Every finding on record at Inspire Hospice and Palliative Care Inc.

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. 1 of 22 (5%) clinical records reviewed of patients who accepted spiritual services on admission revealed that the agency did not ensure that the chaplain completed an initial assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 13: The patient elected hospice care on 04/17/2024 with a diagnosis of COPD (chronic obstructive pulmonary disease) with Acute Exacerbation. The Chaplain's initial assessment was not completed until 04/24/2025 (7 calendar days from the election of hospice care). There was no documented reason why the initial spiritual assessment was not completed by the Chaplain within the required 5 calendar days. During an interview and joint clinical record review on 03/11/2026, the RN/VP of Operations confirmed the finding and agreed that the Chaplain did not complete the initial Spiritual Assessment in the required 5-day timeframe. No further information was provided.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 1 of 21 (5%) clinical records reviewed of patients receiving hospice aide (HA) services revealed that the agency did not ensure that the HA reported changes to the registered nurse (RN). CLINICAL RECORD 2: The patient elected hospice care on 11/01/2024 with a diagnosis of Cerebral infarction. The HA care plan created by the RN assigned the tasks of mouth care and nail care 3 times a week. The HA documented, on 03/09/2026 and 03/11/2026, that the patient's daughter completed both tasks. The HA did not complete both tasks on both days. There was no documented evidence that the HA informed the RN about tasks not completed. During an interview on 03/11/2026. The RN/VP of Operations confirmed the finding. She stated that the aide did not inform the RN of tasks not completed. No further information was provided.

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. 1 of 2 (50%) clinical records reviewed, where the patients were admitted to a Medicare/Medicaid-certified hospital, revealed that the agency did not ensure that a discharge summary was forwarded to the receiving facility. CLINICAL RECORD 18: The patient elected hospice care on 03/03/2025 with the diagnosis of Malignant Neoplasm of Temporal Lobe. The Registered Nurse (RN) documented on 03/11/2025 that the patient was admitted to a hospital. A discharge summary was completed. A review of clinical record revealed no evidence that the completed discharge summary was forwarded to the receiving hospital. On 03/11/2026 a joint record review and interview was conducted with the RN/VP of Operations who confirmed that a discharge summary was not forwarded to the receiving hospital. No further information was provided.

Based on policy titled “Plan of Care Process,” clinical record review, and care giver and staff interviews, it was determined that the Interdisciplinary team (IDT) failed to ensure that plan of care reflected the specific problems identified in the assessments, goals and interventions, and services necessary to meet the assessed needs for three patients (P) (P#4, P#11 and P#12) of 23 patients who were current hospice beneficiaries. --- The findings include: Review of policy titled "Plan of Care Process" dated 9/1/24 reveals the following:II. The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. 1. Review of P#11’s nursing Summary note dated 1/29/26, revealed that patient was admitted to hospice agency on 1/28/26. Review of “Nursing Summary Notes,” dated 1/29/2026 for P#11 revealed patient has a midline tracheostomy (is a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea, to breathe), capped with a Lary tube (a flexible silicone tube used to maintain the stoma (hole) after laryngectomy surgery, ensuring an open airway for breathing), size 10 in place. P#11 also has a gastrostomy tube (an opening in the stomach for feeding), (G-tube) for nutrition and is receiving Jevity 1.5 calorie feedings. Review of plan of care dated 1/28/26 failed to reveal orders for tracheostomy care, G-tube care and orders for Jevity 1.5 calorie feedings. An interview was conducted on 2/4/26 at 1:25 p.m., with the P#11's caregiver (CG) revealed that the CG cleans the Larry tube with soap and water on daily basis. CG also stated that G-tube care is also provided by the CG. An interview was conducted on 2/4/26 at 2:30 p.m., with Vice President of Operations (VPO).  VPO revealed that the plan of care lack orders for tracheostomy care, G-tube care and orders for Jevity 1.5 calorie feedings. 2. Review of P#12’s record revealed that patient was admitted to hospice on 10/1/25. Review of the plan of care dated 10/1/25 revealed order Foley catheter (a medical device that helps drain urine from your bladder) as needed. May irrigate catheter. The order fails to reveal the size and type of catheter, the type and amount of solution to inflate the balloon and type and amount of solution to irrigate the catheter as needed. On 2/4/26 at 2:00 p.m., an interview was conducted with the Vice President of Operations (VPO).  VPO revealed that the plan of care lacks complete orders for Foley catheter and its management. 3. Review of P4’s record revealed that patient was admitted to hospice on 4/26/24. Review of the plan of care dated 4/26/24 revealed Foley catheter as needed. The order fails to reveal the type and amount of solution to inflate the balloon. Review of P#4’s Skilled Nurse (SN) visit note dated 9/27/25 revealed that SN placed 16 Fr foley catheter during visit and retrieved 100 cc of clear yellow urine.  Review of SN visit note dated 2/9/25 revealed that patient has 18 fr Foley catheter.  The clinical record failed to reveal orders for 18 fr foley catheter.  On 2/4/26 at 2:00 p.m., an interview was conducted with the Vice President of Operations (VPO).  VPO revealed that the plan of care lacks complete orders for Foley catheter and its management.

