  The POC revealed the patient was on fall precautions, had a hospital bed, a cardiac defibrillator, oxygen, a walker, wheelchair and wound care supplies.  The aide care plan was void of the above equipment and safety precautions.  ED #1 reviewed and acknowledged these findings during an interview on 11/12/25 at 3:25 p.m. P-9 was admitted to hospice on 10/28/25 with a terminal diagnosis of Chronic Combined systolic and diastolic Heart Failure. The record review conducted on 11/12/25 at 12:00 p.m. revealed that hospice aide services were to be provided at a frequency of 1x/wk. x 13 wks.  The POC revealed the patient had fall precautions, used a wheelchair for mobility, a bed/chair alarm, bedside commode and oxygen.  The aide care plan was void of the aforementioned medical equipment and safety precautions. ED #1 reviewed and acknowledged the above findings during an interview on 11/12/25 at 3:39 p.m.

Based on observation, interview and record review, the agency failed to ensure the hospice aide provided care and services as ordered in the plan of care in 5 (P-2, P-19, P-20, P-22, and P-24) of 13 records of patients ordered to receive hospice aide services, from a total of 27 records reviewed, resulting in patients not receiving services in accordance with their identified needs.  Findings include: --- Patient #19 (P-19) was admitted to this hospice agency on 9/29/25 with the terminal diagnoses of a malignant neoplasm of the lung and a secondary malignant neoplasm of the brain (lung and brain cancer). During record review on 11/12/25, it was determined the aide care plan dated 9/29/25 ordered oral care and fingernail care every visit (in addition to other tasks). Upon further review of the record, it was determined “N” (no) was marked next to oral care and fingernail care on 11/3/25 due to “not required this visit.” There was no documentation the nurse was informed that all tasks were not performed according to the plan of care.Patient #20 (P-20) was admitted to this hospice agency on 9/30/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 11/12/25, it determined the aide care plan dated 9/30/25 ordered a shower with a seat, dressing, ear care, fingernail care, foot care, hair care, oral care, skin care, and companionship every visit. Upon further review of the record, it was determined “N” (no) was marked next to multiple tasks for hospice aide visits dated 10/7/25, 10/9/25, 10/21/25, 10/28/25, 11/3/25, 11/6/25, and 11/10/25 for various reasons. Upon review of the coordination notes, it was noted the case manager was contacted by e-mail after all hospice aide visits, however, there was no documentation regarding communication that the tasks were not performed according to the plan of care.Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was determined shampoo, oral care, and empty urinary drainage bag were ordered every visit. Upon further review of the record, it was determined “N” (no) was marked next to shampoo and oral care on a hospice aide visit dated 4/10/25 and next to empty urinary drainage bag on hospice aide visits dated 4/15/25, 5/9/25, and 5/13/25. There was no documentation the nurse was informed that all tasks were not performed according to the plan of care.Patient #24 (P-24) was admitted to this hospice agency on 10/22/25 with the terminal diagnoses of heart failure, atrial fibrillation, and chronic kidney disease. During record review on 11/6/25, it was determined the aide care plan ordered shampoo and fingernail care every visit (in addition to other tasks). Upon further review of the record, it was documented the patient refused shampoo and fingernail care on 11/6/25. There was no documentation the nurse was informed that all tasks were not performed according to the plan of care.During an interview on 11/12/25 at 1:45 PM, the executive director (ED #1) was asked about the agency expectation regarding hospice aide tasks not completed according to the plan of care. ED #1 stated documentation should include what was communicated with the nurse regarding the incomplete tasks. ED #1 was unable to provide evidence of this in the examples listed above and acknowledged the findings at the time of interview. Patient #2 (P-2) was admitted to hospice on 5/19/23.  The benefit period of review began on 10/5/25 with a terminal diagnosis of Alzheimer’s Disease.  During the record review on 11/5/25 at 9:00 a.m., it was noted that the plan of care (POC) ordered hospice aide services to be provided at a frequency of 2x/wk. x 12 wks., 1x/wk. x 1 wk.The Aide Care Plan Report” dated 10/5/25 instructed the aide to complete the following tasks every visit: shampoo, bed bath, dressing, foot care, hair care, routine catheter care (Purewick urinary collection system), empty urinary drainage bag.  On 11/5/25 at 2:00 p.m., a scheduled survey home visit was conducted with the hospice aide (HHa #1).  During the visit, HHa #1 performed a complete bed bath for P-2.  Upon completion of the bath, HHa #1 called P-2’s caregiver in to perform care of the Purewick system and stated, “She (caregiver) usually does that part.”, The caregiver was also observed emptying the urinary collection container.  During the visit, HHa #1 informed this writer that the caregiver usually shampoos the patient’s hair. HHa #1 failed to perform the assigned tasks as ordered in the plan of care. A review of the “Coordination Notes” dated 10/15/25 and 10/22/25, noted that HHa #1 documented that all tasks had been completed.  There was no documented acknowledgement of failure to complete the ordered tasks.  Additionally, there was no documented evidence that HHa #1 informed the clinical manager of the tasks that had not been completed, so the aide care plan could be updated. The Executive Director reviewed and acknowledged these findings during an interview on 11/7/25 at 9:20 a.m.

