Every finding on record at Live Well Hospice, LLC

Based on record review and interview, the hospice failed to ensure a discharge patient was provided community resource information for one (Pt #2) of three discharge patients. --- Findings: Pt #A plan of care dated 3/15/26 to 05/13/26 did not show the patient was provided with community resource information prior to discharge. On 06/04/26 at 1:57 pm, Staff A stated documentation did not show the patient was provided with community resource information at discharge.

Based on record review and interview, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of their hospice diagnosis for five (Pt #1, 3, 9, 11, and 13) of nineteen patients. --- Findings: Pt #1A plan of care dated 01/20/26 to 03/26/26 failed to include interventions for the diagnosis of Aneurysm of other specified arteries. Pt #3 A plan of care dated 02/02/2 6 to 05/02/26 failed to include interventions for the diagnosis of hypertensive heart and chronic kidney disease with heart failure Stage 1-4/unspecified. Pt #9A plan of care dated 05/18/26 to 08/15/26 failed to include interventions for the diagnosis of hypertensive heart and chronic kidney disease without heart failure. Pt #11A plan of care dated 05/13/26 to 08/10/26 failed to include interventions for the diagnosis of B-cell lymphoma. Pt #13A plan of care dated 05/20/26 to 08/17/26 failed to include interventions for the diagnosis of malignant neoplasm of prostate. On 06/04/26 at 2:20 pm, Staff A stated the plan of cares did not include goals or interventions for the hospice diagnosis for Pt #1, 3, 9, 11, and 13.

Based on record review and interview, the hospice failed to ensure the governing body provided oversight of the QAPI program for all patients and staff. --- Findings: A review of administrative records did not show governing body monitoring or approval of the QAPI program for 2024 and 2025. On 06/04/26 at 11:20 a.m., Staff B stated there was no documentation the governing body approved the QAPI program for 2024 and 2025.

Based on record review and interview, the hospice failed to maintain an Infection Control Program, for all patients and staff. --- Findings: A review of administrative records did not show any information for the infection control program from 01/01/26 to 06/04/26.  Requested the policy for Infection Control Program, the request yielded no results. On 06/04/26 at 11:15 a.m., Staff E stated:They have not documented anything for the Infection Control Program this year.They do not have a policy for Infection Control.

Based on record review and interview, the hospice failed to ensure wound assessments were completed as ordered for one (Pt #8) of two wound care patients. --- Findings: Pt #8A review of a plan of care dated 05/15/26 to 08/12/26 the plan of care showed orders to assess coccyx and excoriated areas each visit.  A nurse note dated 05/19/26 documented a stage II pressure ulcer to left inner buttock with a new order apply chamosyn w/mannuka honey topically to left inner buttock every shift and following each incontinent episode.  A nurse note dated 05/21/26 documented skin intact (pressure ulcer was not documented healed) , no information regarding an assessment of the coccyx or any wound care.   A nurse note dated 05/22/26 showed a prn visit for wound care stage II pressure ulcer to left inner gluteal fold measuring 6.5 cm x 1.5 cm x 0.  New orders obtained to cleanse wound to left inner gluteal fold w/wound cleanser and pat dry with gauze, apply a thin layer of dynarex gel with honey and cover with bordered proximal dressing three times per week and as needed,  On 06/04/26 at 2:16 pm, Staff A stated:1. Wound assessment and care were not completed 05/21/26.2. The nurse no longer works here.

Based on record review and interview, the hospice failed to ensure volunteers provided services that equaled 5% of the total patient care hours of all paid hospice employees for 2024 and 2025 for all patients and staff. --- Findings: A request for volunteer records and hours for Calendar year 2024 and 2025.  The monthly volunteer hours for January 2024 to April 2026 are as follows: January 2024 - 1.12%February 2024 - 5.07%March 2024 - 4.5%April 2024 - 2.17%May 2024 - 2.58%June 2024 - 3.08%July 2024 - 2.76%August 2024 - 1.75%September 2024 - 2.70%October 2024 - 1.70%November 2024 0.42%December 2024 1.70%Yearly total = 2.46% January 2025 - 1.64%February 2025 - 0.52%March 2025 - 0.35%April 2025 - 1.13%May 2025 - 0.88%.June 2025 - 1.06%July 2025 - 1.63%August 2025 - 1.12%September 2025 - 1.86%October 2025 - 1%November 2025 - 4.20%December 2025 - 6%Yearly total = 1.78January 2026 - 0.96%February 2026 - 0.32%March 2026 - 0.46%April 2026 - 2.6% On 06/04/26 at 10:28 am, Staff N stated the volunteer required hours have not been met.

