Every finding on record at Olive Branch Hospice LLC

Based on review of the policy titled “Bereavement Services,” clinical record review, and staff interview, it was determined that the hospice failed to establish a bereavement plan of care to reflect the needs of the bereaved for three patients (P) (P11, P12, P15) of three sampled bereavement charts. --- Findings included: Review of an undated policy titled “Bereavement Services,” revealed the following:“POLICYBereavement services shall be available a minimum of five (5) days a week and for up to one year following the death of a patient.PROCEDURE1. Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient’s death.2. An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to the patient and family members to be provided by the Social Worker, Chaplain or Bereavement Counselor. The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery.5. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated. 9. Bereavement assessment and  clinical notes are documented in the patient’s permanent clinical record.  1. Record review reveals P11 was admitted to hospice on 04/20/2025 and expired on 06/27/2025. Further review of the patient’s chart failed to reveal a bereavement plan of care. 2. Record review reveals P12 was admitted to hospice on 07/31/2025 and expired on 09/12/2025. Further review of the patient’s chart failed to reveal a bereavement plan of care. 3. Record review reveals P15 was admitted to hospice on 12/26/2024 and expired on 12/17/2025. Further review of the patient’s chart failed to reveal a bereavement plan of care. On 05/06/2026 at 11:15 AM, an in-office interview was conducted with the Administrator who acknowledged that the clinical records lacked bereavement care plans. The Administrator further explained, “our bereavement calendars show me that we have a gap in the bereavement.”The Chaplain was unavailable for interview.

Based on agency policy titled “Rehabilitation Services,” and staff interview, it was determined the agency failed to ensure that physical therapy services, occupational therapy services, and speech language pathology services are available to patients for home safety assessments as needed. --- Findings included: Review of undated policy titled “Rehabilitation Services,” revealed the following:“Patients receiving rehabilitation services (PT,OT and/or SLP) will have appropriate assessments, evaluations, IDG care planning, reassessments and established outcomes performed." During a review of agency contracts, it was revealed that a therapy contract with the hospice agency was not included. On 05/05/2026 at 2:00 PM, an interview was conducted with the Administrator. The Administrator acknowledged that the hospice agency does not provide any therapy services as those services are not offered with hospice, therefore they have not contracted for any therapy services.A request was made for a contract for therapy services.

Based on policies and procedures, clinical records review, and staff interview, it was determined the agency failed to manage and provide hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. Specifically the facility failed to: establish a bereavement plan of care to reflect the needs of the bereaved for three patients (P) (P13, P14, P15) of three sampled bereavement charts.ensure the hospice agency made physical therapy services, occupational therapy services, and speech language pathology services available to patients for home safety assessments as needed.authenticate an entry in their electronic medical records in accordance with accepted standards of practice for one (P) P10 of 15 sampled patients. --- Findings included: Review of undated policy titled “Governing Body,”  revealed the following:“POLICYThe Governing Body assumes full legal authority and responsibility for the management of Hospice, the provision of all Hospice services, its fiscal operations and assumes responsibility for the safety and quality of care provided.PURPOSETo ensure lines of authority are established and to ensure appropriate quality services are provided to patients.” Cross Reference to L0596 related to development of a bereavement plan of care.Cross Reference to L0603 related to the availability of physical therapy services, occupational therapy services, and speech-language pathology services.Cross Reference to L0679 related to authentication of clinical records.

Based on review of policy titled “ Physician Orders Policy,” record review, and staff interview, it was determined that the agency failed to authenticate an entry in their electronic medical records in accordance with accepted standards of practice for one patient (P) P10 of 15 sampled patients. Specifically, the hospice failed to authenticate a verbal order received and signed by a non-licensed personnel. --- Findings included: Review of undated policy titled “Physician Order Policy,” revealed the following:Policy StatementAll orders must comply with applicable federal regulations, state Department of Community Health requirements, and hospice Conditions of Participation.To establish standardized procedures for obtaining, documenting, implementing, and reviewing physician orders to ensure safe, effective, and compliant patient care.DefinitionsVerbal Order (VO): An order communicated orally by a physician or authorized practitioner.3. Verbal and Telephone Orders  The receiving licensed nurse must:Write/read back the order for verificationDocument date, time, and provider nameSign the order with credentials4. Written and Electronic OrdersOrders may be documented via:Electronic Medical Record EMR)Electronic signatures must meet legal and regulatory standards9. Documentation RequirementsSignature and credentialsAuthentication (if verbal) Review of clinical record revealed physician's order dated 04/30/26 11:50 AM. The Administrator received and electronically signed a verbal order. An interview was conducted on 05/05/2026 at 03:10 PM with the Administrator who confirmed that she had received and electronically signed a physician's verbal order. The Administrator confirmed that she is not a licensed nurse and that she failed to follow the agency's Physicians Orders Policy. The Administrator stated that she was aware that she does not have the appropriate credentials to document and sign a physician's verbal order.