Based on record review and interview, the hospice aide failed to communicate missed visits for 3 (P-5, P-20, and P-23) of 13 patients who received hospice aide services; and failed to communicate changes in patient status for 1 (P-22) of 13 patients who received hospice aide services, from a total of 27 sampled records reviewed, resulting in the patient not receiving services based on their identified needs.  Findings include: --- Patient #20 (P-20) was admitted to this hospice agency on 9/30/25 with the terminal diagnosis of unspecified protein-calorie malnutrition. During record review on 11/12/25, it was determined hospice aide services were ordered 1 time a week for 1 week and 2 times a week for 12 weeks. Upon further review of the record, it was determined the hospice aide documented missed visits on 10/17/25 and 10/30/25. There was no documentation of attempts made to reschedule these visits to meet the frequency ordered in the plan of care. In addition, there was no evidence the nurse case manager was notified.Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of the heart). During record review on 11/7/25, it was determined hospice aide services were ordered 1 time a week for 12 weeks. Upon further review of the record, it was determined P-23 did not receive a visit from the hospice aide during the week of 6/29/25. There was no documentation of the missed visit, a reason for the missed visit, attempts to reschedule the visit to meet the frequency in the plan of care, and no evidence of communication with the nurse manager.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was determined P-22 was ordered to receive hospice aide services 1 time a week for 1 week and 2 times a week for 8 weeks. Upon further review of the record, it was noted the aide care plan (dated 4/2/25) included an intervention that pain rated as 8 or higher should be reported to the physician by the nurse. Upon review of the hospice aide notes, the following was noted:Hospice aide visit note dated 4/22/25 indicated P-22 “co (complained of) leg pain.” There was no documentation of a pain rating or that this change in conditions was reported to the nurse.Hospice aide visit note dated 4/29/25 indicated “pt moans and complains during care.” There was no documentation of a pain rating or that this change in condition was reported to the nurse.Hospice aide visit note dated 5/13/25 indicated “heels soft red. Sore on bottom.” [sic] There was no documentation this change in condition was reported to the nurse.The agency failed to ensure the hospice aide reported changes in patient condition to the nurse.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.  (P-5) Policy: OP-103 HOS, Management of Missed Visits, 9/7/22 stated, “Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting.  A missed visit will be rescheduled the same week if possible.  Missed visits will be documented in the clinical record…, If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures…” P-5 was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructed Pulmonary disease.  During the record review on 11/7/25 at 11:05 a.m., it was noted that the POC ordered hospice aide services to be provided at a frequency of 1x/wk. x 14 wks.   During the clinical record review, it was noted that the aide made a visit to the patient’s home on 2/28/25 and documented that all tasks were completed by the caregiver.  A “Coordination Note” dated 2/28/25 documented “Any necessary communication for RN/CM? No.” The hospice aide documented “Missed Visits” on the following dates: 3/4/25, 3/11/25, 3/18/25, 3/25/25, 4/1/25, 4/8/25 and 4/10/25.  The missed visit documentation indicated patient/family denial of care.  The “Coordination Notes” for all the above missed visits read, “Did you speak directly with patient’s provider? No.”  There was no documented evidence that the hospice aide informed the nurse in charge of any of the aforementioned missed visits.The Executive Director (ED #1) reviewed and acknowledged these findings during an interview on 11/12/25 at 3:12 p.m.  When asked to clarify who the provider was, ED #1 stated, “It’s the RN Case Manager.”  When asked if she could determine if the hospice aide communicated any of the missed visits to the RN, ED #1 reviewed the above Coordination Notes and reported, “There is no communication to the RN.  It’s not there.”

Based on record review and interview, the Hospice failed to ensure the Registered Nurse made on-site visits to the patient's home no less than every 14 days to assess the adequacy of aide services for 1 (P-5) of 13 records in which Hospice Aide services were provided; and failed to ensure aide supervisory visit included who was being supervised in 7 (P-19, P-20, P-22, P-23, P-24, P-26, and P-27) of 13 records in which hospice aide services were provided, from a total of 27 records reviewed, resulting in the potential for the rendering of unauthorized substandard care, missed visits and the potential for unmet patient care needs.  Findings include: --- During record review from 11/5/25 through 11/12/25, it was determined Patient #19 (P-19), Patient #20 (P-20), Patient #22 (P-22), Patient #23 (P-23), Patient #24 (P-24), Patient #26 (P-26), and Patient #27 (P-27) were ordered to receive services from a hospice aide. Upon review of the registered nurse notes for records noted above, it was determined a section titled “Supervisory Functions” was used to document the supervision of hospice aides every 14 days. Upon further review of this section, it was determined the documentation failed to include the name of which hospice aide was being supervised at that time. Additionally, it was determined the skilled nursing notes for P-26 included aide supervisory notes on 9/7/25 and 9/10/25 before an aide made a visit with this patient.The agency failed to adequately document the supervision of hospice aides.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. P-5 was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructed Pulmonary disease.  During the record review on 11/7/25 at 11:05 a.m., it was noted that the Plan of Care (POC) ordered hospice aide services to be provided at a frequency of 1x/wk. x 14 wks.  During the clinical record review, it was noted that the aide made a visit to the patient’s home on 2/28/25 and documented that all tasks were completed by the caregiver.  A “Coordination Note” dated 2/28/25 documented “Any necessary communication for RN/CM? No.” The hospice aide documented “Missed Visits” on the following dates: 3/4/25, 3/11/25, 3/18/25, 3/25/25, 4/1/25, 4/8/25 and 4/10/25. A Skilled Nurse visit note dated 3/17/25 documented, “Were supervisory functions performed? Yes; Discipline of employee being evaluated: Home Health Aide; Does the aide follow the plan of care? Yes; Do the services meet the needs of the patient? Yes; Is patient/family satisfied with the care delivered? Yes.”  Upon further review of the clinical record, it was determined that the Nurse conducted a supervisory visit without having any aide services to critique.  Additionally, there were no other supervisory visits made by the Nurse to assess the adequacy of aide services or to ascertain it the aide made onsite visits to the patient’s home to render ordered care. The Executive Director reviewed and acknowledged the above findings during an interview on 11/12/25 at 3:12 p.m.  ED #1 offered no response.