Based on record review and interview, the hospice failed to:1. Approve the annual budget for all patients and staff.2. Create policies for all patients and staff. --- Findings: A review of administrative records showed no governing body approval of an annual budget for Calendar years 2024 and 2025.  The request for infection control policy, TB policy, and catheter policy yielded no results. On 06/04/26 at 11:20 am, Staff B stated the governing body minutes for Calendar years 2024 and 2025 did no show approval of an annual budget. On 06/04/26 at 3:00 pm, Staff E stated they do not have policies on infection control, TB, and catheters.

Based on record review and interview, the agency failed to ensure personnel records included orientation to hospice philosophy for six (Staff G, H, I, J, K and M) of seven personnel. --- Findings:Staff GA review of the personnel record showed no orientation to the hospice philosophy.  Staff HA review of the personnel record showed no orientation to the hospice philosophy.  Staff IA review of the personnel record showed no orientation to the hospice philosophy.  Staff JA review of the personnel record showed no orientation to the hospice philosophy.  Staff KA review of the personnel record showed no orientation to the hospice philosophy.  Staff MA review of the personnel record showed no orientation to the hospice philosophy.  On 06/04/26 at 1:11 p.m., Staff A stated the personnel files for Staff G, H, I, J, K and M had no documentation of orientation to the hospice philosophy.

Based on record review and interview, the hospice failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was developed and implemented and/or was review for all patients and employees. --- Findings: A review of administrative records showed no documentation a community-based risk assessment was developed, implemented or reviewed for the agency, its patient population, or its employees. On 08/09/23 at 11:00 a.m., Staff B stated the agency showed no All Hazard Risk Assessment developed, implemented, or reviewed for the agency.

Based on record review and interview, the hospice failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff. --- Findings: A review of administrative records showed no documentation the Emergency Preparedness Communication Plan included staff contact information for the Hospice. On 08/09/22 at 11:00 a.m., Staff B stated the active staff member call list was not included in the Emergency Preparedness Communication Plan for the Hospice.

