Every finding on record at Silverleaf Hospice, Inc.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to send a nurse to P1 for treatment and nursing interventions for pain symptom management for one patient (P) (P5) of three sample patients. --- Findings included: Review of document titled “Patient Bill of Rights,” revised November 2018 revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of text messages sent on 02/19/2026 from the family of P5 to the case manager revealed a request for a nurse visit to address a crisis and pain. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). The case manager failed to  provide a nurse visit until 02/23/2026. Review of on call and complaint logs failed reveal the complaint from P5. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain.

Based on policy titled "COMPLAINT/GRIEVANCE PROCESS," review of on call and complaint logs, and family and staff interview, it was determined that the agency failed to investigate a complaint for one patient (P) (P5) of three sampled patients related to a crisis and pain. --- Findings included: Review of policy titled "COMPLAINT/GRIEVANCE PROCESS," revised date November 2018, revealed its purpose is to set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. The hospice agency staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five days of the alleged grievance. Review of on call and complaint logs failed to reveal the complaint from P5. During an interview on 03/30/2026 at 2:10 PM, the Administrator revealed the agency failed to document the complaint from the family of P5 and that the agency failed to send a nurse to address a crisis and manage pain. The Administrator confirmed the complaint from the family of P5 had been reported to her by the case manager. The Administrator confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction. An interview was conducted on 03/30/2026 at 1:19 PM with family member of P5 who stated that she texted the Case Manager (CM) requesting a nurse visit to manage a crisis and pain. The family member of P5 states the CM instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family member of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the CM made a visit on 02/23/2026 four days later. The family member of P5 stated she did not want any other patient to experience a delay in care.

Based on record review, staff and family interviews, it was determined that he agency failed to immediately investigate a complaint and resolve the complaint for one patient (P) (P5) of three sampled patients related to a crisis and pain. --- Findings included: Review of text messages sent on 02/19/2026 from family member of P5 to the case manager revealed a request for a nurse visit to address a crisis (potential bowel impaction) and pain. Review of text messages sent on 02/19/2026 from the family of P5 to the case manager revealed a request for a nurse visit to address a crisis (potential bowel impaction) and pain. An interview was conducted on 03/30/2026 at 2:00 PM with the case manager who stated that she received a text message from the family of P5 with a complaint. She stated she reported to the complaint to the Administrator. She states she failed to document the complaint according to the agency's policy.   An interview was conducted on 03/30/2026 at 1:19 PM with family member of P5 who stated that she texted the case manager requesting a nurse visit to manage a crisis and pain. The family of P5 stated she would forward the text messages to surveyors phone for viewing. The family member of P5 states the case manager instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family member of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the case manager made a visit on 02/23/2026 four days later. The family member of P5 stated she did not want any other patient to experience a delay in care. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to investigate the grievance for P5 and resolve the grievance to the patient’s satisfaction.

Based on policy titled “PATIENT BILL OF RIGHTS,” facility documents, record review, and staff and family interviews, it was determined that the agency failed to manage the patient’s pain and symptoms related to the terminal illness and related conditions in a timely fashion for one patient (P) (P5) of 19 patients reviewed. --- Findings included: Review of policy titled “PATIENT BILL OF RIGHTS,”  revised November 2018 revealed the patient has the right to receive effective pain and symptom management for conditions related to terminal illness(es). Review of text messages sent on 02/19/26 from the family member P5 to the case manager (revealed a request for a nurse visit to address a crisis and pain. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of record for P5 failed to reveal a nursed visit after request on 02/19/2026 until 02/23/2026. Review of on call and complaint logs failed to reveal the complaint from P5. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5.

Based on policy titled “THE PLAN OF CARE,” record review, and staff interview, it was determined that the agency failed to manage the pain and symptoms of the crisis for one patient (P) (P5) of 19 patients reviewed. --- The findings included: Review of policy titled “THE PLAN OF CARE,” Policy No. 4-027.1, revised  November 2024 revealed the following:“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.10. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.R. Pain and symptom management interventions.14. Care provided to the patient will be in accordance with the plan of care.” Review of text messages sent on 02/19/2026 from family member of patient P5 to the case manager revealed a request for a nurse visit to address a change in patient status, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication regarding the caregiver concerns or change in patient status or any follow up to medication effectiveness. Review of record for P5 failed to reveal a nursed visit after request on 02/19/2026 until 02/23/2026. Review of text messages sent on 02/19/2026 from family member of P5 to the case manager revealed a request for a nurse visit to address a crisis and pain. The case manager failed to complete a nurse visit until 02/23/2026. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5.