Based on a review of policy titled “Plan of Care Policy,” record reviews, and staff interviews, it was determined that the agency failed to include interventions on the plan of care for tracheostomy care, tube feedings and care of gastric tube, wound care, catheter care, and colostomy care for two patients (P) (P#1 and P#3) of three sampled patients. --- Findings include: Review of the undated policy titled “Plan of Care Policy,” reveals the following:Procedure:2. The plan of care includes at a minimum:•           identified problems and needs•           specific interventions to address each need•           frequency of services•           medications, treatments, and therapies related to the terminal illness 1. Review of the clinical records reveal P#1 was admitted to hospice on 1/20/26 and was receiving tube feedings and water flushes via a gastric tube (a soft, flexible tube surgically placed into the stomach through a small opening in the skin designed to provide nutrition and/or medication directly into the stomach). The patient had a tracheostomy (a surgical opening in the neck to assist with breathing), and wound which required wound care Review of the plan of care failed to include interventions for the care and maintenance of the gastric tube, the tracheostomy, and wound care orders for the care and maintenance of the wound. Review of document titled “Hospice Certification and Plan of Care,” dated 1/20/26, failed to include interventions for care of the gastric tube or specific orders for tube feedings and failed to include interventions for tracheostomy and wound care. During an interview on 2/11/26 at 2:00 p.m., the Administrator agreed that the plan of care did not contain pertinent interventions. It was also confirmed the plan of care failed to identify all identified patient problems and needs related to the gastric feeding tube, tracheostomy and wound care. 2. Review of the clinical records reveal P#3 was admitted to hospice on 8/30/25 with a suprapubic catheter (flexible tube surgically inserted in the bladder to drain urine) and a colostomy system (a surgically created opening in the stomach so waste can exit the body and into a changeable pouch).  Review of document titled “Hospice Certification and Plan of Care,” dated 8/30/25, failed to identity the presence of the supra pubic catheter or the colostomy system and failed to include interventions for care and maintenance of the supra pubic catheter and colostomy care. During an interview on 2/11/26 at 2:00 p.m., the Administrator agreed that the plan of care did not contain needed interventions. It was also confirmed the plan of care failed to identify all the patient problems and needs.

Based on review of policy titled “Coordination of Patient Care,” review of  records, and family and staff interviews, it was determined the agency failed to coordinate with members of the Interdisciplinary Group (IDG), to ensure supplies were readily available and services were provided for one patient (P) (P#1) of three sampled patients. --- Findings include: Review of undated policy titled "Coordination of Patient Care," revealed the following:Coordination of Care: The deliberate organization of patient care activities and sharing of information among all participants concerned with a patient's care to achieve safer and more effective care. Review of the clinical record revealed that P#1 was admitted to services on 1/20/26 with a stage three wound (wound with exposed tissue).  Review of the plan of care failed to reveal physician's orders to care for the wound. Review of the “Client Coordination Note Report,” revealed a skilled nurse (SN) visited the patient at the start of care visit on 1/20/26 and provided wound care to the sacral wound. The SN failed to obtain wound care orders for the wound care provided. The SN visited the patient on 1/21, 1/28, and 1/30/26, and the wound was not assessed during the visits. The SN documented each visit that wound care had already been done by the family.  The SN failed to coordinate with the physician to coordinate wound care treatment and interventions to treat the wound. The SN failed to notify the physician that the wound had not be assessed since admission on 1/20/26. The clinical record lacked coordination of care with team members to ensure wound treatment interventions were ordered to ensure adequate supplies were readily available to assist in the management of the patient's care. During a telephone interview with the family on 2/10/2015 at 2:10 p.m., the family confirmed that P#1 was receiving skilled nursing services however, the family reported that they were doing the wound care and not the nurses. The family additionally stated that the nurses were not caring for the wound and did not provide the necessary wound care supplies in a timely manner. During a telephone interview with the Case Manager (CM) on 2/11/26  at 11:10 a.m., the CM did confirm she wrote an order for wound care in her notes but failed to write a verbal order for the physician to sign. The CM reported she thought a mobile wound care center would be caring  for the wound however she did acknowledge that there was no order for a wound center to provide treatment the patient. The CM reports she did discuss the patient wound with the physician however, failed to document any communication with the physician in the clinical record. A telephone interview was conducted on 2/11/2026 at 11:35 a.m. with Registered Nurse (RN) AA regarding the care of P#1. RN AA recalled visiting P#1 two or three times however denied being aware that the patient had a wound. RN AA states that she assessed the blood sugar during the visits, but she could not recall if she documented the value. RN AA stated that she notified the medical director regarding the concerns the family had regarding the blood sugars and tube feedings and that the doctor gave her a verbal order to start tube feeding at 7 A.M and stop at 8 PM. RN AA then stated that she missed putting the blood sugar result in the computer. A telephone interview was conducted on 2/11/2026 at 11:50 a.m., with the Medical Director (MD) of Olive Branch Hospice regarding the care of P#1. The MD denied being able to recall P#1 without reviewing his notes. MD confirmed that his note states patient has a stage #3 sacral wound. MD stated he did not recall a specific order for that patient and did not recall signing an order. MD stated he depends on the nurses to put in the orders and when he gets them, he signs off on them. He also stated he does not physically see the patients so relies on the nurses to tell him. He also stated there are so many patients with wounds, his assumption was that wound care was being done and was not aware that it was not being done. An interview with the Administrator on 2/11/26 at 2:00 .pm., confirmed that the agency failed to coordinate with the team members to ensure care was coordinated in a clear and effective manner to meet the needs of the patient.

