Every finding on record at Circle of Care Hospice, LLC

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. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Volunteer Coordinator on 03/02/2026 revealed that volunteer utilization for the agency was below the 5% required by regulation. The annual volunteer report for calendar year 01/01/2024 through 12/31/024 volunteer utilization was 1.78%; and for calendar year 01/01/2025 through 12/31/2025 volunteer utilization was 1.57%. Agency policy HR.95, titled "Volunteers", states in part , "Volunteers will provide day-to-day administrative and/or direct patient amount that, at a minimum, equals five percent of the total patient hours of paid Hospice employees and contract staff." During an interview and document review, the Volunteer Coordinator confirmed the findings. No further information was provided. A joint review of the agency report titled " Hospice Volunteer Requirement Report" with the Volunteer Coordinator on 03/02/2026 revealed that volunteer utilization for the agency was below 5% per regulation. The annual volunteer report for report for calender year 01/01/2023, through 12/31/2023 revealed volunteer utilization was 0.71%, 01/01/2024, through 12/31/024 revealed volunteer utilization was 1.78%. The annual volunteer report for calendar year 01/01/2025, through 12/31/2025, revealed volunteer utilization of 1.57%. Agency policy HR.95 titled " Volunteers" states in part "Volunteers will provide day-tiday administrative and/or direct patient amount that, at a minimum, equals five percent of the total patient hours of paid Hospice employees and contract staff."

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: 1. The hospice discharge summary described in HCDT 40.I; and 2. The patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with care transferred to another Medicare facility, the agency did not ensure that a discharge summary was forwarded to the receiving facility. Agency policy PE .15, titled "Patient Transfer" states in part, "If the care of a patient is transferred to another Medicare/Medicaid-Certified Facility, the hospice forwards copies of the Hospice discharge summary, a summary of the patient's care and the patient's plan of care." CLINICAL RECORD 16: The patient elected the hospice benefit on 05/09/2025. The Registered Nurse (RN) documented that the patient was admitted to a hospital on 05/22/2025 to seek aggressive treatment. A discharge summary was completed but there was no evidence in the record that a hospice discharge summary and/or any clinical records were sent to the receiving Medicare/Medicaid Facility. During an interview with the RN Patient Care Manager on 03/05/2026, it was confirmed that the agency did not send a discharge summary or the patient's records to the receiving hospital. No further information was provided. Agency policy PE .15 titled " Patient Transfer" states in part, "If the care of a patient is transferred to another Medicare/Medicaid-Certified Facility, the hospice forwards ciopies of the Hospice discharge Summary, a summary of the patient's care and the patient's plan of care."

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 3 of 19 (16%) clinical records reviewed, the hospice did not ensure the initial spiritual assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 8: The patient elected hospice care on 9/21/2022. A clinical record review revealed no documented evidence of an initial spiritual assessment completed no later than five days after the election of hospice care. Clinical Record 13: The patient elected hospice care on 9/28/2022. The Chaplain completed the initial spiritual assessment on 10/5/2022, seven (7) days after the election of hospice care. A clinical record review revealed no documented reason for the delay and no evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 14: The patient elected hospice care on 5/16/2022. The Chaplain completed the initial spiritual assessment on 5/26/2022, ten (10) days after the election of hospice care. A clinical record review revealed no documented reason for the delay and no evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. During an interview on 5/12/2023, the Area Clinical Manager agreed there was no documented evidence that the initial spiritual assessments were completed no later than five days after the election of hospice care or the reason for the delay. Record 8: The patient’s date of election was 9/21/2022. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Record 13: The patient’s date of election was 9/28/2022. The initial spiritual assessment was completed by the Chaplain on 10/5/2022. There was no documented reason for the delay. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Record 14: The patient’s date of election was 5/16/2022. The initial spiritual assessment was completed by the Chaplain on 5/26/2022. There was no documented reason for the delay. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. The Area Clinical Manager was interviewed on 5/12/2023 and agreed, there was no documented evidence the initial spiritual assessments were completed no later than five days after the election of hospice care or reason for the delay.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the plan of care was individualized to include planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 6: The patient elected hospice care on 4/8/2021 with the primary hospice diagnosis of heart failure. The Licensed Vocational Nurse (LVN) visit note dated 2/16/2023 documented "4+ pitting edema." The Registered Nurse (RN) assessment dated 2/23/2023 documented the patient was uncomfortable due to pain, moderate pain to bilateral extremities." The patient's documented goal was "mild pain." The RN assessment dated 3/21/2023 documented, "pt continues to have 4+ edema, is taking Norco, Morphine and Fentanyl patch for pain." Additionally, the LVN visit note dated 5/4/2023 documented "4+ pitting edema to RLE and 3+ to LLE, always in pain when walking but used to it, tolerable." The plan of care dated 2/16/2023 through 5/11/2023 documented "Problem: Pain/comfort. Goal: Pain treatment and analgesic regimen will be based on characteristics/type of pain." A review of the clinical record revealed the plan of care did not include documentation of the patient's and family's goals for pain and documentation of planned interventions and goals for the patient's edema. The Area Clinical Manager was interviewed on 5/12/2023 and agreed there was no documented evidence the plan of care included planned interventions for the edema or an individualized patient and family goal for the edema and pain. Record 6: The patient’s date of election was 4/8/2021.The primary hospice diagnosis was heart failure. The Licensed Vocational Nurse visit on 2/16/2023 revealed 4+ pitting edema. The Registered Nurse assessment on 2/23/2023 revealed the patient was uncomfortable due to pain, moderate pain to bilateral extremities, goal mild pain. The Registered Nurse assessment on 3/21/2023 revealed pt continues to have 4+ edema, is taking Norco, Morphine and Fentanyl patch for pain. The Licensed Vocational Nurse visit on 5/4/2023 revealed 4+ pitting edema to RLE and 3+ to LLE, always in pain when walking but used to it, tolerable. The plan of care was reviewed 2/16/2023-5/11/2023. Problem: Pain/comfort. Goal: Pain treatment and analgesic regimen will be based on characteristics/type of pain. There was no documented evidence that the plan of care was individualized to reflect patient and family goals for pain. There was no documented evidence that the plan of care included a patient and family goal or planned interventions for the edema. The Area Clinical Manager was interviewed on 5/12/2023 and agreed, there was no documented evidence the plan of care included planned interventions for the edema or an individualized patient and family goal for the edema and pain.

