Every finding on record at Phr of Baltimore, Inc.

It is required that the hospice maintains an emergency preparedness (EP) training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by personnel record review and interview. In 1 of 11 (9%) personnel records reviewed, the hospice did not ensure hospice employees completed emergency preparedness training at least every two years. PERSONNEL RECORD 3: Hospice Medical Director date of hire 07/16/2011. Personnel record review revealed no documented evidence that emergency preparedness training was completed for 2023, 2024, and year to date for 2025. During a joint record review and interview on 08/20/2025, the Acting Human Resources Manager confirmed emergency preparedness training was not documented for the Hospice Medical Director. The Acting Human Resources Manager stated, "I am not sure why it wasn’t completed."

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, clinical record review, interviews, and review of the findings with the Administrator and Alternate Administrator, which revealed issues related to ensuring the protection and promotion of patient rights in the following areas: Failure to ensure the patient’s right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property [HPFC.2.D/L517]; Failure to ensure the Social Worker immediately reported allegations made by a patient against the Registered Nurse to the Hospice Administrator [HPFC.7.D/L508]; Failure to ensure allegations of suspected abuse by the hospice Registered Nurse were reported to appropriate entities as required by agency policy [HPFC.8.D/L511]; and Failure to ensure immediate action was taken to prevent further potential violations while the allegation was being investigated [HPFC.8.D/L509]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.52: Patient Rights. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care services from the agency.

It is required that the hospice has a defined process to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately by the hospice employee to the hospice administrator. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with patient allegation of potential abuse, the hospice did not ensure the Social Worker immediately reported allegations made by a patient against the Registered Nurse to the Hospice Administrator. Agency policy titled Hospice Family/Patient Centered Care: Reporting Suspected Abuse, Neglect or Misappropriation of Property, required in part, "all alleged violations involving mistreatment, neglect or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately." Agency policy titled Patient Centered Care: Complaint and Grievance Process, required in part, all complaints that pose an immediate risk to the patient shall be addressed within 24 hours or the next business day after receipt of the complaint. Complaints are documented and investigated in accordance with (Agency Name) policy and state regulation. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025. The Social Worker (SW) documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, that the patient alleged exploitation by an agency nurse. The agency Registered Nurse Case Manager (RNCM) (Personnel Record 10) was allegedly providing custodial care for direct payment and the RNCM came to the patient’s home around 1:00 AM on July 25 unannounced. Documentation included that was why the patient stopped service previously, three months ago, because the nurse was coming to the patient’s home at 3:00 AM and odd times when people were not there, and identifying himself as a doctor. The SW documented additional community services needed: Adult Protective Services. An email dated 08/08/2025 from the Director of Hospice Program (employed with the agency until 08/11/2025) to the President/Administrator and other agency leaders included documentation that the Director of Hospice Program, talked with MSW (Personnel Record 7) on 08/07/2025 related to ongoing concerns. External reporting process: As mandating reporters, social worker and I will be filing appropriate reports with state board of nursing for potential ethical violations, APS (Adult Protective Services) to investigate possible exploitation, OIG (Office of Inspector General) for any Medicare related fraud. The agency was unable to provide evidence that the MSW reported these alleged violations to the Administrator prior to 08/07/2025, which was 4 days after the MSW was notified of the allegation by the patient. The MSW did not follow agency policy and report the alleged abuse immediately when it was reported by the patient on 08/03/2025. During a joint review of the record on 08/22/2025, the Alternate Administrator agreed there was no documented evidence that the allegations were reported to the Administrator or Alternate Administrator prior to 08/08/2025. During a joint review of the record on 08/22/2025, the Administrator agreed there was no documented evidence that the allegations were reported to the Administrator or Alternate Administrator prior to 08/08/2025. A review of records revealed the hospice did not ensure that the social worker reported allegations made by a patient against the Registered Nurse were reported immediately to the Administrator.