Based on review of policies and procedures, record reviews, and staff interviews, it was determined the agency’s governing body failed to take responsibility for implementing and monitoring patients’ plans of care to include coordinating services based on the patient problems and needs for two patients (P) (P#1, P#3) of three sampled patients. Additionally, the Governing Body failed to coordinate with members of the Interdisciplinary Group (IDG), to ensure supplies were readily available and services were provided for P#1 and P#3 of three sampled patients. --- Findings included: Cross refer to L0545 relating to care plansCross refer to L0554 relating to Coordination of Services

Based on review of policy titled “Physicians Orders – Verbal Orders,” review of records, and staff interviews, it was determined the agency failed to obtain physicians orders for treatment provided to two patients (P) (P#1 and P#3) of three sampled patients. --- Findings include: Review of policy titled " Physicians Orders – Verbal Orders," revised March 2013 revealed the following:POLICY:  Drugs and treatments are administered by Hospice staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN (or qualified therapists) responsible for furnishing or supervising the care.PURPOSE: To document verbal orders received from the patient's physician. 1. Review of the clinical records reveal P#1 was admitted to hospice on 1/20/26. The skilled nurse (SN) admitted the patient on 1/20/26 and provided wound care to sacral wound. The clinical record failed to include a physician's order for the wound care provided.During an interview on 2/11/26 at 2:00 p.m., the Administrator confirmed the SN failed to obtain a physician's order for the wound care provided. 2. Review of the clinical records reveal P#3 was admitted to hospice on 8/30/25 with a suprapubic catheter (flexible tube surgically inserted in the bladder to drain urine) and a colostomy system (a surgically created opening in the stomach so waste can exit the body and into a changeable pouch/bag).  The skilled nurse (SN) visit notes dated 1/13/26 and 2/3/26 indicate the suprapubic catheter was changed using a 24 French catheter. Documentation by the SN on 1/13/26 revealed that the suprapubic catheter has been leaking since admission and the SN packed area with gauze to prevent saturation.  Additionally, the SN documented on 1/13/26 that the colostomy bag is replaced 2 times a week. Review of the clinical record failed to include a physician's order for the catheter change or packing the catheter area and for the care and maintenance of the colostomy bag. During an interview with the Administrator on 2/11/26 at 11:30 a.m., it was confirmed the clinical record did not contain an order for catheter and colostomy care. The Administrator also stated the SN must obtain verbal or written orders from the physician prior to performing any care for the patient.