Based on record review and interview, the Hospice failed to provide documented evidence to ensure the skilled discipline made an annual onsite observation visit at the patient's residence to observe the care being provided, by 2 (HHa #1, HHa #2) of 3 hospice aides whose file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs.  Findings include: --- On 11/6/25 at 9:30 a.m., the Executive Director (ED #1) was asked for permission to review documentation for the required annual onsite visit for hospice aides (HHa #1 and HHa #2).  ED #1 provided 2 documents titled “Beaumont Hospice Aide Checklist for field Experience.  Neither of the documents had been signed by the prospective hospice aides, nor had they been signed/verified/authenticated by a Registered Nurse as per this requirement. Further, there was no evidence if the hospice aides passed/failed the onsite review. The form listed “shower/tub bath and hair care/shampoo (bed and shower), however there was no clear indication of which tasks was directly observed.  Further, there was no option to assess if the aide followed the plan of care.  The hospice failed to provide sufficient documented evidence to support that an annual onsite visit had been conducted as per this requirement.  ED #1 reviewed and acknowledged the above findings at the time of discovery during the above review.

Based on record review and interview, the agency failed to ensure the duties of its hospice volunteers were reflected in the plan of care for 3 (P-5, P-22, and P-25) of 3 patients who received unauthorized volunteer services, from a total of 27 sampled records reviewed.  Findings include: --- Patient #22 (P-22) was admitted to this hospice agency on 4/2/25 with the terminal diagnosis of unspecified protein-calorie malnutrition and hypertension (high blood pressure). During record review on 11/7/25, it was determined P-22 received visits from a volunteer on 4/11/25, 5/2/25, and 5/10/25.  Upon further review of the record, it was determined the plan of care did not include volunteer services to identify the scope and frequency of visits. Although P-22 did have a volunteer plan of care, it was noted the volunteer plan of care also failed to include a visit frequency so the volunteer would know when to make visits.Patient #25 (P-25) was admitted to this hospice agency on 2/13/25 with the terminal diagnosis of metastatic melanoma with metastasis to the lungs (skin and lung cancer). During record review on 11/6/25, it was determined P-25 received visits from a volunteer on 2/25/25 and 3/6/25. Upon further review of the record, it was determined the plan of care did not include volunteer services to identify the scope and frequency of visits. Although P-25 did have a volunteer plan of care, it was noted the volunteer plan of care also failed to include a visit frequency so the volunteer would know when to make visits.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM. Policy: OP-082 HOS, Volunteer Services, 9/7/22 stated, "Purpose: to ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs. The volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care."Hospice volunteers are instructed to complete the following documentation when making Tuck-In calls to the patient's place of residence:"Tuck-In Volunteer Program:  Call Script and Documentation LogPatient’s Name _______________________ Patient’s phone number_______________Volunteer’s Name ____ _________________Spoke To ________________________________ Date:  __________       Time: _________Relationship to Patient_______________________ No Answer _____ Message left_____1.      “Hello, my name is {insert your name}. I am a volunteer with Beaumont Hospice and calling on behalf of your nurse to check on you and {insert patient’s name}. We would like to ensure you have everything that you need before the weekend and that we are providing excellent care. May I ask whom I am speaking with?”(Speak to either the patient or primary caregiver, if possible and document above)." Patient #5 (P-5) was admitted to hospice on 2/27/25 with terminal diagnoses that included Lung Cancer and Chronic Obstructive Pulmonary disease.  The plan of care ordered Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social Work (MSW) services to be provided.  During the clinical record review on 11/7/25 at 11:05 a.m., it was noted that the agency's volunteers made "Tuck-In" calls to P-5's place of residence on 3/6/25, 3/13/25 and 3/27/25.  Upon further review, there was no patient care plan or volunteer care plan in place that authorized the calls and provided instruction or guidance on the aforementioned Tuck-In calls as per this requirement. The Executive Director reviewed and acknowledged the above findings during an interview on 11/12/25 at 3:12 p.m.

Based on record review and interview, the agency failed to ensure volunteers provided administrative and/or direct patient care services equal to 5 percent of the total patient care hours provided by all paid hospice employees for 1 (2024) of 1 year reviewed. Findings include: --- A review of agency policy titled “Volunteer Services” (last revised 9/7/22) revealed, “4. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will at minimum equal 5% of the total patient care hours of paid and contracted hospice personnel. The Volunteer Coordinator will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities. “During an interview with the volunteer coordinator (VC #1) on 11/6/25 at 11:07 AM, VC #1 was asked to provide evidence of volunteer hours compared to paid employee hours. Upon review of the data provided for 2024, it was determined volunteers provided 1000.92 hours out of a total of 28,239.55 paid hospice employees hours, equaling to 3.54%. Therefore, the agency did not meet the requirement noted above.VC #1 acknowledged the findings at the time of interview. The executive director (ED #1) was also present during the interview and acknowledged the findings.

Based on record review and interview, the agency failed to ensure speech therapy services were provided to a patient in need for 1 (P-26) of 27 records reviewed, resulting in the potential for unmet care needs. Findings include: --- Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During record review on 11/5/25, it was noted a coordination note written by the skilled nurse on 9/8/25 stated the following:“WRITER SPOKE WITH FN [facility nurse] WHO IS REQUESTING [P-26] DIET ORDERS. PER LAST NOTE 9/7/25 SHE IS A PUREED DIET PER [facility doctor]. FN REQUESTING A ORDER FOR SPEECH EVAL. WRITER ADVISED THAT THIS IS NOT A HOSPICE COVERED SERVICE AND IF FACILITY WANTS ONE THEY WOULD NEED TO GET ORDERS FROM THEIR MEDICAL DIRECTOR AND IT WOULD BE FACILITY PAY. PER [facility nurse] THEY WILL NOT REQUIRE A SPEECH EVAL AT THIS TIME. FN REQUESTING A SUCTION MACHINE. WRITER PLACED ORDERS IN DME TRACK. NO FURTHER CONCERNS TODAY.”A review of agency policy titled "BTS Scope of Services Beaumont" (last revised 9/5/25) revealed, "The Agency provides hospice services that are intendent to meet the physical, psychosocial, practical, and spiritual needs of hospice patients and families/caregiver." The policy also stated, "3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which will include, as appropriate, the following services:...3.6 Therapists (physical, occupational, and speech)...".During an interview with the executive director (ED #1) on 11/12/25 at 1:45 PM, ED #1 was asked if speech therapy was a covered benefit under hospice. ED #1 stated if speech therapy was needed for an evaluation or on a short-term basis to meet the needs of the patient, the agency would contract through their home care department to coordinate a referral. There was no documentation of a speech therapy evaluation in the record.When asked about the documentation above by the nurse, ED #1 stated the nurse may have misunderstood due to the patient being in a facility. ED #1 stated that sometimes facilities have their own speech pathologist see the patient and bill the hospice after. When that was the case, the hospice would help coordinate the referral for the patient to receive the needed service. ED #1 stated it should not be an out-of-pocket expense in any situation. ED #1 acknowledged the findings at the time of interview.

