Every finding on record at S B Healthcare LLC

Based on the policy titled “Complaint /Grievance Process,” the agency’s complaint logs, record review, email correspondence provided by the agency, and family member and staff interviews, it was determined the agency failed to investigate the complaints reported by patient’s family members and take appropriate corrective action for three patients (P) (P#2, P#3, and P#4) of six patients reviewed. --- Findings include: Review of the policy titled “Complaint /Grievance Process,” Policy No.2-006.1 revised  November 2018 revealed the following:PROCEDURE1. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of alleged grievance. The supervisor will investigate the grievance within five (5) days of receipt of such grievance and will make every effort to resolve the grievance to the patient’s satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt.4. Complaints and any action taken will be documented on a complaint form.5. Corrective action will be specific and related to complaint.6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. 1. Review of document titled “Complaint Report,” dated December 16, 2025, at 12:00 a.m. revealed P#2 called the agency to complain she (P#2) had not received a Certified Nurse Aide visit (CNA) visit on her scheduled day. 2. Review of document titled “Complaint Report,” dated October 6, 2025, at 6:30 p.m. revealed the family member of P#3 called the agency to complain that P#3 did not receive a CNA visit yesterday. Records review failed to reveal any resolutions to the missed visit complaints of P#2 and P#3. 3. Records review revealed an email correspondence dated December 18, 2025, at 8:54 p.m. from the family member of P#4 to the agency’s Regional Vice President of Operations (RVP OP), Executive Director (ED), and the Registered Nurse (RN). The family member of P#4 requested to speak with the doctor and requested an updated care plan. Records review revealed an email correspondence dated January 4, 2026, at 1:45 p.m. from the family member of P#4 to the agency’s RVP OP, ED, and the RN. The family member of P#4 made another request to speak with the doctor immediately and expressed concerns of a medical breach. Records review revealed an email correspondence dated January 6, 2026, at 3:53 p.m. from the ED to the family member pf P#4 stating that the doctor will be available to speak with him over the phone on January 8, 2026. Records review revealed an email correspondence dated January 7, 2026, at 9:01 p.m. from the Area Director of Clinical Services (ADCS) to the family member of P#4 with the aide care plan and nursing care plan attached. Records review revealed an email correspondence dated January 8, 2026, at 2:22 p.m. from the family member P#4 to ADCS, ED, RN, and RVP OP stating his call with the doctor was scheduled for 2:10 p.m. but as of 2:22 p.m., he had not spoken with the doctor. On January 20, 2026, at 1:55 p.m., during a phone interview, the family member of P#4 confirmed he was unhappy with the care P#4 received from the hospice due to their lack of communication. On January 21, 2026, at 12:30 p.m., during a phone interview, RN AA revealed that the family member for P#4 had the doctor waiting on the phone for thirty-five minutes because the family member wanted an in-person meeting with the doctor.

Based on review of policies and procedures, record reviews, and staff and family interviews, it was determined the agency failed to communicate and coordinate care in order to address the needs of patients and families for five patients (P) (P#1, P#2, P#4, P#5, P#6) of eight sampled patients.Specifically, the facility failed to:•           Communicate with families, patients and other team members in order to respond to the needs of patients and families for two patients (P#4, P#6).•           Include the patient representative in updates to the plan of care updates for one patient (P#4).•           Ensure care was provided in accordance with the hospice plan of care for five patients (P#1, P#2, P#4, P#5, P#6). Patients did not receive Hospice Aide visits as ordered. --- Findings include: Cross reference to L0539 relating to coordination of care by the IDG.Cross reference to L0543 relating to coordination of care with the patient representative.Cross reference to L0555 relating to following the plan of care.