It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by taking immediate action to prevent further potential violations while the alleged violation is being verified. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with patient allegation of potential abuse, the hospice did not ensure immediate action was taken to prevent further potential violations while the allegation was being investigated. Agency policy titled Hospice Family/Patient Centered Care: Reporting Suspected Abuse, Neglect or Misappropriation of Property, required in part, "The hospice responds to alleged violations involving anyone working on the hospice's behalf by immediately investigating all alleged violations." Agency policy titled Patient Centered Care: Complaint and Grievance Process, required in part, "All complaints that pose an immediate risk to the patient shall be addressed within 24 hours or the next business day after receipt of the complaint. Complaints are documented and investigated in accordance with (hospice agency name) policy and state regulation. The Agency Administrator or designee is responsible for initiating investigation of complaints and grievances. The Administrator or designee is responsible for thoroughly investigating and resolving the complaint and subsequent follow up as appropriate for the nature and seriousness of the concern and in compliance with state law and standards of professional practice." CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025. The Masters Social Worker (MSW) documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, that the patient alleged exploitation by an agency nurse. The agency Registered Nurse Case Manager (RNCM) (Personnel Record 10) was allegedly providing custodial care for direct payment and the RNCM came to the patient’s home around 1:00 AM on July 25 unannounced. Documentation included that was why the patient stopped service previously, three months ago, because the nurse was coming to the patient’s home at 3:00 AM and odd times when people were not there, and identifying himself as a doctor. The SW documented additional community services needed: Adult Protective Services. An email dated 08/08/2025 from the Director of Hospice Program (employed with the agency until 08/11/2025) to the President/Administrator and other agency leaders included documentation that the Director of Hospice Program, talked with MSW (Personnel Record 7) on 08/07/2025 related to ongoing concerns. External reporting process: As mandating reporters, social worker and I will be filing appropriate reports with state board of nursing for potential ethical violations, APS (Adult Protective Services) to investigate possible exploitation, OIG (Office of Inspector General) for any Medicare related fraud. The agency was unable to provide evidence that the MSW reported these alleged violations to the Administrator prior to 08/07/2025, which was 4 days after the MSW was notified of the allegation by the patient. The MSW did not follow agency policy and report the alleged abuse immediately when it was reported by the patient on 08/03/2025. Review of the printed transcript from a meeting dated 08/11/2025 with agency leadership and RNCM (Personnel Record 10) revealed, the RNCM denied accepting money from the patient and offered to provide a year of bank statements. A leader stated it would not be needed. The Senior Vice President of Analytics and Operations stated, “There are some sexual accusations that they and (self-proclaimed POA [power of attorney] with no proof of POA) and whoever had stated to CMS.” The meeting transcript did not include further discussion related to the sexual accusations mentioned and there was no documented evidence that the sexual allegation was investigated. The printed transcript from a (Board of Directors) QAPI (quality assurance performance improvement) meeting dated 08/12/2025 included the statement, the previous Director of Hospice Program was "targeting the RNCM (Personnel Record 10), because of, you know, because of the accusation of the POA that he had sexual relationship with the patient, that the patient had paid him (RNCM) money, extra money, and we are not, they are not supposed to accept any money. You know, that’s what he was accusing (RNCM).” The President/Administrator was part of this meeting and there was no documentation of further discussion related to the sexual relationship mentioned. There was no documented evidence that the sexual allegation was investigated. Review of an email dated 08/19/2025 which included the Chief Nurse Executive of Clinical Operations/Alternate Administrator, included documentation that mentioned, sexual exploitation and RNCM (Personnel Record 10) writing checks and having the patient sign them. The email did not include documentation that the alleged sexual exploitation was investigated. Review of a complaint report dated 08/19/2025 documented by Alternate Administrator revealed documentation that the patient himself reported the complaint to the Medical Social Worker (MSW). The MSW documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, the patient reported alleged exploration by the RNCM. The MSW was unable to enter the complaint due to technical problems with the EMR (electronic medical record). The Intervention section of the complaint form included the documentation: Provide education to staff member. F/U (follow up) with client/caregiver/family. Change in staff assignment. The Intervention/Resolution Comments section included documentation: Meeting was held with hospice Administrator and RNCM (Personnel Record 10) to discuss allegations and reinforce agency policy and practices preventing clinicians from accepting payment of any kind or gifts from patient. RNCM denied allegations. Patient did not produce any evidence of allegations. RN was notified that patient was reassigned to different RN and instructed not to contact or receive calls from the patient, caregivers, NP or self-proclaimed POA. The Prevention section included documentation: Change in staff assignment. Informed hospice Administrator of the events. Prevention comments: New RN was assigned to case. There was no documented evidence that the hospice immediately investigated the allegations, prior to 08/11/2025, 8 days after the allegations were reported by the patient to the hospice social worker and no documentation that the hospice took immediate action to prevent further violations while the alleged violation was being verified. The RNCM was not removed from the patient’s care assignment until 8 days after the violations were reported by the patient. During a joint review of the record on 08/22/2025, the Alternate Administrator agreed there was no documented evidence that the sexual allegations were investigated. The Chief Nurse Executive of Clinical Operations/Alternate Administrator confirmed the agency did not have any documentation to show that the hospice reached out to the patient to discuss the sexual allegations or requested evidence of the allegations. The Chief Nurse Executive of Clinical Operations/Alternate Administrator stated, "I am not sure if we requested it. But, if he had evidence, he could just send it in, but he didn't." During a joint review of the clinical record and agency documents on 08/22/2025, the Administrator confirmed the agency did not have documentation that the sexual allegations were investigated. A review of records revealed the hospice did not ensure that alleged violations involving a hospice Registered Nurse (PR#10) was immediately investigated.