Based on record review and interview, the Hospice failed to ensure a Discharge Summary that detailed the course of care provided, including symptom and pain management, was forwarded to the Physician for 1 (P-3) of 3 patients that were discharged to the community, from a total of 27 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs.  Findings include: --- Patient #3 (P-3) was admitted to hospice on 11/6/24 with a terminal diagnosis of Malignant Neoplasm of the Lung.  During the clinical record review on 11/5/25 at 12:15 p.m., it was noted that P-3 was discharged to the community by way of revocation on 11/11/24 to seek aggressive treatment.  Upon review of the "Discharge-Transfer Summary Report" dated 11/11/24, there was no documented evidence that the summary had been forwarded to the Physician, as per this requirement.  The Executive Director reviewed and acknowledged these findings during an interview on 11/7/25 at 9:26 a.m.

Based on record review and interview, the Hospice failed to ensure a Discharge Summary was completed, detailed the course of care provided, including symptom and pain management, Physician's orders and the patient's health status at the time of discharge for 2 (P-3, P-12) of 3 patients who were discharged to the community, from a total of 27 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: --- Patient #12 (P-12) was admitted to hospice on 8/8/25 with a terminal diagnosis of Malnutrition. During record review on 11/5/25, it was noted that P-12 was discharged to the community by way of revocation on 8/28/25. The "Discharge-Transfer Summary Report" dated 8/28/25, was void of a summary of care that detailed the course of care provided with treatments, responses to pain and symptom management, and the overall status of the patient at the time of discharge/revocation. The Discharge-Transfer Summary Report stated, "Status: Discharge to home or self-care. Reason: Hospice revocation. Condition: Unknown." The Executive Director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 4:15 p.m. Patient #3 (P-3) was admitted to hospice on 11/6/24 with a terminal diagnosis of Malignant Neoplasm of the Lung.  During the clinical record review on 11/5/25 at 12:15 p.m., it was noted that P-3 was discharged to the community by way of revocation on 11/11/24 to seek aggressive treatment.  The "Discharge-Transfer Summary Report" dated 11/11/24, was void of a summary of care that detailed the course of care provided with treatments, responses to pain and symptom management, and the overall status of the patient at the time of discharge/revocation, as per this requirement.  The Executive Director reviewed and acknowledged these findings during an interview on 11/7/25 at 9:26 a.m.

Based on record review and interview, the agency failed to ensure the plan of care was established and maintained in consultation with the skilled nursing facility (SNF) (L773); failed to ensure the plan of care for patients who resided at a SNF identified who was responsible for performing needed care and services (L774); failed to ensure communication between the hospice and SNF regarding orders for medications and services (L780); failed to ensure the SNF was provided with the most recent hospice plan of care, hospice election benefit form, hospice certification of terminal illness (CTI), and hospice medication information specific to each patient (L781); and failed to ensure staff at skilled nursing facilities were oriented to the hospice philosophy and how to care for patients receiving hospice services (L782). --- .

Based on record review and interview, the agency failed to ensure the plan of care was established and maintained in consultation with the skilled nursing facility (SNF) for 1 (P-26) of 1 patients with a home visit who resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- A review of agency policy titled “Coordination of Care – SNF, NF, or ICF, IID” (last reviewed 9/7/22) revealed, “4. A written plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives.  All hospice care provided must be in accordance with this plan of care.  The plan of care must:…B. Reflect the participation of the hospice, the SNF/NF or ICF/IID, and the patient and family to the extent possible.”Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During record review on 11/5/25, it was determined there was no evidence the hospice plan of care was written in consultation with the skilled nursing facility (SNF) where P-26 resided.During a joint home visit with the licensed practical nurse (LPN #1) on 11/5/25 at 11:00 AM, LPN #1 was asked to show collaboration between the skilled nursing facility (SNF) and the hospice in the plan of care. LPN #1 provided a copy of the SNF plan of care; however, it was noted it was last updated on 1/2/25 and the patient was not admitted to hospice until 9/5/25. Additionally, the SNF plan of care provided for review also failed to include evidence of consultation between the hospice and the SNF.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.

Based on record review and interview, the agency failed to ensure the plan of care for patients who resided at a skilled nursing facility (SNF) identified who was responsible for performing needed care and services for 1 (P-26) of 1 patients with a home visit who resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- A review of agency policy titled “Coordination of Care – SNF, NF, or ICF, IID” (last reviewed 9/7/22) revealed, “4. A written plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives.  All hospice care provided must be in accordance with this plan of care.  The plan of care must: A. Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions.”Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During record review on 11/5/25, it was determined the plan of care only contained interventions in past tense. There were no active interventions listed. Additionally, there was no documentation of which interventions and services would be provided by which provider (the hospice or skilled nursing facility).Following a joint home visit with the licensed practical nurse (LPN #1) on 11/5/25 at 12:00 PM, LPN #1 was asked how she knows which provider was to provide which services to the patient if it was not listed in the plan of care in the patient’s record. LPN #1 stated the SNF has their own plan of care that included all interventions and was able to provide a copy for review. During review of the SNF plan of care, it was noted there was no mention of the hospice providing any services.The agency failed to ensure the plan of care identified which provider would be responsible for which interventions and services for P-26.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.