Based on staff interview, review of undated policy titled "Quality Assessment and Performance Improvement (QAPI) Plan", and review of quality assessment performance improvement (QAPI) data, it was determined that the hospice failed to maintain an effective quality improvement program with participation involving all hospice services to provide ongoing and periodic collection of assessment data focused on indicators related to improved hospice performance. The findings include: --- Review of an undated policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan" revealed: OBJECTIVES To educate and involve appropriate staff in QAPI activities. Review of the quality assessment performance improvement (QAPI) data revealed a lack of participation from all hospice services and patient care disciplines, methodology for monitoring and evaluating the quality of care provided, priorities for resolution of problems and lacked a focused review of the QAPI program. The data presented failed to provide a proactive approach to improve agency performance for specific areas of concern identified such as untimely documentation. The QAPI failed to include regular meetings documented by signed meeting minutes. An interview conducted with the Executive Director and the Director of Operations at the agency on 5/10/2023 at 12:00 p.m. revealed both failed to provide any additional information regarding QAPI data.

Based on staff interview, and review of quality assessment performance improvement (QAPI) data, it was determined that the hospice failed to collect data on an ongoing basis to show measurable improvements to ensure the effectiveness, safety and quality of care and services. Findings include: --- The hospice failed to ensure a quality assessment and performance improvement (QAPI) process that was able to show specific measurable improvement in indicators related to improvement of palliative outcomes and hospice services. The data collected indicated monthly monitoring of quality indicators; there was no documentation of any measurable improvements in the outcomes of services. An interview conducted with the Executive Director and the Director of Operations at the agency on 5/10/2023 at 12:00 p.m., revealed both failed to provide any additional information regarding QAPI data.

Based on review of the quality assessment performance improvement data and staff interview, it was determined that the hospice failed to develop and implement an ongoing performance improvement project. Findings include: --- Review of the quality assessment performance improvement data provided revealed the lack of documentation for a performance improvement project. An interview conducted with the Executive Director and the Director of Operations at the agency on 5/10/2023 at 12:00 p.m. revealed both were unable to provide documentation of an ongoing performance improvement project.

Based on staff interview, record reviews, and review of the undated policy titled ";Discharge Criteria", the agency failed to ensure that a comprehensive discharge summary was completed and included in the documentation to assist in continuity of care post-discharge for three patients (P) (P#9, P#10, P#11) of three patients (P#9, P#10, P#11) who were discharged, transferred, or revoked the hospice benefit. Findings include: --- The agency undated policy titled "Discharge Criteria" revealed: PROCEDURE 8. Staff will be knowledgeable about discharge procedures including instructions and follow-up responsibilities. 10. Patients will receive verbal or written discharge instructions. 11. A complete list of reconciled medications with be provided to each patient on discharge. The list will be explained to patient/family and interaction documented. Patients and families.... pharmacies. 1. Review of the record for P#9 revealed the patient admitted on 11/19/2021 with cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) and hypertension (blood pressure that is higher than normal). P#9 discharged from hospice on 2/28/2022 per patient request. The clinical record contained a revocation form dated 2/28/2022. The revocation form failed to include a patient or caregiver signature. Additionally, the clinical record failed to include a comprehensive discharge summary of P#9s stay including treatment, symptoms and pain management, the current plan of care, latest physician orders and any additional documentation to assist in post-discharge planning. 2. Review of the clinical record for P#10 revealed admitted to hospice on 7/8/2022 with the diagnosis of hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness on one side of the body). Review of the discharge note dated 10/5/2022 revealed the patient was discharged from hospice on 10/5/2022. The discharge note indicates the patient was discharged for cause. The clinical record lacked documentation to indicate specific reason for the discharge revealing the patient unable to be seen to recertify during certification period. The clinical record lacked documentation to indicate the Registered Nurse (RN) attempted to see the patient prior to the last day of the certification period. Additionally, the record lacked a comprehensive discharge summary to include a summary of P#10s stay including treatment, symptoms and pain management, the current plan of care, latest physician orders, and any additional documentation to assist in post-discharge planning. 3. Review of the clinical record for P#11 revealed that patient admitted to hospice on 8/31/2022 with the diagnosis of atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Review of skilled nurse note dated 12/15/2022 revealed P#11 discharged from hospice on 12/15/2022 per patient/family request to transfer to another hospice. The clinical record failed to include a comprehensive discharge summary of P#10's stay including treatment, symptoms and pain management, the current plan of care, latest physician orders and any additional documentation to assist in post-discharge planning. An interview was conducted with the Executive Director and the Director of Operations at the agency on 5/10/2023 at 12:00 p.m. The Executive Director and the Director of Operations confirmed the record lacked a complete discharge summary. The agency failed to obtain a signed revocation form by the patient or caregiver, documentation to indicate specific reason for the discharge and include a comprehensive discharge summary.