It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by ensuring that verified violations are reported to the state and local bodies having jurisdiction (including the State Survey and Certification Agency) within five (5) working days of becoming aware of the violation. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with patient allegation of potential abuse, the hospice did not ensure that allegations of suspected abuse by the hospice registered nurse were reported to appropriate entities as required by agency policy. Agency policy titled Hospice Family/Patient Centered Care: Reporting Suspected Abuse, Neglect or Misappropriation of Property, required in part, "All alleged violations involving mistreatment, neglect or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately. Patients have a right to be free of deliberate or inadvertent neglect, mistreatment, verbal, mental, sexual and physical abuse and/or misappropriation of patient property. Licensed clinicians are required by (Agency Name) and state Mandated Reporting legislation to report suspected neglect, abuse and/or misappropriation of property to the appropriate Adult Protective Services agency." CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025. The Masters Social Worker (MSW) documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, that the patient alleged exploitation by an agency nurse. The agency Registered Nurse Case Manager (RNCM) (Personnel Record 10) was allegedly providing custodial care for direct payment and the RNCM came to the patient’s home around 1:00 AM on July 25 unannounced. Documentation included that was why the patient stopped service previously, three months ago, because the nurse was coming to the patient’s home at 3:00 AM and odd times when people were not there, and identifying himself as a doctor. The MSW documented additional community services needed: Adult Protective Services. An email dated 08/08/2025 from the Director of Hospice Program (employed with the agency until 08/11/2025) to the President/Administrator and other agency leaders included documentation that the Director of Hospice Program, talked with MSW (Personnel Record 7) on 08/07/2025 related to ongoing concerns. External reporting process: As mandating reporters, social worker and I will be filing appropriate reports with state board of nursing for potential ethical violations, APS (Adult Protective Services) to investigate possible exploitation, OIG (Office of Inspector General) for any Medicare related fraud. The agency had no documented evidence that the Social Worker, the Director of Hospice Program, the President/Administrator, or the Alternate Administrator reported the allegations to the State Agency, Adult Protective Services, Board of Nursing, or CHAP (Community Health Accreditation Partner) as required by agency policy. Review of an email dated 08/19/2025 which included the Chief Nurse Executive of Clinical Operations/Alternate Administrator, included documentation that mentioned, sexual exploitation and RNCM (Personnel Record 10) writing checks and having the patient sign them. The email did not include any documented evidence that the alleged sexual exploitation and misappropriation of patient property was reported to the State Agency, Adult Protective Services, Board of Nursing, and/or CHAP. During a joint review of the record and agency documents on 08/22/2025, the Alternate Administrator agreed the agency did not have documentation that the hospice staff reported the allegations to the State Agency, Adult Protective Services, Board of Nursing, and CHAP. During a joint review of the record and agency documents on 08/22/2025, the Administrator confirmed the agency did not have documentation that hospice staff reported the allegations to the State Agency, Adult Protective Services, Board of Nursing, and CHAP. The President/Administrator stated, "We were thinking of doing that next." A review of records revealed the hospice did not ensure that allegations of sexual exploitation and misappropriation of patient property were reported to State, Adult Protective Services, Board of Nursing, and CHAP. As a result, there was a potential for the allegations not to have been investigated by the appropriate agencies.