Based on review of policies and procedures, record reviews, and staff and family interviews, it was determined that the hospice's governing body failed to organize, manage, and administer its resources as evidenced by failure to:1. Provide on call staff 24 hours a day, seven days a week to meet the needs of the patient2. Provide pain assessments and management in a timely manner3. Provide staff for a patient visit for a significant change patient in condition4. Ensure all incoming complaints were documented and investigated in a timely manner5. Ensure the hospice administrator provided responsible oversight for day-to-day operations and supervision of hospice staffThese systemic failures impact the agency’s ability to provide care and services necessary for the management of the hospice patients’ terminal illness and related conditions. --- Findings included: An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who revealed the agency failed to send a nurse to address a crisis and manage pain. The Administrator confirmed the complaint from the family of P5 had been reported to her by the case manager. The Administrator confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction. An interview was conducted on 03/30/2026 at 2:00 PM with the case manager who stated that she received a text message from the family of P5 with a complaint. She stated she reported to the complaint to the Administrator. She states she failed to document the complaint per the agency's policy An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to investigate the grievance and resolve the grievance to the patient’s satisfaction Cross reference to L0508 and L509 relating to patient rightsCross refer to L0651 relating to the governing body and administrator.Cross refer to L0653 relating to availability of staff on a 24-hour basis seven days a week

Based on review of policies and procedures, record reviews, staff interviews, and family interview, it was determined the hospice agency failed to provide patient care that optimized comfort and safety to meet the needs and goals of the patient for one patient (P) (P5) of 19 sampled patient charts reviewed. --- Findings included: Review of record for P5 failed to reveal a nursed visit after request on 02/19/2026 until 02/23/2026. Refer to citation L512 for findings related to timely assessment of painRefer to citation L546 for findings related to pain management.

Based on review of policies and procedures, record reviews, staff and family interviews, it was determined the agency’s governing body failed to ensure hospice on call staff were available 24 hours a day, seven days a week to provide services to the patient such as change in patient condition, pain management and implementing and monitoring patients’ plans of care to include coordinating services based on the patient problems and needs for one patient (P) (P5) of 19 sampled patients. Additionally, the Governing Body failed to coordinate with members of the Interdisciplinary Group (IDG), to ensure staff were available at all times to meet the needs of the patient. --- Findings included: Cross reference to L0512 relating to right to effective pain managementCross reference to L0546 relating to Coordination of Services

Based on policy titled “HOSPICE NURSING CARE,” record review, staff and family interviews the hospice agency failed to ensure hospice staff were made available on a 24-hour basis 7 days a week to meet the needs of the patient for one patient (P) (P5) 19 patients reviewed. --- Findings included: Review of policy titled “HOSPICE NURSING CARE,” policy No. 4-002.1”  revised November 2018 revealed the following:“3. The hospice nurse will:   A.  Manage discomfort and provide symptom relief5. A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of the patients and families/caregivers admitted to the hospice program.” Review of text messages sent on 02/19/2026 from the caregiver of patient P5 to the case manager revealed a request for a skilled nurse visit to assess the patient for a change in patient condition, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication regarding the caregiver concerns or change in patient status or follow up to medication effectiveness. The case manager failed to complete a nurse visit until 02/23/2026. An interview conducted on 03/30/2026 at 1:19 PM with family member of  P5 stated that she texted the case manager requesting a nurse visit to manage a crisis and pain. The family of P5 states the case manager instructed her to administer Morphine 1ml (for pain) and Ativan (for agitation). The family of P5 stated the agency did not send a nurse to assess and manage the crisis. The family of P5 stated the case manager made a visit on 02/23/2026 four days later. The family of P5 stated she did not want any other patient to experience a delay in care. An interview on 03/30/2026 at 1:50 PM with the case manager who revealed that the she did receive a text message from the caregiver of P5 on 2/19/26  who reported that P5 had a bowel impaction and was in severe pain and agitation evidenced by screaming and crying. The case manager stated she had a family emergency and did not make the visit instead, advising the caregiver to medicate the patient for pain. The case manager reports she did pass the message to the Administrator but did not document any communication in the clinical record regarding communication with the caregiver or interventions provided. An interview was conducted on 03/30/2026 at 2:10 PM with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5. The Administrator confirmed that she did not have a nurse to send so she asked an as needed (PRN) nurse if she could completed the visit but did not follow up to see if the PRN nurse completed the visit. The PRN nurse did not complete the visit and the patient did not receive a skilled nurse visit until four days later on 02/23/2026.