Based on review of agency policy, record reviews, and staff interview it was determined the agency’s governing body failed to ensure the Interdisciplinary Team (IDT) updated the plan of care reflected the specific problems identified in the assessments, goals and interventions, and services necessary to meet the assessed needs of three patients (P) (P#4, P#11 and P#12) of  23 sampled patients. --- Findings include: Cross reference to citation L0545 for findings regarding content of plan of care.

Based on review of policy titled “Plan of Care Process,“ record review and staff interview’s, it was determined the agency failed to follow an individualized written plan of care for one patient (P) (P#1) of one record reviewed. --- Findings include: Review of agency policy titled “Plan of Care Process,” last reviewed 01/26/24, revealed the following:PolicyI. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group (IDG/IDT) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs. Review of document titled “Plan of Care,” with effective date of 5/6/25, revealed P#1 with a Social Worker (SW) frequency order for one visit monthly and 2 PRN (as needed) visit(s) every 30 days. Plan of care failed to reveal completed or missed visits by the SW for the months of May, June, and July 2025. On 9/3/2025 at 10:30 a.m., during an in-office interview, the Administrator acknowledged the missing SW visits for the months of May, June, and July 2025 for P#1. The Administrator explained she was made aware by the SW, in April 2025, that the patient’s family had refused SW visits, but she did not know why the order was not updated to reflect the refusal of SW services. On 9/3/2025 at 10:40 a.m., during a phone interview, the SW admitted she had reached out the family referred to in complaint #2580565 on 4/1/2025, 4/2/2025, and 4/3/2025 without response. The SW further explained that the patient’s family refused SW services, but she did not document the conversation with the patient’s caregiver in the patient’s Chart.

Based on review of policy titled “Levels of Care,” record review, staff interview, and caregiver interview, it was determined the agency failed to provide care that met the patient and family’s needs and goals for one patient (P) (P#1) of one chart reviewed. --- Findings include: Review of policy titled “Levels of Care,” last reviewed 03/01/24, revealed the following:ProcedureIII. Continuous Home Care is nursing care provided for as much as 24 hours a day from midnight to midnight, during a period of crisis to achieve palliation and management of pain and other acute medical symptoms, while maintaining the patient at home.C. The following circumstances may qualify as continuous home care but is not inclusive:       2. Collapse of caregiver or family support system that provides the patient’s             skilled care; Review of an email document dated 7/15/2025 revealed the patients primary nurse, RN AA, had voiced concerns about the patient’s caregiver being fatigued and showing signs of “caregiver burnout.” Furthermore, RN AA requested the patient receive continuous care in the home or to be transferred to a General Inpatient (GIP) care unit for continuous care due to the caregiver fatigue. On 9/3/2025 at 10:00 a.m., during an office interview, the Administrator acknowledged the documented RN AA concerns previously stated. The Administrator added that a five-day respite (short term) stay in a skilled nursing facility was offered to the patient’s family, but the family refused the respite. On 9/2/2025 at 6:30 p.m., during a phone interview, the patient’s caregiver (CG) stated, “We were not offered any help. We were denied GIP (General Inpatient Care) because they said (the patient) was not appropriate”.  The CG added “I was her (the patient) full time caregiver and I was exhausted. I needed help and they refused us GIP or any continuous care.”