It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with patient allegation of potential abuse, the hospice did not ensure the patient’s right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. Agency policy titled Hospice Family/Patient Centered Care: Reporting Suspected Abuse, Neglect or Misappropriation of Property, required in part, "The hospice responds to alleged violations involving anyone working on the hospice's behalf by immediately investigating all alleged violations." Agency policy titled Patient Centered Care: Complaint and Grievance Process, required in part, "All complaints that pose an immediate risk to the patient shall be addressed within 24 hours or the next business day after receipt of the complaint. Complaints are documented and investigated in accordance with (hospice agency name) policy and state regulation. The Agency Administrator or designee is responsible for initiating investigation of complaints and grievances. The Administrator or designee is responsible for thoroughly investigating and resolving the complaint and subsequent follow up as appropriate for the nature and seriousness of the concern and in compliance with state law and standards of professional practice." CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025. The Masters Social Worker (MSW) documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, that the patient alleged exploitation by an agency nurse. The agency Registered Nurse Case Manager (RNCM) (Personnel Record 10) was allegedly providing custodial care for direct payment and the RNCM came to the patient’s home around 1:00 AM on July 25 unannounced. Documentation included that was why the patient stopped service previously, three months ago, because the nurse was coming to the patient’s home at 3:00 AM and odd times when people were not there, and identifying himself as a doctor. The MSW documented additional community services needed: Adult Protective Services. An email dated 08/08/2025 from the Director of Hospice Program (employed with the agency until 08/11/2025) to the President/Administrator and other agency leaders included documentation that the Director of Hospice Program, talked with MSW (Personnel Record 7) on 08/07/2025 related to ongoing concerns. External reporting process: As mandating reporters, social worker and I will be filing appropriate reports with state board of nursing for potential ethical violations, APS (Adult Protective Services) to investigate possible exploitation, OIG (Office of Inspector General) for any Medicare related fraud. The agency had no documented evidence that these entities were notified of the suspected violations. The agency was unable to provide evidence that the MSW reported these alleged violations to the Administrator prior to 08/07/2025, which was 4 days after the MSW was notified of the allegation by the patient. The MSW did not follow agency policy and report the alleged abuse immediately when it was reported by the patient on 08/03/2025. Review of the printed transcript from a meeting dated 08/11/2025 with agency leadership and RNCM (Personnel Record 10) revealed, the RNCM denied accepting money from the patient and offered to provide a year of bank statements. A leader stated it would not be needed. The Senior Vice President of Analytics and Operations stated, “There are some sexual accusations that they and (self- proclaimed POA [power of attorney] with no proof of POA) and whoever had stated to CMS.” The meeting transcript did not include further discussion related to the sexual accusations mentioned and there was no documented evidence that the sexual allegation was investigated. The printed transcript from a (Board of Directors) QAPI (quality assurance performance improvement) meeting dated 08/12/2025 included the statement, the previous Director of Hospice Program was "targeting the RNCM (Personnel Record 10), because of, you know, because of the accusation of the POA that he had sexual relationship with the patient, that the patient had paid him (RNCM) money, extra money, and we are not, they are not supposed to accept any money. You know, that’s what he was accusing (RNCM).” The President/Administrator was part of this meeting and there was no documentation of further discussion related to the sexual relationship mentioned. There was no documented evidence that the sexual allegation was investigated. Review of an email dated 08/19/2025 which included the Chief Nurse Executive of Clinical Operations/Alternate Administrator, included documentation that mentioned, sexual exploitation and RNCM (Personnel Record 10) writing checks and having the patient sign them. The email did not include any documented evidence that the alleged sexual exploitation and misappropriation of patient property was reported to State Agency, Adult Protective Services, Board of Nursing, and/or CHAP (Community Health Accreditation Partner. There was no documented evidence that the alleged sexual exploitation was investigated. Review of a complaint report dated 08/19/2025 documented by Alternate Administrator revealed documentation that the patient himself reported the complaint to the Medical Social Worker (MSW). The MSW documented on a coordination note dated 08/11/2025 from the 08/03/2025 MSW visit. The MSW was unable to enter the complaint due to technical problems with the EMR (electronic medical record). The Intervention section of the complaint form included the documentation: Provide education to the employee. F/U (follow up) with client/caregiver/family. Change in staff assignment. The Intervention/Resolution Comments section included documentation: Meeting was held with hospice Administrator and RNCM (Personnel Record 10) to discuss allegations and reinforce agency policy and practices preventing clinicians from accepting payment of any kind or gifts from the patient. RNCM denied allegations. The patient did not produce any evidence of allegations. RN was notified that patient was reassigned to different RN and instructed not to contact or receive calls from the patient, caregivers, NP (nurse practitioner) or self-proclaimed POA. The Prevention section included documentation: Change in staff assignment. Informed hospice Administrator of the events. Prevention comments: New RN was assigned to case. There was no documented evidence that the hospice immediately investigated the allegations, prior to 08/11/2025, 8 days after the allegations were reported by the patient to the hospice social worker. There was no documented evidence that the hospice included the patient in the investigation and no documented evidence that the hospice requested evidence of allegations. The hospice was unable to ensure the patient’s right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property when the hospice did not investigate the patient’s complaint of sexual misconduct and misappropriation of property by the hospice nurse/RNCM (Personnel Record 10). During a joint review of the record on 08/22/2025, the Alternate Administrator agreed that the agency did not have documentation that the patient’s allegations were investigated. The Chief Nurse Executive of Clinical Operations/Alternate Administrator confirmed the agency did not have any documentation to show that the hospice reached out to the patient to discuss the sexual allegations or requested evidence of the allegations. The Chief Nurse Executive of Clinical Operations/Alternate Administrator stated, "I am not sure if we requested it. But, if he had evidence, he could just send it in, but he didn't." During a joint review of the record on 08/22/2025, the Administrator agreed the agency did not have documentation to show that the patient’s rights were protected when the patient’s complaint of sexual misconduct and misappropriation of property was not fully investigated. A review of records revealed the hospice did not ensure that patient rights were protected by immediately investigating and reporting sexual allegations and allegations of misappropriation of property.