Based on policy titled “ON-CALL/WEEKEND SERVICES,” clinical record reviews, on-call log, and staff interviews, it was determined the agency failed to comply with the nursing services one-hour response time of a patient experiencing a crisis situation or change in condition for one patient (P) (P5) of three patients sampled from the agency’s on-call report. --- The findings included: Review of policy titled “ON-CALL/WEEKEND SERVICES,” Policy no. 4-036.1, revised November 2024” revealed the following:“PROCEDURE5. The on-call nurse will provide follow-up appropriate to the call:A. Call the patient/family/caregiverB. Visit the patient, if necessary6. The on-call nurse will document each patient/family interaction in a clinical note.7. The on-call nurse will maintain an on-call log of all patient contacts during on-call hours.8. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page.)” Review of on-call and complaint logs for the year of 2026 failed to reveal the complaint was documented and investigated. Review of text messages sent on 02/19/2026 from family member of patient P5 to the case manager revealed a request for a skilled nurse visit to assess the patient for a change in patient condition, pain and symptom management. The case manager advised the family of P5 to administer Morphine 1ml (for pain) and Ativan (for agitation). The case manager failed to complete a nurse visit until 02/23/2026. Review of the clinical record for P5 failed to reveal skilled nurse documentation of communication concerns or change in patient status or any follow up to medication effectiveness. On 03/30/2026 at 1:50 PM an interview was conducted with the case manager. The case manager  revealed that she did receive a text message from the caregiver of P5 on 02/19/2026 who reported that P5 had a bowel impaction and was in severe pain and agitation and evidenced by screaming and crying. The case manager stated she had a family emergency and did not make the visit but advised the caregiver to medicate the patient for pain. The case manager reports she did pass the message to the Administrator but did not document any communication in the clinical record regarding communication with the caregiver or interventions provided. On 03/30/2026 at 2:10 PM an interview was conducted with the Administrator who confirmed the agency failed to send a nurse to address bowel impaction and pain of P5. The Administrator confirmed that she did not have a nurse to send so she asked an as needed (PRN) nurse if she could complete the visit but did not follow up to see if the PRN nurse completed the visit. The PRN nurse did not complete the visit and the patient did not receive a skilled nurse visit until four days later on 02/23/2026. Cross reference to L0508 and L0509 relating to patient rights.Cross reference to L0546 relating to the care plan.Cross reference to L0651 relating to the governing body and administrator.Cross reference to L0653 relating to availability of staff on 24-hour basis seven days a week

Based on review of clinical records, staff interview, and review of policy titled ";ADMISSION CRITERIA AND PROCESS", it was determined that the hospice agency failed to ensure that the initial comprehensive assessment was completed within 48 hours after the election of hospice care for one patient (P) (P#5) of 17 sampled patients (P#1, P#2, P#3, P#4, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). --- The Findings Include: Review of the policy titled ";ADMISSION CRITERIA AND PROCESS", Policy No. 4-021.5. ACHC Hospice/Revised November 2018 reveals: PURPOSE To establish standards and a process by which a patient can be evaluated and accepted for admission. 15. The hospice registered nurse will complete an initial assessment during this visit within 48 hours after the election of the hospice care (unless the physician, patient or representative requests that the initial assessment be completed in less than 48 hours.) (See" Initial Assessment" Policy No. 4-041.) Review of the clinical record for (P#5), with a primary diagnosis of cerebral infarction (or a stroke, is actually a brain lesion where a cluster of brain cells die when they fail to get enough blood) revealed the admission was completed on 7/4/2020. The initial skilled nurse assessment was completed on 7/7/2020, 72 hours after the election of hospice care. The clinical record failed to have documentation regarding the staff's delay in completing the assessments. An interview conducted with the Assistant Vice President of Operation (AVPO) on 4/3/2023 at 3:15 p.m., revealed that they had a problem with their previous electronic documentation systems, which was why the Hospice agency switched to new electronic documentation system. Additionally, the AVPO confirmed the surveyor has been provided with all available documentation for P#5.

Based on review of clinical records, staff interview, and policy titled, ";ADMISSION CRITERIA AND PROCESS", it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one patient (P) (P#2) of 17 sampled patients (P#1, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). --- The Findings Include: Review of the policy titled ";ADMISSION CRITERIA AND PROCESS," Policy No. 4-021.3. ACHC Hospice/Revised November 2018 reveals: PURPOSE To establish standards and a process by which a patient can be evaluated and accepted for admission. 4. In the event that the time frame for assessment cannot be met, the patients physician and the referral source, as well as the patient, will be notified for approval of the delay. A. Such notification and approval will be documented. B. If approval is not obtained for the delay, the patient will be referred to another hospice for services. P#2 admitted on 6/29/2022 with diagnosis of heart disease of native coronary artery (the arteries of the heart cannot deliver enough oxygen-rich blood to the heart). Review of the clinical record for P#2 revealed the initial spiritual assessment completed on 7/6/2022, seven days after the patient's admission. The clinical record failed to have documentation regarding the staff's delay in completing the assessments. In an interview with the Chaplin (CH) DD on 4/4/2023 at 1:00 p.m., revealed that the previous part time Chaplain was assigned to do the assessment and failed to document the reason she did not do it; after she resigned, they assigned P#2, spiritual assessment to him, seven days after initial comprehensive assessment. The CH DD additionally confirmed, surveyor received all available documentation for P#2.