Based on review of the policy titled “The Plan of Care,” record reviews, facility correspondence, and staff and family interviews, it was determined the agency’s interdisciplinary group (IDG) failed to communicate and coordinate care in order to address the needs of patients and families for two patients (P) (P#4, P#6) of eight sampled patients. --- Findings include: Review of the policy titled “The Plan of Care,” Policy No. 4-027.2, revised November 2018, revealed the following:PolicyThe plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. This plan will focus on identified problems, goals and interventions. Record review revealed P#4 was admitted to hospice on 12/9/2024. Review of emails provided by the agency revealed an email from P#4’s family member, dated 12/18/2025 to four hospice staff (Regional VP of Clinical Operations, RN Case Manager (RN CM), Executive Director, and Social Worker) with a complaint regarding “no updated care plan for me to see” at the personal care home’s (PCH) care plan meeting.  The email further revealed family member of P#4 calling Medicare, who informed him that he should get a copy of the care plan, “but I never do.” Regional VP of Clinical Operations emailed the plan of care for P#4 to the family on 1/7/2026. Further review of emails revealed P#4’s family member emailed hospice staff (Regional VP of Clinical Operations, Executive Director, and Social Worker) on 12/7/2025 at 3:54 p.m. to report that P#4 was having abdominal pain. On 12/9/2025 at 3:39 p.m., the email was forwarded to the P#4’s RN CM, who responded to family on 12/10/2025 at 3:16 p.m., reporting the patient was in no acute distress. The clinical record failed to explain the delay in addressing the concern. On 1/21/2026 at 9:45 a.m., a telephone interview was conducted with the family member of P#6, who revealed a call was made to the office on 1/20/2026 to report P#6 was nauseous and dizzy and requesting a call back. Family member verbalized that no return call was received yet and explained it was not unusual for the hospice to not return her calls and there was an overall lack of communication from the hospice. On 1/21/2026 at 12:00 p.m., an office interview was conducted with Regional VP of Clinical Operations (RVPCO) and Area Director of Clinical Services (ADCS), who explained that copies the plan of care are made once a month and placed in patients’ homes. Neither the RVPCO or the ADCS could explain why the family of P#4 did not have or promptly receive a care plan. They additionally verbalized they were not aware of the call from P#6’s family member or had knowledge of why the call was not returned.

Based on a policy titled “The Plan of Care,” record reviews, and staff and family interviews, it was determined the agency failed to include the patient representative in the plan of care updates for one patient (P) (P#4) of eight sampled patients. --- Findings include: Review of the policy titled “The Plan of Care,” Policy No. 4-027.1, revised November 2018, revealed the following:PolicyThe patient and family/caregiver will be encouraged to participate in the development and continued updating of the plan of care.Procedure4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement.9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Record review for P#2 revealed the following physician medication orders:1/24/2025:D/C Bupropion (an antidepressant that works by increasing norepinephrine and dopamine in the brain, helping to improve mood and focus) 150 mgStart Bupropion, 75 mg at bedtime nightlyLorazepam (a medication used to treat anxiety) 0.5 mg qHS 4/2/2025:Please change Bupropion 75 mg to be given in the morning. Please crush pill and give in applesauceD/C Lorazepam 0.5 mg at bedtimeLorazepam 0.5 mg po q 4 hours prn for sleeplessness or agitationD/C hyoscyamine (can be used to treat excessive secretions at the end of life) per family request Further review of the clinical record failed to reveal that the family member of P#4 was made aware of the new medication orders. On 1/20/2026 at 1:55 p.m., a telephone interview was conducted with the family member of P#4, who revealed he was P#4’s family member and that the hospice had ordered and changed medications for P#4 without notifying or discussing it with him. On 1/21/2026 at 12:00 p.m., an office interview was conducted with Regional VP of Clinical Operations (RVPCO) and Area Director of Clinical Services (ADCS), who agreed the clinical record did not contain communication or collaboration with P#4’s family member when medications were ordered or changed.