It is required that the hospice designates a registered nurse member of the IDG (intradisciplinary group) to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed, the hospice did not ensure the Registered Nurse (RN) provided a continuous assessment of patient needs. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/11/2025, with a terminal diagnosis of non-ST elevation myocardial infarction. The Hospice Aide documented on the aide visit note dated 06/23/2025, that the patient was experiencing burning and hurting with urination, RN aware. The clinical record included a missed visit note dated 06/27/2025, that the patient's daughter refused a nursing visit and stated that she would take the patient to the hospital because the patient is dehydrated. There was no documented evidence in the clinical record that the nurse assessed the patient’s needs after the aide documented the patient was complaining of burning and hurting with urination. The patient revoked the hospice benefit on 06/28/2025. The discharge summary dated 06/28/2025 revealed that the patient went to the hospital due to dehydration and poor po intake. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/07/2024, with a terminal diagnosis of chronic systolic (congestive) heart failure. The RN documented on the nursing visit note dated 08/21/2024 that the patient was unable to rate pain and the patient’s bed sores were painful. The RN documented that 0.5ml Morphine was administered and would follow up with RNCM (Registered Nurse Case Manager) in AM, will continue nursing for symptom management. There was no documented evidence in the clinical record that the RN followed up, visited, or called the patient to assess the patient’s comfort level and medication effectiveness until the nursing visit on 08/24/2024. The RN then documented sacral wound deteriorating, moans and groans due to wound pain, administered 1ml of Morphine (20mg), plan to administered 20mg more in 1 hour. There was no documented evidence that the RN followed up on the pain from 08/22/2024 through 08/24/2024 to assess the patient's comfort and response to the Morphine. During a joint review of the records and interview on 08/22/2025, the Alternate Administrator agreed that the clinical records did not include documentation that the RN followed up to assess the patient’s needs when changes in the patients’ status were reported.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review and interview. In 3 of 11 (27%) personnel records reviewed, the hospice did not ensure employees completed infection control education annually. PERSONNEL RECORD 3: Hospice Medical Director date of hire 07/16/2011. Personnel record review revealed no documented evidence that infection control education was completed for 2023, 2024, and year to date for 2025. PERSONNEL RECORD 4: Alternate Medical Director date of hire 02/26/2016. Personnel record review revealed no documented evidence that infection control education was completed for 2023, 2024, and year to date for 2025. PERSONNEL RECORD 9: Registered Nurse Case Manager date of hire 05/14/2018. Personnel record review revealed no documented evidence that infection control education was completed for 2023, 2024, and year to date for 2025. During a joint record review and interview on 08/20/2025, the Acting Human Resources Manager confirmed that the personnel records did not include documentation that infection control education was completed annually. The Acting Human Resources Manager stated, "They are assigned annually. I am not sure why they weren't completed."

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 hospice did not ensure documentation of the hospice volunteer hours. A review of the Hospice Volunteer Requirement Report for the period dated 01/01/2024 through 12/31/2024 revealed no documented evidence that the hospice had calculated the hospice volunteer hours to ensure that hospice volunteers had provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent of the total patient care hours. The report did not include documentation of volunteer hours for the year of 2024. During a joint review of the report and interview on 08/22/2025, the Volunteer Coordinator agreed there was no documentation of volunteer hours for 2024. A review of the Hospice Volunteer Requirement Report for 2024 revealed the hospice did not ensure that the cost savings achieved through volunteers was at least 5%.