Based on record review on interview, the agency failed to ensure communication between the hospice and skilled nursing facility (SNF) regarding orders for medications and services for 2 (P-23 and P-26) of 3 record reviewed of patients who resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- A review of agency policy titled “Coordination of Care – SNF, NF, or ICF, IID” (last reviewed 9/7/22) revealed, “6. The Company will ensure that the interdisciplinary group communicates with the SNF/NF or ICF/IID Medical Director, the patient’s attending physician, and other physicians participating in the provision of care as needed to coordinate the hospice care with the medical care provided by other physicians. “Patient #23 (P-23) was admitted to this hospice agency on 6/17/25 with the terminal diagnoses of chronic diastolic heart failure, chronic respiratory failure with hypoxia (low oxygen levels), and endocarditis (swelling of th heart). During record review on 11/7/25, it was noted a triage call from the skilled nursing facility (SNF) indicated the following:"WRITER SPOKE WITH FN [facility nurse] WHO REPORTS PT WITH COUGHING, LOTS OF PHLEGM BUILD UP. PER [facility nurse] SHE RECEIVED A CALL FROM FACILITY MED TECH REPORTING THAT [P-23] WAS HAVING DIFFICULTY SWALLOWING HIS PILLS THIS MORNING. FN [facility nurse] THINKS [P-23] MAY HAVE ASPIRATED AND WOULD LIKE A CRUSH ORDER PUT IN PLACE. HOB ELEVATED AT 45 DEGREES CURRENTLY. NURSE WILL KEEP [P-23] NPO UNTIL HOSPICE NURSE ARRIVES TODAY. NO CURRENTLY C/O SOB. LPN [LPN #1] UPDATED AND ASSIGNED TO VISIT." [sic]The licenses practical nurse (LPN #1) saw the patient later on 7/1/25 and documented the following: "[Facility nurse] WAS CONCERNED PATIENT MAY HAVE ASPIRATED. WRITER OBSERVED PATIENT EATING LUNCH WITHOUT DIFFICULTY. NO COUGHING NOTED. LUNGS SOUNDS DIMINISHED THROUGHOUT CHEST CLEAR ON AUSCULTATION.  PATRICE REQUESTED ORDER TO CRUSH MEDICATIONS.  WRITER SPOKE WITH [doctor] NEW ORDER TO CRUSH ALL MEDICATIONS IF APPLICABLE. ORDER PLACED ON PHYSICIANS ORDER FORM AND GIVEN TO STAFF MEMBER [at facility]." [sic]During an interview on 11/12/25 at 1:45 PM, the executive director (ED #1) was asked to provide evidence of follow through on the order request noted above. ED #1 stated there was no order in the record for crushed medication. ED #1 acknowledged the lack of order follow-up and acknowledged the findings at the time of interview.Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. Upon arrival for a joint home visit with the licensed practical nurse (LPN #1) on 11/5/25 at 10: 00 AM, LPN #1 asked staff at the SNF for P-26's medication list so she could compare and reconcile them. Upon first look at the lists, LPN # 1 indicated they did not match, and she would fully review them after the scheduled visit.Following the scheduled skilled nursing visit, the medication lists were reviewed. Upon review of the medication lists, it was determined the hospice plan of care listed 8 medications. Of the 8 medications listed, 6 were not on the SNF medication report and 1 had the wrong dosage. Additionally, the SNF medication report listed 12 additional medications that were not on the hospice orders. LPN #1 confirmed the discrepancies and called the doctor to get orders to reconcile them. The agency failed to coordinate medication orders for P-26.Additionally, prior to the joint home visit, a SNF nurse asked LPN #1 if an order could be written to discontinue blood sugar monitoring for P-26 because she "did not like being poked 2 times per day". LPN #1 reviewed P-26’s plan of care and noted there was no intervention listed for blood sugar testing. Following the visit, the binder with information regarding P-26 was reviewed at the facility. In the binder, a verbal order dated 10/15/25 was written by the hospice medical director to discontinue blood sugar monitoring. LPN #1 was shown the form. LPN #1 stated this form should have been given to the SNF staff for the order to be completed. LPN #1 stated the nurse who wrote it must have forgotten. The agency failed to coordinate orders for the provision of care for P-26.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.

Based on record review and interview, the agency failed to ensure the skilled nursing facility (SNF) was provided with the most recent hospice plan of care, hospice election benefit form, hospice certification of terminal illness (CTI), and hospice medication information specific to each patient for 1 (P-26) of 1 patients with a home visit who resided in a SNF, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: --- A review of agency policy titled “Coordination of Care – SNF, NF, or ICF, IID” (last reviewed 9/7/22) revealed, “7. The Company will provide the SNF/NF or ICF/IID the following information specific to each patient: A. The most recent plan of care, B. Hospice election form and Advance Directives, C. Physician certification and recertification of the terminal illness, D. Names and contact information for hospice personnel involved in hospice care, E. Instructions on how to access the hospice’s 24-hour on-call system, F. Hospice medication information, G. Hospice physician and attending physician (if any) orders.” Patient #26 (P-26) was admitted to this hospice on 9/6/25 with the terminal diagnoses of Alzheimer’s disease and severe protein-calorie malnutrition. During a joint home visit with the licensed practical nurse (LPN #1) on 11/5/25 at 10:00 AM, LPN #1 was asked where the documents listed above were kept for the skilled nursing facility (SNF). LPN #1 indicated there was a binder at the nurse station that contained all information and communication between the hospice and the SNF. Upon review of the binder on 11/5/25 at 11:37 AM, it was determined the binder failed to include a hospice plan of care, hospice election of benefits form, hospice certification of terminal illness (CTI), and hospice medication information.On 11/5/25 at 12:05 PM, a SNF nurse who was taking care of P-26 was asked where he would find hospice information for this patient. The nurse stated anything they have would be located in the hospice binder at the nurse station. There was no other location where this would be kept. The agency failed to provide the facility with the required documents.The executive director (ED #1) reviewed and acknowledged the findings during an interview on 11/12/25 at 1:45 PM.

