Every finding on record at Careview Hospice Inc

It is required that the comprehensive assessment includes consideration of the following factors: the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included cardiac, respiratory, and/or urinary assessments of the patient’s condition at the time of the assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/20/2025 with a diagnosis of Parkinson’s disease. The Registered Nurse documented on the nursing comprehensive assessment dated 11/20/2025, "Cardiovascular: comments see note... Respiratory: Shortness of Breath No; Over the past two days, how has the patient been affected by Shortness of Breath: Not at all... Nursing Summary Notes: Cardio - no extensive cardiac history. Patient does not take any BP [blood pressure] medications. Resp [respiratory] - PRN [as needed] Nebulizers required for occasional wheezing, risk for aspiration due to overall muscle weakness and advanced neuromuscular disease. Refused supplemental 02 and oxygen offered despite education." The comprehensive assessment did not include an assessment of the patient’s cardiac and respiratory status at the time of admission. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/03/2026 with a diagnosis of chronic obstructive pulmonary disease with comorbidities of resting tachycardia and recent hospitalization for UTI (urinary tract infection)/bladder infection. The Registered Nurse documented on the nursing comprehensive assessment dated 02/03/2026, "Genitourinary: General: Comments: see note... Nursing Summary Notes: GI/GU [gastrointestinal/genitourinary] ... recent UTI with hospitalization with antibiotics at hospital." The comprehensive assessment did not include an assessment of the patient’s GI/GU status at the time of the assessment. CLINICAL RECORD 10: The patient elected the hospice benefit on 03/25/2025 with diagnoses of severe protein-calorie malnutrition, abnormal weight loss, cachexia, anorexia, and muscle wasting. The Registered Nurse documented on the comprehensive nursing assessment dated 03/25/2026, "Respiratory Findings: Respiratory Assessed, No Respiratory Symptoms identified - NA [not applicable] Yes; Other Respiratory Notes: No s/s [signs and symptoms] of respiratory distress; Cardiovascular: Cardiac/Circulatory: Cardiovascular Assessed, No Cardiac Symptoms Identified - NA Yes; Comments: No s/s of respiratory distress... Nursing Summary Notes: ... with hospice diagnosis of hypertensive heart disease with heart failure and comorbidities of HTN [hypertension], CHF [congestive heart failure], chronic ischemic heart disease... Dyspnea on exertion noted, requires frequent rest periods between minimal activities." The comprehensive assessment did not include an assessment of the patient’s cardiac and respiratory status at the time of admission. During a joint clinical record review and interview on 02/27/2026, the Supervising Nurse confirmed that the initial comprehensive assessments did not include documentation of a comprehensive cardiac, respiratory, or genitourinary assessment.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure documentation of ongoing efforts to recruit and retain volunteers. Review of the volunteer program revealed no documentation of recruitment and retention efforts from April 2023 to December 2025. The documentation consisted of two pages with the names of 13 locations for holding "Sip, Snack, Serve" events. Two dates were written on the document for 12/10/25 and 02/15/2026. During a joint document review and interview on 02/27/2026, the Administrator/Volunteer Coordinator confirmed that there were no documented recruitment efforts from April 2023 to December 2025. The Administrator/Volunteer Coordinator stated that they are marketing locations but are not documenting them for volunteer recruitment. The Administrator/Volunteer Coordinator stated that venues would call and cancel. Upon reviewing the volunteer program, the documentation lacked sufficient evidence of efforts to retain volunteers. The documentation consisted of two pages with the names of 13 locations for holding "Sip, Snack, Serve" events. Two dates were written on the document for 12/10/25 and 02/15/2026. There is no documentation from April 2023 through 12/10/2025.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours. Upon reviewing the volunteer program, the documentation revealed no documented volunteer hours prior to April 2025. The total number of patient care hours from February 2025 through January 2026 was 2600.22. The total number of volunteer hours documented was 102. The volunteer hours totaled 3.92%, which did not meet the minimum of 5%. During a joint review of the volunteer program records and an interview on 02/27/2026, the Administrator/Volunteer Coordinator confirmed that the agency had no record of any documented volunteer hours prior to April 2025. The Administrator/Volunteer Coordinator confirmed that the total volunteer hours, compared to the total patient care hours, did not meet the minimum 5% requirement. Upon reviewing the volunteer program, the documentation revealed no documented volunteer hours prior to April 2025. The total number of patient care hours from February 2025 through January 2026 was 2600.22. The total number of volunteer hours documented was 102. The volunteer hours totaled 3.92%, which did not meet the minimum of 5%. The volunteer time was recorded for each month on a quarterly spreadsheet. The documentation did not include specific dates, hours worked, or the duties the volunteer performed each day.

It is required that for those individuals eligible to be fully vaccinated for COVID-19, Organization policy and procedure define what vaccination documentation is accepted, who receives the vaccination documentation, reviews it, and accepts or rejects it; and how each individual’s vaccination information is securely maintained. This standard was not met as evidenced by document review and interview. The agency did not ensure that the organization's policy defined a process for tracking and securely documenting the COVID-19 vaccination status of all staff eligible to receive the vaccination. A review of the agency's policy titled "IC.16 Emergency Temporary Standards: COVID-19 Plan," revised 8/1/2021 and approved by the Interdisciplinary Team (IDT) on 1/14/2023, revealed that the plan did not state specifically what documentation the agency would accept as valid proof of an employee's COVID-19 vaccination and who in the agency is allowed to receive the vaccination documentation to review it, and accept or reject it. Additionally, there was no agency procedure stating how the employee's proof of vaccination was to be safely and securely filed and maintained. In an interview on 4/20/2023, the Administrator/Director of Patient Care Services (DPCS) and the Alternate Administrator confirmed that the agency was using the Healthcare ConsultLink policies alone as their COVID-19 Policy, Procedure, and Plan and that the agency had no procedure outlined for what was considered acceptable, documented proof of vaccination or who was allowed to receive that documented evidence. They also confirmed that the agency did not have a person listed as the one to receive and review the employee's proof of vaccination and make the decision to accept or reject that documentation as valid. And lastly, the Administrator and Alternate Administrator confirmed that there was no procedure written down as to how the employee's vaccination proof would be secured. A review of the agency's policy IC.16 - "Emergency Temporary Standards: COVID-19 Plan," revised 8/1/2021 and approved by the Interdisciplinary Team (IDT) on 1/14/2023, revealed that the agency did not ensure that there was a policy and procedure stating specifically what documentation the agency would accept as valid for proof of an employee's COVID-19 vaccination and who in the agency is allowed to receive the vaccination documentation to review it and accept it or reject it. Additionally, there was no agency procedure stating how the employee's proof of vaccination was to be safely and securely filed. It was confirmed in an interview with the Administrator/Director of Patient Care Services (DPCS) and the Alternate Administrator on 4/20/2023 that the agency was using the Healthcare ConsultLink policies alone as their COVID-19 Policy, Procedure, and Plan and that the agency had no procedure outlined for what was considered as acceptable documented proof of vaccination or who was allowed to receive that documented evidence. They also confirmed that the agency did not have a person listed as the one to receive and review the employee's proof of vaccination and make the decision to accept or reject that documentation as valid. And lastly, the Administrator and Alternate Administrator confirmed that there was no procedure written down as to how the employee's vaccination proof would be secured.