Based on policies titled “The Plan of Care” and “Missed Visits,” records review, and staff and family interviews, it was determined the agency failed to ensure care was provided in accordance with the hospice plan of care for five patients (P) (P#1, P#2, P#4, P#5, P#6) of eight sampled patients. Specifically, patients failed to receive Hospice Aide visits as ordered. --- Findings include: Review of the policy titled “The Plan of Care,” Policy No. 4-027.1, revised November 2018, revealed the following:PolicyThe care provided to the patient must be in accordance with the plan of care.Procedure4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement.12. The written plan of care will contain, but will not be limited to, the following:M. Frequency/Amount/Duration of services14. Care provided to the patient will be in accordance with the plan of care. Review of the policy titled “Missed Visits,” Policy No. 4-101.1, revised November 2018, revealed the following:PolicyMissed visits will be documented in the clinical record.Procedure2. If a visit is missed and not rescheduled the clinician will:B. Document in the patient’s clinical record the following information:3. Reason for the missed visit4. Description of any unmet needs and how the patient’s needs were met6. Other person(s) that were notified of the missed visit3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/ supervisor will take the appropriate measures stated above.5. If a patient is routinely refusing visits, the clinician and IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director. 1. Record review for P#1 revealed a physician order dated 12/5/2025, ordering HHA (Hospice Aide) visits six times a week for one week, then five times a week, effective 12/7/2025. Review of Hospice Aide Visit Notes revealed the following:From 12/7/2025 to 12/13/2025 five HHA visits revealed on 12/8/2025, 12/9/2025, 12/10/2025, 1211/2025 and 12/12/2025. Review of  documentation by HHA dated 12/8/25 on the Missed Visit Notification revealed “Not working. No coverage for today.” From 12/14/2025 to 12/20/2025 three HHA visits revealed on 12/17/2025, 12/18/2025 and 12/19/2025. Further review of the clinical record failed to reveal documentation of the two missed visits for the week of 12/14/2025. 2. Record review for P#2 revealed a physician order dated 12/4/2025, for HHA (Hospice Aide) visits two times a week for two weeks and one time a week for one week, effective 12/7/2025. Review of Hospice Aide Visit Notes revealed the following:From 12/14/2025 to 12/20/2025 revealed one Hospice Aide visit on 12/18/2025. Further review of the clinical record failed to reveal documentation of missed visit for the week of 12/14/2025. Review of Complaint Report dated 12/16/2025 revealed P#2 called in a complaint stating she did not get a visit from the Hospice Aide on her scheduled day and had to wait two days to be seen again. 3. Record review for P#4 revealed a physician order for HHA (Hospice Aide) visits three times a week, effective 12/7/2025. Review of Hospice Aide Visit Notes revealed the following:From 12/21/2025 to 12/27/2025 revealed twoHHA (Hospice Aide) visits on 12/22/2025 and 12/24/2025. From 12/28/2025 to 1/3/2026 revealed  two HHA (Hospice Aide) visits on 12/29/2025, and 12/31/2025. Further review of the clinical record failed to reveal documentation of missing visits for the week of 12/21/2025 and the week of 12/28/2025. 4. Record review for P#5 revealed a physician order for HHA (Hospice Aide) visits two times a week for one week and three times a week for eight weeks, effective 9/23/2025. Review of Hospice Aide Visit Notes revealed the following:From 9/28/2025 to 10/4/2025 revealed two HHA (Hospice Aide) visits revealed on 9/29/2025 and 10/3/2025. Review of a Missed Visit Notification, dated 10/1/2025, revealed family was notified but failed to reveal details. From 10/5/2025 to 10/11/2025 revealed one HHA (Hospice Aide) visit on 10/6/2025. Review of the clinical record failed to reveal details regarding the second missed visit for the week of 10/5/2025.                      From 10/12/2025 to 10/18/2025 revealed one HHA (Hospice Aide) visit on 10/17/2025. From 10/19/2025 to 10/25/2025 revealed two HHA (Hospice Aide) visits on 10/20/2025 and 10/22/2025. Further review failed to reveal documentation of the missed visit. From 10/26/2025 to 11/1/2025 failed to reveal HHA (Hospice Aide) visits. Review of the clinical record failed to reveal documentation of the third missing visit for the week of 10/29/2025.                                                                      Further review of Missed Visit Notifications for P#5 revealed a Hospice Aide Missed Visit Notification, dated 12/8/2025 stating, “Not working. No coverage for today.” 5. Record review for P#6 revealed a physician order dated 8/12/2025 for HHA (Hospice Aide) visits two times a week for eight weeks. Review of Hospice Aide Visit Notes revealed one HHA (Hospice Aide) visit for the week of  9/29/2025 through 10/4/2025.  Review of a Missed Visit Notification note, revealed a late entry for 9/30/2025 that family was contacted but failed to include the reason or any unmet care needs. On 1/20/2026 at 1:55 p.m., a telephone interview was conducted with family member of P#4, who revealed he was P#4’s POA. He confirmed missed Hospice Aide visits but was unable to state any reasons why they were missed as P#4 lives in a personal care home (PCH). On 1/20/2026 at 3:00 p.m., an office interview was conducted with the Clinical Support Specialist (CSS), who revealed that she is responsible for reassigning staff visits if they are out. She explained that on weekends or after hours, the Administrator or other on-call staff is responsible for reassignments. She further revealed recent staff turnover in that position and agreed that some of the missed visit documentation did not follow the agency’s policy. On 1/21/2026 at 9:45 a.m., a telephone interview was conducted with the family member of P#6, who confirmed P#6 had missed visits from the Hospice Aide. She was unable to recall the reasons given to her why the Hospice Aide didn’t come but confirmed there had been issues with the Hospice Aide coming as scheduled. On 1/21/2026 at 12:00 p.m., an office interview was conducted with Regional VP of Clinical Operations (RVPCO) and Area Director of Clinical Services (ADCS), who explained that the electronic medical record (EMR) did not have the options needed for documentation of missed visits, as it was a pre-filled checklist without the option to add details. The ADCS revealed that the Hospice Aides are to write a Coordination Note explaining the specifics of why the visit was not made, who was notified, and what arrangements were made to cover patient needs. Both the RVPCO and ADCS confirmed all documentation of Hospice Aide visits, missed visits and coordination notes had been provided for P#1, P#2, P#4, P#5, and P#6 and acknowledged there were incomplete or missing notes.