Based on record review and interview, the agency failed to ensure staff at skilled nursing facilities were oriented to the hospice philosophy and how to care for patients receiving hospice services in 2 (SNF #1 and SNF #2) of 3 skilled nursing facilities reviewed, resulting in the potential for untrained individuals caring for hospice patients. Findings include: --- A review of agency policy titled “Coordination of Care – SNF, NF, or ICF, IID” (last reviewed 9/7/22) revealed, “8. The Company must assure orientation of SNF/NF or ICF/IID staff furnishing care to hospice patients in the following: A. Hospice philosophy, B. Hospice policies and procedures regarding methods of comfort, pain control and symptom management, C. Principles about death and dying and individual responses to death, D. Patient rights, E. Appropriate forms and record keeping requirements.” During review of agency contracts with skilled nursing facilities on 11/5/25 at 3:27 PM, the executive director (ED #1) was asked where to find evidence of skilled nursing facility (SNF) staff orientation and training. ED #1 stated it should be in the contract folders provided for review. Upon review of the contract folders requested, it was noted 2 (SNF #1 and SNF #2) of 3 contracts reviewed failed to contain evidence of skilled nursing facility staff orientation and training.ED #1 reviewed and acknowledged the findings during a follow-up interview on 11/7/25 at 9:20 AM.

Based on interview and record review, the agency failed to ensure that patient complaints were resolved and documented in 4 of 10 complaint records reviewed from a total of 31 complaints received by the agency over the last 12 months, resulting in the potential for violation of patient rights. Findings include: --- During record review on 7/18/23, a sample of 10 of the 31 complaints received over the last 12 months were reviewed. All 10 complaint records documented the intervention/resolution as "Being managed by the PE (Patient Experience) Team/See PE follow up note". The Administrator (Staff A) was queried during an interview on 7/18/23 at 3:30 p.m. regarding where to find documentation of the resolution. Staff A reported these notes could be found in the "Coordination Notes" section of the electronic medical record. During further record review, it was determined that 4 of 10 complaints did not have a Coordination Note that documented the resolution of the complaint. During a second interview with Staff A on 7/19/23 at 11:00 a.m., Staff A was unable to provide evidence of these complaints being resolved. After further investigation, Staff A reported these 4 complaints had all been managed by a previous Clinical Manager (who has since retired) and it did not appear that she followed-up with the proper documentation. Staff A acknowledged the findings and agreed that there should have been documentation of the follow-up/resolution for each complaint.

Based on record review and interview, the hospice agency failed to ensure the patient was involved in the plan of care in 1 of 27 (P-24) sample records, resulting in a lack of inclusion in planning and potential unmet care needs. Findings include: --- P-24: The Start of Care (SOC) was dated 6/7/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/19/23, it was noted that on 6/8/23 the Medical Social Worker stated, ";...P-24 asked about PT (Physical Therapy) services and LMSW (Licensed Medical Social Worker) explained she can do the exercises on her own but is not able to have a PT provide care..." This finding was reviewed with and acknowledged by the Staff A (Administrator) during an interview on 7/21/23 at 8:55 am and stated, ";That is not a true statement, we can do a onetime PT visit for education and training."

