Every finding on record at Primavera Hospice LLC

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for patients that expired revealed the agency did not ensure a post-death bereavement plan of care (POC) was completed. CLINICAL RECORD 4: The patient death was on 03/28/2025. The record had evidence of a completed post-death bereavement assessment. There was no documented evidence of a post-death bereavement POC. CLINICAL RECORD 5: The patient death was on 05/03/2025. The record had evidence of a completed post-death bereavement assessment. There was no documented evidence of a post-death bereavement POC. The Director of Nursing stated in an interview while performing joint clinical record reviews on 09/18/2025 that the post-death bereavement POCs were missing from the records.

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 review of the "Volunteer Savings Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Agency Volunteer Savings Report: The review of the 2024 "Volunteer Saving Report" revealed the volunteer percentage of hours worked was 0.81% for 2024. The Volunteer Coordinator and the Director of Nursing stated in an interview on 09/19/2025 that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the "Volunteer Savings Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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 2 of 2 (100%) clinical records reviewed that the patient/family either revoked the hospice benefit or transferred to another hospice revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient's family revoked the hospice benefit on 08/21/2025 to pursue aggressive treatment. The family had called 911, and the patient was transported to the hospital. The record lacked evidence that the agency forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient transferred to another hospice on 08/08/2025. The record lacked evidence that the agency forwarded the discharge summary to the patient's attending physician. The Director of Nursing stated in an interview while performing joint clinical record reviews on 09/18/2025 that the discharge summaries were not sent to the patient's attending physician for patients that either revoked and went to the emergency room or transferred to another hospice.