Based on the review of policies and procedures, records review, and family member and staff interviews, it was determined the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, and the provision of all hospice services to include the following:1. failure to investigate complaints reported by patient’s family members and take appropriate corrective action,2. failure to ensure Certified Nurse Aide (CNA) visit frequencies were met, and3. failure to encourage patient (P) and patient caregiver (PCG) participation in developing and updating the plan of care (POC). --- Findings include: Cross reference to L0509 relating to the hospice’s failure to investigate complaints reported by patient’s family members and take appropriate corrective action for P#2, P#3, and P#4. Cross reference to L0555 relating to the hospice’s failure to ensure Certified Nurse Aide (CNA) visit frequencies were met for P#1, P#2, P#4, P#5, and P#6. Cross reference to L0543 relating to the hospice’s failure to encourage patient (P) and patient family member participation in developing and updating the plan of care for P#4.

Based on clinical record reviews, home visit observations, and staff interviews, it was determined the agency staff failed to ensure that patients' medication profiles were updated to reflect current medications for 2 of 4 (#13, and #15) patients receiving home visit observations. 1. Review of record review for P#13 with certification period of 9/4/22 - 12/2/22 revealed a diagnosis of senile degeneration of brain, During home visit on 9/7/22 at approximately 8:00a.m. , this surveyor compared the patient's medication administration report at the Inpatient unit (IPU) with the agency's medication profile. According to the IPU the medications Vasopression and Norepinephrine were discontinued on 9/5/22. The agency staff failed to update the medication profile to reflect the patient's current medication regimen at each visit as required. 2. During Home visit on 9/7/22 at approximately 09:45 a.m. a review of records for Patient (#15) with the certification period 8/10/22 - 11/7/22, start of care on 8/10/22 and Diagnosis of Unspecified Dementia with behavioral Disturbances was conducted. During record review this surveyor compared the patient's medication administration report given by the caregiver with the agency's medication profile. During interview of patient Care Giver on 9/7/22 at approximately 10:15 A.M. the caregiver presented the surveyor with 3 medications the patient was taking during admission assessment on 9/7/22. Admitting RN failed to obtain an order on admission for the continuation of Amlodipine 2.5 mg taken 1 time a day, Aspirin 81 mg taken 1 time a day, and Mirtazapine 15 mg taken 1 time a day. During an interview on 9/7/22 at 12:00 p.m., the Adminsitrator acknowledged that the medication profile was not reconcilled on above mentioned patients.