Based on interview and record review, the hospice agency failed to provide 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 in 14 of 27 (P-1, 5, 6, 13,18, 19, 20, 21, 22, 23, 24, 25, 26, 27) of 27 sampled records resulting in the potential for lack of support for individuals who may be impacted by the patients death. Findings include: --- P-18: This 71-year-old patient was admitted to hospice on 1/11/23 with a diagnosis of interstitial (space between cells) lung disease. An initial bereavement assessment for the patient's spouse was completed on 1/11/23. During record review on 7/19/23, it was noted that visit notes and coordination notes dated 1/11/23 thru 1/19/23 documented the presence of the patient's daughter, son, and granddaughter involved in patient care during these visits. The patient passed away on 1/20/23. There was no documented evidence of an initial bereavement assessment for the patient's other family members. The finding was reviewed with and acknowledged by Staff A during an interview on 7/21/23 at 9:40 a.m. P-19: This 75-year-old patient was admitted to hospice on 4/11/23 with a terminal diagnosis of brain cancer. An initial bereavement assessment for the patients son was completed on 4/11/23. During record review on 7/19/23, it was noted that visit notes and coordination notes dated 4/11/23 thru 4/14/23, documented the presence of the patients daughter-in- law, daughter, and 11-year-old grandson. The patient passed away on 4/14/23. No other bereavement assessments were found in the medical record. The finding was reviewed and acknowledged by Staff A during an interview on 7/21/23 at 9:45 a.m. P-20: This 87-year-old patient was admitted to hospice on 6/1/23 with the terminal diagnosis of pancreatic cancer and diabetes. An initial bereavement assessment for the patients son was completed on 6/1/23. During record review on 7/19/23, it was noted that the patient is residing with her son, daughter-in-law, and their two children. The patients other two sons were also noted in the care coordination notes. No other bereavement assessments were found in the medical record. The finding was reviewed and acknowledged by Staff A during an interview on 7/21/23 at 9:45 a.m. P-21: This 85-year-old patient was admitted to hospice on 6/7/23 with the terminal diagnosis of lung cancer. An initial bereavement assessment for the patients daughter was completed on 6/7/23. During record review on 7/19/23, it was noted that visit notes and coordination notes documented the involvement of the patients three sons. No other bereavement assessments were found in the medical record. The finding was reviewed and acknowledged by Staff A during an interview on 7/21/23 at 9:45 a.m. P-22: The Start of Care (SOC) was dated 6/24/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/20/23, it was noted that the bereavement risk assessment was completed by the Skilled Nurse (SN) on 6/24/23 and noted the patients sister. On 6/27/23, the Medical Social Worker (MSW) noted, ";...Pt (Patient) has a son who is minimally involved. Pt has a supportive relationship with neighbor with whom she has known over 12 years that assists with Pt care and finances." The bereavement risk assessment failed to include the patients son and neighbor. P-23: The Start of Care (SOC) was dated 6/5/23. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 7/19/23, it was noted that the bereavement risk assessment was completed by the SN on 6/5/23 and noted the patients wife. On 6/5/23, the SN noted, ";...wife is main CG (Caregiver) but has medical issues of her own. Limited support system. One son who lives in area..." The bereavement risk assessment failed to include the patients son. P-24: The Start of Care (SOC) was dated 6/7/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/19/23, it was noted that the bereavement risk assessment was completed by the SN on 6/7/23 and noted the patients husband. On 6/8/23, the MSW noted, (P-24 and husband provided HX (History). They had 2 sons, one dies at age 29, the other lives in Florida. There are 2 granddaughters. There are 5 great grandkids...." The bereavement risk assessment failed to assess the patients son, granddaughters and grandkids. P-25: The Start of Care (SOC) was dated 6/9/23. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 7/19/23, it was noted that the bereavement risk assessment was completed by the SN on 6/9/23 and noted the patients daughter. On 6/12/23, the Chaplain noted, ";Patients wife shared that she and PT have been married for 70 years, have 2 sons and 3 daughters as well as 10 grandchildren and 12 greatgrandchildren." The bereavement risk assessment failed to assess the patients wife, sons, daughters, grandchildren, and greatgrandchildren. P-26: The Start of Care (SOC) was dated 7/13/23. The Plan of Care (POC) identified a terminal diagnosis of Protein Calorie Malnutrition. During record review on 7/19/23, it was noted that the bereavement risk assessment was completed by the SN on 7/13/23 and noted the patients son. On 7/14/23, the MSW noted, ";...Pt met his wife in New York, and she is still alive living in her own apartment...The couple has 2 children, daughter and son." The bereavement risk assessment failed to include the patients wife and daughter. P-27: The Start of Care (SOC) was dated 1/18/22. The Plan of Care (POC) identified a terminal diagnosis of Cirrhosis of Liver. During record review on 7/18/23, it was noted that the bereavement risk assessment was completed by the SN on 1/18/22 and noted the patients sister. On 7/7/23, the MSW noted, ";...Pt informed MSW that shes preparing for a family gathering tomorrow to meet her grandniece. The baby is her nephew and his wifes first child. Sister, brother-in-law, and niece will be there also" The bereavement risk assessment failed to include the patients nephew, brother-in-law and niece. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 7/21/23 at 8:40 am. Agency policy titled ";OP-081 HOS Bereavement Services ";, revised 09/07/2022, was reviewed on 7/21/23 and stated: ";Purpose: To ensure that appropriate and coordinated bereavement services are provided to families/caregivers... and to identify and appropriately refer those persons who may be experiencing complicated grief reactions ..." P-1: This 95-year-old was admitted to the agency on 12/4/22 with a terminal diagnosis of protein calorie malnutrition. The medical record was reviewed on 7/18/23. An Initial Bereavement Assessment (IBA) was completed for the patients son on 12/14/22. On a client coordination narrative note entered by the Medical Social Worker dated 12/19/22, documentation noted the patient had a son and daughter involved in the patients life, and 3 nephews that visit daily and are also involved in the patients care. No other bereavement assessments were found in the medical record. P-6: This 96-year-old was admitted to the agency on 4/24/23 with a terminal diagnosis of heart failure. The medical record was reviewed on 7/20/23. An IBA was completed for the patients daughter on 4/24/23. On a note entered by the Medical Social Worker dated 4/24/23, documentation noted the patient had a daughter and a son involved in the patients life. No other bereavement assessments were found in the medical record. These findings were reviewed and acknowledged with the Administrator (Staff A) on 7/21/23 at 9:25 a.m. Staff A stated that the expectation would be that any family, especially those noted to be involved, would have a bereavement assessment. P-5: This 96-year-old patient was admitted to Hospice on 4/28/23 with the terminal diagnosis of ischemic cardiomyopathy and hypertension. During record review on 7/20/23, it was determined the patient lived with his wife and a daughter (according to a note by the registered nurse on 4/28/23) and that he had another son and daughter who were involved in his care (according to a note by the social worker on 5/1/23). Upon further review, it was determined that his wife was the only person assessed for bereavement risk. During an interview on 7/21/23 at 9:00 a.m., the Administrator (Staff A) was queried regarding the risk assessment for the other individuals identified. Staff A reported the son and two daughters were listed as emergency contacts but were not checked off for needing a bereavement risk assessment according to the medical record. Staff A acknowledged the findings and reported that the patient's son and daughters should have been included in the bereavement risk assessment and that it must have been missed. P-13: This 92-year-old patient was admitted to Hospice on 6/9/22 with the terminal diagnosis of heart failure. During record review on 7/19/23, it was determined that one daughter was listed under the bereavement risk assessment. Upon further review of bereavement activity after the patient passed away on 7/29/22, it was determined that a card was sent and a call was made to a daughter by a different name who was not listed in the bereavement risk assessment. There was no evidence of contact made to the daughter who was listed. Findings were reviewed with and acknowledged by Staff A during an interview on 7/21/23 at 9:00 a.m. Staff A reported the other daughter should have been listed under the bereavement assessment section and the daughter already listed should have received a card and call as well per the bereavement plan of care.