It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s, overall management and operation, provision of care and services, and fiscal operations. This standard was not met as evidenced by document review, clinical record review, and interview. The hospice governing body did not ensure the patient’s reported allegations of abuse and misappropriation of property by the hospice nurse were immediately investigated and reported to the appropriate entities as required by agency policy. Agency policy titled Hospice Family/Patient Centered Care: Reporting Suspected Abuse, Neglect or Misappropriation of Property, required in part, "All alleged violations involving mistreatment, neglect or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately. Patients have a right to be free of deliberate or inadvertent neglect, mistreatment, verbal, mental, sexual and physical abuse and/or misappropriation of patient property. Licensed clinicians are required by (Agency Name) and state Mandated Reporting legislation to report suspected neglect, abuse and/or misappropriation of property to the appropriate Adult Protective Services agency." CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025. The Masters Social Worker (MSW) documented on a coordination note dated 08/11/2025, for an update to the social work visit dated 08/03/2025, that the patient alleged exploitation by an agency nurse. The agency Registered Nurse Case Manager (RNCM) (Personnel Record 10) was allegedly providing custodial care for direct payment and the RNCM came to the patient’s home around 1:00 AM on July 25 unannounced. Documentation included that was why the patient stopped service previously, three months ago, because the nurse was coming to the patient’s home at 3:00 AM and odd times when people were not there, and identifying himself as a doctor. The MSW documented additional community services needed: Adult Protective Services. An email dated 08/08/2025 from the Director of Hospice Program (employed with the agency until 08/11/2025) to the President/Administrator and other agency leaders included documentation that the Director of Hospice Program, talked with MSW (Personnel Record 7) on 08/07/2025 related to ongoing concerns. External reporting process: As mandating reporters, social worker and I will be filing appropriate reports with state board of nursing for potential ethical violations, APS (Adult Protective Services) to investigate possible exploitation, OIG (Office of Inspector General) for any Medicare related fraud. The agency had no documented evidence that the Social Worker, the Director of Hospice Program, the President/Administrator, or the Alternate Administrator reported the allegations to the State Agency, Adult Protective Services, Board of Nursing, or CHAP (Community Health Accreditation Partner) as required by agency policy. Review of the printed transcript from a meeting dated 08/11/2025 with agency leadership and RNCM (Personnel Record 10) revealed, the RNCM denied accepting money from the patient and offered to provide a year of bank statements. A leader stated it would not be needed. The Senior Vice President of Analytics and Operations stated, “There are some sexual accusations that they and (self-proclaimed POA [power of attorney] with no proof of POA) and whoever had stated to CMS.” The meeting transcript did not include further discussion related to the sexual accusations mentioned and there was no documented evidence that the sexual allegation was investigated. The printed transcript from a (Board of Directors) QAPI (quality assurance performance improvement) meeting dated 08/12/2025 included the statement, the previous Director of Hospice Program was "targeting the RNCM (Personnel Record 10), because of, you know, because of the accusation of the POA that he had sexual relationship with the patient, that the patient had paid him (RNCM) money, extra money, and we are not, they are not supposed to accept any money. You know, that’s what he was accusing (RNCM).” The President/Administrator was part of this meeting and there was no documentation of further discussion related to the sexual relationship mentioned. There was no documented evidence that the sexual allegation was investigated. Review of an email dated 08/19/2025 which included the Chief Nurse Executive of Clinical Operations/Alternate Administrator, included documentation that mentioned, sexual exploitation and RNCM (Personnel Record 10) writing checks and having the patient sign them. The email did not include any documented evidence that the alleged sexual exploitation and misappropriation of patient property was reported to the State Agency, Adult Protective Services, Board of Nursing, and/or CHAP. There was no documented evidence that the alleged sexual exploitation was investigated. During a joint review of the record and agency documents on 08/22/2025, the Alternate Administrator agreed that the agency did not have documentation that the patient’s allegations were investigated and reported to the State Agency, Adult Protective Services, Board of Nursing, and CHAP. During a joint review of the clinical record and agency documents on 08/22/2025, the Administrator confirmed the agency did not have documentation that the sexual allegations were investigated. The Administrator stated, "It was brought to my attention, but I did not report it." A review of records revealed the hospice did not ensure that the Administrator immediately investigated and reported sexual and misappropriation of property allegations to the appropriate agencies.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed in which the patient revoked the hospice benefit, the hospice did not ensure the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/25/2025 and revoked the hospice benefit on 08/15/2025. There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/11/2025 and revoked the hospice benefit on 06/28/2025. There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 14: The patient elected the hospice benefit on 11/20/2023 and revoked the hospice benefit on 01/18/2024. There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient’s attending physician. During a joint review of the records and interview on 08/22/2025, the Alternate Administrator agreed the records did not include documentation that the discharge summaries were sent to the attending physicians.

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. In 1 of 4 (25%), clinical records reviewed revealed the hospice did not ensure that the spiritual assessment was completed within five days of the election of benefits. Clinical Record 3: The patient was admitted to hospice services on 5/26/23, diagnosed with Senile Degeneration of the Brain. The initial plan of care ordered a chaplain visit one time for one week. The chaplain visit was made on 6/2/23; this is two days outside of the required 5-day window. There was no documentation explaining the reason the spiritual assessment was late. During an interview, the VP of Clinical Operations stated that she reached out to the chaplain to see if any documentation had been made about why the visit was late, and he responded no.