Based on observation, clinical record review, staff interviews, and review of ";Administrative Policy Manual" last reviewed 100121, it was determined that the agency failed to update plan of care (POC), to provide stage 2, pressure ulcer coccyx wound care for one Patient (P) (P#1) of fifteen sampled Patients, (P#1) (P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14 and P#15). --- The Findings include: On 2/7/2023 at 3:40 p.m., surveyor reviewed Hospice Agency ";Policy and Procedures, dated 10/1/2021, (Page 1-2. number 1.D) The IDG/IDT Plan of Care (POC) will be developed within 15 days of the start of care and updated at least every 15 days". The hospice agency failed to update the POC for P#1 to include stage 2 pressure ulcer coccyx wound care. Review of plan of care (POC), dated 11/16/2022, P#1 was admitted to Hospice Agency on 11/16/2022, with a diagnosis of heart failure unspecified (disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements). On 2/7/2023 at 11:00 a.m., surveyor observed Registered Nurse (RN) AA, performing stage 2, pressure ulcer coccyx wound care to P#1, used wound cleanser to clean coccyx wound, pat dry, then covered it with bordered gauze adhesive island wound dressing. There was nothing written on P#1s POC for stage 2, pressure ulcer coccyx wound care. On 2/7/2023 at 11:23 a.m., an interview was conducted with RN AA, who stated that she did not update P#1, POC for stage 2, pressure ulcer coccyx wound care. During an interview on 2/7/2023, at 4:15 p.m., the Administrator confirmed that the hospice agency did not update P#1s POC for stage 2, pressure ulcer coccyx wound care.

Based on observation, clinical record review, staff interviews, and policies and procedures review, it was determined that the agency failed to obtain physician orders to provide stage 2 pressure ulcer wound care for one Patient (P) (P#1) of fifteen sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14 and P#15). --- The Findings include: On 2/7/2023 at 3:40 p.m., surveyor reviewed Hospice Agency ";Policy and Procedures, dated 10/1/2021, (Page 1-2, number 1.G), Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders. Orders will be signed by the physician and/or non-physician practitioner prior to billing." The hospice agency failed to obtain physician order prior to providing stage 2 pressure ulcer wound care for P#1. Record review of ";Patient Face Sheet" for (P#1) reveals admitted to Hospice Agency on 11/16/2022 with a diagnosis of heart failure, unspecified (disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements). On 2/7/2023 at 11:00 a.m., surveyor observed Registered Nurse (RN) AA, performing stage 2, pressure ulcer coccyx wound care to P#1. RN AA used wound cleanser to clean stage 2 coccyx wound, pat dry, and then covered it with bordered gauze adhesive island wound dressing. During an interview on 2/7/2023 at 11:23 a.m., with RN AA, revealed that she was not aware that she needed to obtain physicians order for stage 2 pressure ulcer coccyx wound care before she could apply the dressing. RN AA, also said that she believed she could call the physician and obtain stage 2, pressure ulcer coccyx wound care order after she finished the dressing. During an interview on 2/7/2023, at 4:15 p.m., the Administrator confirmed that the agency did not have physicians order for stage 2 pressure ulcer coccyx wound care.