Based on interview and record review, the agency failed to ensure the care and services were provided in accordance with the plan of care in 2 (P-5, 20, 22, 23) of 27 records reviewed, resulting in the potential for unmet care needs. Findings include: --- P-20: This 87-year-old patient was admitted to hospice on 6/1/23 with the terminal diagnosis of pancreatic cancer and diabetes. During record review on 7/19/23, it was noted that MSW (social work) completed an initial evaluation on June 1 and had a subsequent visit on June 20. The plan of care indicates the MSW would provide three visits in June. There is no evidence of a third visit taking place nor documentation of a missed visit in June. During an interview on 7/21/23 at 9:45 a.m., Staff A acknowledged the missed visit and stated that she ";couldnt find anything" documented in the medical record. **Agency Policy titled, "OP - 103 HOS Management of Missed Visits" (revised 9/7/22) stated, "If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit." It further stated, "The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits." P-5: This 96-year-old patient was admitted to Hospice on 4/28/23 with the terminal diagnosis of ischemic cardiomyopathy and hypertension. During record review on 7/20/23, it was determined the frequency of hospice aide visits ordered was 1 time per week for 12 weeks starting 4/30/23. Upon further record review, it was noted the patient had missed visits on 5/2/23, 6/24/23, 6/29/23 and 7/5/23 with no documentation of attempt made to reschedule the visit. There were also orders to cancel aide visits for the patient on 6/1/23, 6/7/23 and 7/14/23. Additionally, the patient has not been seen by a hospice aide since 6/14/23. There was no documentation of this being communicated with or discussed by the Interdisciplinary Group (IDG) during the meetings nor was there documentation of the clinical supervisor being aware to assist in making any changes to the plan. The Administrator (Staff A) was queried regarding the policy for missed visits. Staff A reported the staff is supposed to make an attempt to reschedule all missed visits to make sure the ordered frequency is being met whenever possible. She also reported that the number of missed visits for this patient should have been flagged for her and the IDG group to assess any necessary changes to the plan of care. She acknowledged the findings during an interview on 7/21/23 at 9:00 a.m. P-22: The Start of Care (SOC) was dated 6/24/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 7/20/23, it was noted that the frequency of hospice aide (HHA) visits ordered was 1w13 (1 time per week for 13 weeks) effective 6/25/23. It was noted that the HHA failed to complete a visit or document a missed visit for week 3, 7/2/23 through 7/8/23. P-23: The Start of Care (SOC) was dated 6/5/23. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 7/19/23, it was noted that the frequency of hospice aide (HHA) visits ordered was 1w13 effective 6/5/23. It was noted that there was an order dated 7/5/23 that stated, ";Declined HHA this week. Calendar Frequency: HHA effective 7/2/23 1q2wk2 (1 visit every other week for 2 weeks), 1w7." The HHA failed to complete a visit or document a missed visit for week 6, 7/9/23 through 7/15/23. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 7/21/23 at 8:50 am.

Based on record review and interview, the hospice failed to provide a spiritual needs assessment of the patient and family for 1 of 20 (P-18) records reviewed with spiritual counseling services, resulting in no evaluation of the spiritual needs of this patient or family at this difficult time. Findings include: --- P-18: This 71-year-old patient was admitted to hospice on 1/11/23 with a diagnosis of interstitial (space between cells) lung disease. The 1/11/23 plan of care ordered the chaplain to provide a spiritual assessment. During record review on 7/19/23, it was noted that there was no documentation of a spiritual assessment and no documentation to indicate the patient or family had declined spiritual counseling services. The patient passed away nine days later on 1/20/23. The finding was reviewed with and acknowledged by Staff A (administrator) during an interview on 7/21/23 at 9:40 a.m.

Based on interview and record review, the hospice agency failed to ensure a copy of the hospice discharge summary was forwarded to the receiving facility in 2 of 3 (P-3, 25) sample records for which a live discharge occurred potentially resulting in the lack of coordination of care and unmet patient needs. Findings include: --- P-25: The Start of Care (SOC) was dated 6/9/23. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 7/19/23, it was noted that the agency failed to verify that the discharge summary was sent to the accepting hospice agency. This finding was reviewed with and acknowledged by the Staff A (Administrator) during an interview on 7/21/23 at 9:00 am. P-3: This 60-year-old patient was admitted to the hospice agency on 1/10/23 with a terminal diagnosis of chronic obstructive pulmonary disease. The medical record was reviewed on 7/19/23. It was noted that the patient moved from the hospice service area and was transferred to another hospice agency on 1/29/23. The discharge summary was completed on 1/29/23. There was no documentation in the medical record that a discharge summary had been sent to the receiving hospice agency following discharge of care. The Administrator (Staff A) was interviewed on 7/21/23 at 9:25 a.m. regarding whether a discharge summary was sent to the receiving facility and was not able to provide evidence of coordination of care following discharge.

Based on interview and record review, the hospice agency failed to ensure a copy of the patient's discharge summary was sent to the physician after patient revocation of services in 1 of 3 (P-2) sample records reviewed for which a live discharge occurred potentially resulting in lack of coordination of care and unmet patient needs. Findings include: --- Agency policy titled ";OP-064 HOS Discharge Planning", last revised 9/7/22 stated on page 5: ";8. A copy of the discharge summary will be sent to the attending physician..." P-2: This 90-year-old patient was admitted to the hospice agency on 5/2/23 with a terminal diagnosis of lung cancer. The medical record was reviewed on 7/19/23. It was noted that the patient revoked hospice care on 5/8/23 to ";seek aggressive treatment". The discharge summary was completed on 5/8/23. There was no documentation in the medical record that a discharge summary had been sent to the attending physician following the revocation of care. The Administrator (Staff A) was interviewed on 7/21/23 at 9:25 a.m. regarding whether a discharge summary was sent to the physician and was not able to provide evidence that the attending physician received the discharge summary following revocation discharge.