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. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice did not ensure that the spiritual assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record #1: was reviewed and identified the patient elected hospice care on 5/27/2021. The clinical record was missing evidence that the spiritual assessment was completed. There was no documentation explaining the reason for the delay for a spiritual assessment. The Administrator/. Director of Nursing (DON) confirmed this finding during the exit conference on 10/07/2022, and indicated that it had been scheduled.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews.1 of 5 (20%) of records reviewed revealed that the hospice did not ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals. Clinical Record #1: was reviewed and identified the patient elected hospice care on 5/27/2022. The initial bereavement risk assessment was not completed as of 10/07/2022. There was no documentation explaining the reason for the delay. The Administrator/ Director of Nursing (DON) confirmed this finding during the exit conference on 10/07/2022.

It is required that medical social services are provided based on a psychosocial assessment and per the plan of care. The psychosocial assessment addresses the patient's and the family's adjustment to the terminal illness. Financial resources and any constraints. The caregiver's ability to function effectively. Obstacles and risk factors that may affect compliance with the plan of care. Family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) of records reviewed revealed the hospice did not ensure that medical social services were provided based on a psychosocial assessment and per the plan of care. Clinical Record #5: The initial plan of care (POC) dated 08/22/2021, ordered a "Medical Social Work Evaluation." The updated POC 08/26/2021, and the subsequent plans of care ordered the medical social worker (MSW) "1 visit every 2 weeks." There was no MSW visits documented as completed 8/22/2021 through 11/04/2021. No reasons for missed visits were documented from 08/22/2021 through 11/04/2021. During an interview on 10/07/2022, the Administrator/Director of Nursing (DON) stated, ”the Social Worker attends the IDG meetings, speaks with the patients and caregivers ,but has difficulty completing notes in the Electronic Medical Record. “

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 a review of clinical records. 1 of 3 (33%) records reviewed revealed the hospice did not ensure the initial comprehensive assessment was completed within 5 days of the election of hospice care. Record # 6 was reviewed and identified the patient elected hospice care on 3/12/2021.The bereavement risk assessment was not completed until 9/14/2021. There was no documentation explaining the reason for the delay. The VP of Operations confirmed this finding during a joint record review.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes: Information on the patient’s progress toward desired outcomes; Reassessment of the patient’s response to care. The assessment update is completed: As frequently as the condition of the patient requires; No less frequently than every 15 days. This standard was not met as evidenced by a review of documents and interview. 1 of 12 (8%) records reviewed revealed that the organization did not ensure the comprehensive assessments were updated to include a change in the patient's condition. Record #4 was reviewed and identified the patient elected hospice on patient on 3/5/2021. The patient died on 3/14/21. The Interdisciplinary Group documentation dated 3/17/2021 did not include an update by the nurse or the social worker. During a joint review of clinical records, the VP of Operations confirmed that the update was missing, but should have been completed.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such, has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICENCY This CONDITION was not met as evidenced by a review of Governing Body documents, policies and procedures, Quality Improvement documents, and interviews with the Vice President of Operations, which revealed issues with the organization's Quality Assessment Performance Improvement (QAPI) program in the following areas: Failure of the organization's Governing Body to appoint one or more individual(s) who are responsible for operating the quality assessment and performance improvement program [HQPI 2.I/L576]; Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions, and mechanisms that include feedback and learning throughout the hospice [HQPI 7.I/L569]; and, Failure of the Governing Body to demonstrate responsibility for ensuring the QAPI program is defined, implemented, maintained, and evaluated [HSLG 2.I/L574]. The cumulative effect of these deficiencies could impact the organization's ability to assess care and services provided by the hospice and ensure the provision of high quality care and services.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by a document review and interview which revealed the hospice did not ensure that the agency had collected data and tracked indicators to demonstrate measurable improvement. There was no documented evidence that the agency had collected data and tracked indicators to measure improvements. The agency's policy "CQI.1.-6/QAPI.1-9" stated in part "the program is capable of showing measurable improvement in indicators related to outcomes, patient safety and quality of care." In an interview, the VP of Operations confirmed that the agency had not tracked data to measure improvements. This standard was not met as evidenced by a review of Documents and interview. Agency policy number CQI.1.-6/QAPI.1-9 states in part "the program is capable of showing measurable improvement in indicators related to outcomes, patient safety and quality of care." The agencies QAPI program lacks indicators that would demonstrate measurable improvement. There was no documented evidence that the agency had any data or tracks any improvement indicators. The VP of Operations confirmed this evidence during interview.