It is required that counseling services must include, but are not limited to, the following: bereavement counseling. The hospice must make bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/MR when appropriate and identified in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. The agency policy, “Bereavement" stated in part, “The hospice will make bereavement services available to the family and other individuals in the bereavement plan of care (POC) before, and for up to one year following the death of the patient. The Bereavement Coordinator will complete a follow-up assessment and develop a plan of care for Bereavement Services based on the reassessment and the family/caregiver’s willingness to receive services. This plan of care will be discussed at the next IDG meeting.” 1 of 3 (33%) clinical records reviewed of patients discharged due to death, the hospice did not ensure that bereavement services were provided to the bereaved. Clinical Record 17: The patient elected hospice care on 5/16/2022. The patient died on 6/17/2022. The IDG (Interdisciplinary Group) note dated 7/1/2022 documented a plan to “conduct assessment, mail condolence card, mailing 3, 6, 9,11,13 months then introduce interventions if needed.” A telephone call documented on 7/11/2022 read in part, “No answer when called, will close out this record labeled no contact, unreachable.” There was no documented evidence that bereavement services were provided to the bereaved or declined by the bereaved. The Bereavement Coordinator was interviewed on 5/11/2023 and stated, “The record should not have been closed because they didn’t decline bereavement.” Additionally, during an interview on 5/11/2023, the Bereavement Coordinator agreed there was no documented evidence bereavement was declined and no documented evidence bereavement was offered and provided to the bereaved. During an interview on 5/11/2023, the Area Clinical Manager stated that the hospice was aware of this. Agency policy, “Bereavement, TX.26,” stated in part, “The hospice will make bereavement services available to the family and other individuals in the bereavement plan of care (POC) before, and for up to one year following the death of the patient. The Bereavement Coordinator will complete a follow-up assessment and develop a plan of care for Bereavement Services based on the reassessment and the family/caregiver’s willingness to receive services. This plan of care will be discussed at the next IDG meeting.” Record 17: The patient’s date of election was 5/16/2022. The bereavement record was reviewed and revealed the patient died on 6/17/2022. There was no documented evidence bereavement was provided to the bereaved. The IDG (Interdisciplinary Group) note on 7/1/2022 revealed a plan to, “conduct assessment, mail condolence card, mailing 3, 6 9, 11, 13 months then introduce interventions if needed.” A telephone call on 7/11/2022 revealed, “no answer when called, will close out this record labeled no contact, unreachable.” There was no documented evidence that bereavement services were provided to the bereaved or declined by the bereaved. The Bereavement Coordinator was interviewed on 5/11/2023 and stated, “the record should not have been closed because they didn’t decline bereavement.” Additionally, during an interview on 5/11/2023, the Bereavement Coordinator agreed, there was no documented evidence bereavement was declined and no documented evidence bereavement was offered and provided to the bereaved. The Area Clinical Manager was interviewed on 5/11/2023 and stated, we are aware of this, we have two performance improvement plans on this and have hired a new bereavement coordinator that started in February.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) clinical records reviewed with a discharge from hospice due to revocation, the hospice did not ensure the discharge summary was provided to the patient’s attending physician. Clinical Record 14: The patient elected hospice care on 5/16/2022. The patient elected revocation of the hospice benefit effective 7/28/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 18: The patient elected hospice care on 4/14/2022. The patient elected revocation of the hospice benefit effective 5/21/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. The Area Clinical Manager was interviewed on 5/12/2023 and agreed there was no documented evidence that the discharge summary was provided to the patient’s attending physician. Record 14: The patient’s date of election was 5/16/2022. The patient elected revocation of the hospice benefit effective 7/28/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Record 18: The patient’s date of election was 4/14/2022. The patient elected revocation of the hospice benefit effective 5/21/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. The Area Clinical Manager was interviewed on 5/12/2023 and agreed, there was no documented evidence that the discharge summary was provided to the patient’s attending physician.