Based on record review and interview, the hospice failed to ensure: 1. Hospice aide services were provided in accordance with the plan of care for nine (Patients #2, 3, 6, 7, 8, 9, 11, 12 and 13) of 19 patients and; 2. Skilled nurse services were provided in accordance with the plan of care for six (Patient #1, 2, 6, 7, 9 and 10) of 19 patients. --- Findings: Patient #1 A review of the plan of care dated 07/09/23 to 09/06/23 and plan of care updates dated 07/12/23, 07/26/23 and 08/03/23 ordered SN visits two times a week. Documentation showed during the weeks of 07/09/23 to 07/15/23 SN visits were conducted on 07/10/23 (two visits ordered, one visits conducted), 07/15/23 to 07/22/23 SN visits were conducted on 07/19/23 (two visits ordered, one visit conducted), 07/23/23 to 07/29/23 SN visits were conducted on 07/24/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. Patient #2 A review of the plan of care dated 06/12/23 to 09/09/23 and plan of care updates dated 06/14/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week and SN visits two times a week. Documentation showed during the weeks of 06/12/23 to 06/17/23 SN visits were conducted on 06/16/23 (two visits ordered, one visit conducted), 07/16/23 to 07/22/23 hospice aide visits were conducted on 07/21/23 (two visits ordered, one visits conducted). 07/30/23 to 08/05/23 hospice aide visits were conducted on 08/02/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #3 A review of the plan of care dated 06/11/23 to 09/08/23 and plan of care updates dated 06/08/23, 06/14/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed during the weeks of 07/02/23 to 07/08/23 hospice aide visits were conducted on 07/21/23 (two visits ordered, one visits conducted). 07/30/23 to 08/05/23 hospice aide visits were conducted on 08/02/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #6 A review of the plan of care dated 06/23/23 to 09/20/23 and plan of care updates dated 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week and SN visits two times a week. Documentation showed during the weeks of 07/23/23 to 07/29/23 SN visits were conducted on 07/25/23 (two visits ordered, one visit conducted), 07/30/23 to 08/05/23 SN visits were conducted on 07/25/23 (two visits ordered, one visit conducted); 07/30/23 to 08/05/23 hospice aide visits were conducted on 08/03/23 (two visits ordered, one visits conducted). 07/30/23 to 08/05/23 hospice aide visits were conducted on 07/31/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #7 A review of the plan of care dated 06/22/23 to 09/19/23 and plan of care updates dated 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week and SN visits two times a week. Documentation showed during the weeks of 06/12/23 to 06/17/23 SN visits were conducted on 06/16/23 (two visits ordered, one visits conducted), 07/02/23 to 07/08/23 hospice aide visits were conducted on 07/06/23 (two visits ordered, one visit conducted), 07/23/23 to 07/29/23 hospice aide visits were conducted on 07/25/23 (two visits ordered, one visit conducted), 07/30/23 to 08/05/23 no hospice aide visits were conducted (two visits ordered, no visits conducted); 07/23/23 to 07/29/23 SN visits were conducted on 07/25/23 (two visits ordered, one visit conducted), 07/30/23 to 08/05/23 SN visits were conducted on 08/03/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #8 A review of the plan of care dated 06/26/23 to 09/23/23 and plan of care updates dated 06/21/23 ordered SN visits two times a week. Documentation showed during the weeks of 07/30/23 to 08/03/23 SN visits were conducted on 07/31/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. Patient #9 A review of the plan of care dated 06/01/23 to 08/29/23 and plan of care updates dated 05/25/23, 06/08/23, 06/21/23, 07/06/23, 07/20/23 and 08/03/23 ordered hospice aide visits at a frequency of zero week one then, two visits every week and SN visits one time a week then, two times a week. Documentation showed during the weeks of 07/30/23 to 08/05/23 SN visits were conducted on 08/03/23 (two visits ordered, one visit conducted); 06/11/23 to 06/17/23 hospice aide visits were conducted on 06/12/23 (two visits ordered, one visits conducted), 07/30/23 to 08/05/23 no hospice aide visits were conducted (two visits ordered, no visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #10 A review of the plan of care dated 06/13/23 to 09/10/23 and plan of care updates dated 06/21/23, 06/28/23, 07/12/23 and 07/26/23 ordered SN visits two times a week. Documentation showed during the weeks of 07/02/23 to 07/08/23 no SN visits were conducted (two visits ordered, no visits conducted), 07/23/23 to 07/29/23 SN visits were conducted on 07/27/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. Patient #11 A review of the plan of care dated 06/29/23 to 09/26/23 and plan of care updates dated 06/21/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed during the weeks of 07/02/23 to 07/08/23 hospice aide visits were conducted on 07/06/23 (two visits ordered, one visits conducted). 07/30/23 to 08/05/23 no hospice aide visits were conducted (two visits ordered, no visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #12 A review of the plan of care dated 07/22/23 to 09/19/23 and plan of care updates dated 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed during the weeks of 07/30/23 to 08/05/23 hospice aide visits were conducted on 07/31/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. Patient #13 A review of the plan of care dated 07/31/23 to 10/28/23 and plan of care updates dated 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed during the weeks of 07/30/23 to 08/05/23 no hospice aide visits were conducted (two visits ordered, no visits conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the hospice aide. On 08/09/23 at 3:25 p.m. to 4:00 p.m., Staff B stated: 1. Hospice aide frequencies were not followed as ordered for patients #2, 3, 6, 7, 8, 9, 11, 12 and 13 and; 2. Skilled nurse frequency were not followed as ordered for patients #1, 2, 6, 7, 9 and 10.

Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. --- Findings: A review of administrative records showed no QAPI program data collection sources or analysis/reporting of collected data activities or reporting for calendar year 2021, 2022 and 01/01/23 to 06/30/23. Additional requests for administrative records yielded no results. On 08/08/23 at 3:00 p.m., Staff C stated the hospice had no QAPI records which showed data collection sources or data analysist of patient care for calendar year 2021, 2022 and 01/01/23 to 06/30/23.

Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. --- Findings: A review of administrative records showed no governing body oversite of ongoing QAPI program activities or infection control for the hospice for calendar year 2021, 2022 and 01/01/23 to 06/30/23. On 08/08/23 at 3:00 p.m., Staff C stated the hospice had no documentation which showed governing body oversite of QAPI program activities or infection control for the hospice for calendar year 2021, 2022 and 01/01/23 to 06/30/23.

Based on record review and interview, the hospice failed to ensure its infection control program was included in QAPI program activities for all patients and staff for calendar years 2021, 2022 and 01/01/23 to 06/30/23. --- Findings: A review of administrative records showed no infection control program surveillance data included in QAPI program activities for calendar years 2021, 2022 and 01/01/23 to 06/30/23. On 08/08/23 at 3:00 p.m., Staff C stated there was no infection control program data included in QAPI program activities for calendar years 2021, 2022 and 01/01/23 to 06/30/23.

Based on record review and interview, the hospice failed to ensure continued review and update of a home health aide care plan for nine (Patients #1, 2, 3, 8, 9, 11, 12, 13 and 14) of 19 patients. --- Findings: Patient #1 A review of the plan of care dated 07/09/23 to 09/06/23 and plan of care updates dated 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 10/12/22. Patient #2 A review of the plan of care dated 06/12/23 to 09/09/23 and plan of care updates dated 06/14/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 03/14/23. Patient #3 A review of the plan of care dated 06/11/23 to 09/08/23 and plan of care updates dated 06/08/23, 06/14/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 03/18/23. Patient #8 A review of the plan of care dated 06/26/23 to 09/23/23 and plan of care updates dated 06/21/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 03/28/23. Patient #9 A review of the plan of care dated 06/01/23 to 08/29/23 and plan of care updates dated 05/25/23, 06/08/23, 06/21/23, 07/06/23, 07/20/23 and 08/03/23 ordered hospice aide visits at a frequency of zero week one then, two visits every week. Documentation showed no update to the hospice aide care plan dated 03/03/23. Patient #11 A review of the plan of care dated 06/29/23 to 09/26/23 and plan of care updates dated 06/21/23, 06/28/23, 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 03/31/23. Patient #12 A review of the plan of care dated 07/22/23 to 09/19/23 and plan of care updates dated 07/12/23, 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 09/25/22. Patient #13 A review of the plan of care dated 07/31/23 to 10/28/23 and plan of care updates dated 07/26/23 and 08/03/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 05/02/23. Patient #14 A review of the plan of care dated 07/03/23 to 08/21/23 and plan of care updates dated 06/28/23, 07/12/23 and 07/26/23 ordered hospice aide visits at a frequency of two visits every week. Documentation showed no update to the hospice aide care plan dated 04/07/23. On 08/02/23 at 3:15 p.m. to 4:00 p.m., Staff B stated the clinical records for patients 1, 2, 3, 8, 9, 11, 12, 13 and 14 showed no updates to the documented hospice aide care plans for CHHA services.

Based on record review and interview, the hospice failed to ensure completion of a discharge summary for one (Patient #19) of 19 patients. --- Findings: Patient #19 A review of the clinical record showed the patient was discharged from the hospice on 04/20/23 to in-patient hospital. care services. Documentation showed no discharge summary. Documentation showed no in-patient follow up communication and no discharge summary was provided to the in-patient hospital service provider or physician. On 08/09/21 at 4:00 p.m., Staff B stated the hospice failed to complete a discharge summary for Patient #19.