It is required that performance improvement activities track adverse patient events, analyze the causes, implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews. A review of the administrative documents provided by the agency, revealed the agency was not tracking and analyzing patient adverse events. There was no evidence of activities involving adverse events and the implementation of preventive actions as part of a performance improvement plan. The agency's policy "CQI.1.-6/QAPI.1-9" stated in part, "Based on the findings in the QAPI data review, clinical charts may be audited. Trends are identified by the team and performance improvement action items are chosen. the BA/CM develop and track the ongoing performance improvement plan and interventions. They monitor weekly and update and evaluate progress toward identified goals as appropriate. Agency utilizes the Performance Improvement plan of Actions as a means of identifying a target area that is measurable." In an interview, the VP of Operations confirmed the agency had not tracked adverse events and had not completed any analysis of data. Agency policy CQI.1.-6/QAPI.1-9 states in part "Based on the findings in the QAPI data review, clinical charts may be audited. Trends are identified by the team and performance improvement action items are chosen. the BA/CM develop and track the ongoing performance improvement plan and interventions. They monitor weekly and update and evaluate progress toward identified goals as appropriate. Agency utilizes the Performance Improvement plan of Actions as a means of identifying a target area that is measurable." There was no documentation presented by the agency that supports the tracking of adverse patient events. There was no data showing areas of high risk and no evidence that the agency had implemented any performance improvement plans. This was confirmed in an interview with the VP of Operations.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s: overall management and operation; provision of care and services; fiscal operations; and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document reviews and interview which revealed the organization failed to ensure that the QAPI program was implemented, maintained, and evaluated. There was no documented evidence identified in the Governing Body (GB) minutes that reflected the Governing Body oversite of the agency's Quality Program. A review of the Governing Body meeting minutes dated November 2019, revealed the Quality program was evaluated by the GB. The GB meeting minutes reviewed dated July 27, 2022, did not address issues related to the Quality Program. The agency was missing evidence of GB meetings for 2020, and 2021. The agency's policy "CQI.1.-6/QAPI.I-9" stated in part, "The Governing Board evaluates the program annually." The VP of Operations confirmed that there were no additional Governing Body minutes that addressed the Quality Program. There was no documentation found in the Governing Body minutes that reflect Governing Body oversite of a Quality Program. Agency Policy #CQI.1.-6/QAPI.I-9 states in part, "The Governing Board evaluates the program annually." The last meeting held on July 27, 2022 did not address any Quality issues and the last time documentation was found that the Quality program was evaluated was November 2019. The VP of Operations confirmed that there were no additional Governing Body minutes that addressed the Quality Program.

It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview which revealed the organization did not ensure an individual was appointed by the governance as responsible to operate the QAPI program. There was no documented evidence that the board appointed an individual to operate the OBQI program. In an interview with VP of Operations, he stated that the agency has not had a viable program since the previous administrator who was responsible for the QAPI program left just short of a year ago. Upon review of governing body documents there was no written evidence to support that there has been someone appointed to operate the QAPI program. In an interview with VP of Operations he stated that the agency has not had a viable program since the previous administrator who was responsible for the QAPI program left just short of a year ago.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and proceduresdescribing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by review of personnel records, interview, and document review.1 of 1 (100%) record reviewed revealed the hospice did not ensure that a competency evaluation was completed annually as per the standard or agency policy. Staff record # 3: The record for the Registered Nurse was reviewed and identified the date of hire as 5/14/2018. There was no documented evidence that a competency evaluation was completed in 2020 and 2021. The agency's policy #HRM.7-A, stated in part, "Annual competencies are evaluated in various ways, which may include, but is not limited to performance evaluations and skills labs." During an interview, the HR manager confirmed there were no competency evaluations completed annually within the identified records.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum; the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by review of clinical records and interviews. 3 of 12 (25%) records reviewed revealed the organization did not ensure the clinical records contained the clinical notes for services provided. Record # 8 was reviewed and identified the patient elected hospice on patient on 2/3/22. The Interdisciplinary Group (IDG) notes dated 2/17/22, 3/3/22 and 3/14/22, did not include documentation by all clinicians that provided care. Record # 3 was reviewed and identified the patient elected hospice on patient on 1/21/21. The IDG note dated 1/22/21, The IDG note dated any of the clinicians. In addition, the IDG note date 2/2/21, did not include documentation by any of the clinicians. Record #15 was reviewed and identified the patient elected hospice on patient on 4/22/22. The IDG notes dated 4/26/22 and 4/30/22, did not include documentation by the nurse. During a joint review of clinical records, the VP of Operations confirmed that the notes were missing, but should have been completed.