Based on observations, clinical record reviews and staff interviews, it was determined that the interdisciplinary group failed to ensure that plan of care addressed specific, individualized interventions necessary for the palliation and management of the terminal diagnosis for 3 of 16 patients (P#) (#5, #6, #13). Findings include: 1. Review of the clinical record for patient # 6 with an admission date of 8/24/22 and a diagnosis of end stage systolic heart failure revealed the Registered Nurse (RN) visited the patient on 9/2/22 and documented the Foley catheter was changed on 8/25/22 using a 16 French catheter. However, the clinical record lacked a physician's order for the care and maintenance of a foley catheter. Furthermore, the plan of care revealed that patient has a peripherally inserted central catheter (PICC), line for infusion therapy. However, the plan of care lacks the frequency to change the PICC line dressing; step by step process in cleaning the insertion site, type and amount of medications /solutions to irrigate/flush the PICC line lumens and apply the specific type of dressing to the insertion site. The skilled nurse failed to obtain a physician's order for the care and maintenance of the PICC line and foley catheter. During an interview on 9/8/22, at 12:00 p.m., the Administrator did provide an order for foley catheter care dated 9/8/22. The clinical record lacked a physician's order for the foley catheter change done on 8/25/22. The Administrator also provided PICC line care order dated 9/8/22, however, the order lacked step by step process in cleaning the insertion site, type and amount of medications/solutions to irrigate/flush the PICC line lumens and apply the specific type of dressing to the insertion site. 2. Review of the clinical record for patient # 5 with an admission date of 6/4/22 and a diagnosis of esophageal cancer revealed the patient has a tracheostomy and gastrostomy /feeding tube. Registered Nurse (RN) visited the patient on 8/9/22 and documented the patient has tracheostomy and all trach care is done by the patient. However, the plan of care lacks specific orders for tracheostomy care to include the size and type of cannula, step by step process in cleaning the cannula and the stoma site of the tracheostomy. On 9/7/22 at 0800 a.m. A review of the patients records for certification period of 9/4/22 - 12/2/22 for (P#13) admitted to Hospice on 9/4/22 with a diagnosis of Senile Degeneration of Brain was conducted. During review of patient records it was revealed Skilled Nurse failed to obtain an order for foley catheter insertion and scheduled changes, Central Venous Catheter (CVC) insertion and schedule dressing change, or Oxygen administered via nasal cannula. During an interview on 9/8/22 at 12:00 p.m., the Administrator provided an order for tracheostomy care dated 9/8/22. The order reads, patient to perform own tracheostomy care every 8 hours and as needed. The order lacks the type and size of the cannula and step by step process in cleaning the cannula and tracheostomy site. 3. On 9/7/22 at 0800 a.m. A review of the patients records for certification period of 9/4/22 - 12/2/22 for (P#13) admitted to Hospice on 9/4/22 with a diagnosis of Senile Degeneration of Brain was conducted. During review of patient records it was revealed Skilled Nurse failed to obtain an order for foley catheter insertion and scheduled changes, Central Venous Catheter (CVC) insertion and schedule dressing change, or Oxygen administered via nasal cannula. During an interview on 9/8/22 at 12:00 p.m., the Administrator acknowledged that SN failed to obtain an order for foley catheter insertion and scheduled changes, Central Venous Catheter (CVC) insertion and schedule dressing change, or Oxygen administered via nasal cannula.

Based on clinical record review, it was determined that the hospice failed to ensure a coordinated plan of care that specifically identified the provider responsible for each intervention included in the plan of care for 1 0f 1 ( #13) sampled patients who resided in a Inpatient Care Unit (IPU). Findings Include: 1.The clinical record for patient #13 reflected that the patient was admitted to the hospice on 9/7/22 with a Diagnosis of Senile Degeneration of the Brain and resided in a Inpatient Care unit. The hospice plan of care (POC) did not identify the specific provider and discipline responsible and accountable for each intervention/task/function. During an interview with RN 9/7/22 at 8:00 a.m., RN reported no POC was given to the IPU for patient (#13). A review of the patients records for certification period of 9/4/22 - 12/2/22 revealed no agreed POC between the IPU and Hospice facility was being found.