Based on record reviews, staff interviews, and review of policy titled ";Compliance Tool for Hospices That Provide Care to Residents of a SNT/NF, ICF/IID or Other Facility", it was determined that the hospice failed to develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures. The hospice failed to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided as evidenced by no hospice care plans at patients facility for two patients (P) (P#1, P#3) of 17 patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). Failure to maintain hospice care plans at the facilities has the potential to impact the quality of care and services of the patients due to the hospices lack of communication with the facilities. --- The findings include: Review of Affinity Hospice Policy No. 4-039.A, Addendum ";Compliance Tool for Hospices That Provide Care to Residents of a SNT/NF, ICF/IID or Other Facility", revised November 2018 reveals: ";The hospice provides a copy of the plan of care, hospice election form, COTI, hospice contact information, how to access the staff 24/7 and hospice physician orders specific to the resident to the facility." 1. P#1 admitted to hospice 5/13/2022 with diagnosis of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A visit was made to P#1 at the personal care home (PCH) with Registered Nurse (RN) AA on 4/4/2023 at 9:00 a.m. Record review during that time reveals no hospice plan of care. Phone interview with PCH Administrator on 4/4/2023 at 9:15 a.m. revealed she has not received care plans or care plan updates from the hospice for P#1. Interview with RN AA on 4/4/2023 at 9:30 a.m., revealed there was no hospice chart in the facility for P#1 and that she was not aware of the hospice process for sharing care plan updates with the facility. 2. P#3 admitted to hospice on 7/18/2021 with diagnosis of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A visit was made to P#3 with Certified Nursing Assistant (CNA) BB on 4/4/2023 at 10:30 a.m. at the assisted living facility (ALF) Record review at that time revealed no hospice plan of care at the ALF. Interview with hospice Director of Clinical Operations on 4/5/2023 at 10:00 a.m. confirmed that there should be hospice folders that include plan of care (POC) and updates at the ALF but was unable to provide documents. Interview with CNA BB on 4/4/2023 at 11:30 a.m. revealed she did not know the location of the patients hospice chart in the facility. Interview with ALF Resident Care Coordinator and ALF Director of Memory Care on 4/4/2023 at 11:45 a.m. revealed there was no hospice plan of care at the ALF. The hospice failed to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided as evidenced by no hospice care plans at patients facility for two patients.

Based on record reviews, staff interviews, and review of policy titled ";Compliance Tool for Hospices That Provide Care to Residents of a SNT/NF, ICF/IID or Other Facility", it was determined that the hospice failed to ensure that each patients record includes the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes at their place of residence for two patients (P) (P#1, P#3) of 17 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). --- The findings included: Affinity Hospice Policy No. 4-039.A Addendum ";Compliance Tool for Hospices That Provide Care to Residents of a SNT/NF, ICF/IID or Other Facility", revised November 2018 reads: ";The hospice provides a copy of the plan of care, hospice election form, COTI, hospice contact information, how to access the staff 24/7 and hospice physician orders specific to the resident to the facility." 1. A visit was made to P#1 with Registered Nurse (RN) AA on 4/4/2023 at 9:00 a.m. at the personal care home (PCH). Record review at home visit for P#1 revealed no hospice records at the PCH. Interview with RNAA on 4/4/2023 at 9:30 a.m. revealed there was no hospice chart in the facility for P#1 and that she was not aware of the hospices process for sharing documentation with the facility. A phone interview with PCH Administrator at 9:15 a.m. on 4/4/2023, revealed she has not received care plans or care plan updates from the hospice for P#1. 2. A visit was made to P#3 with Certified Nursing Assistant (CNA) BB at 10:30 a.m. on 4/4/2023 at the assisted living facility (ALF). Record review at home visit for P#3 reveals no hospice records at the ALF. Interview with CNA BB at 11:30 a.m. on 4/4/2023 revealed she did not know the location of the patients hospice chart in the facility. Interview with ALF Resident Care Coordinator and ALF Director of Memory Care at 11:45 a.m. on 4/4/2023 revealed there were no hospice records for P#3 on site. Failure to maintain hospice records at the facilities has the potential to negatively impact patient care due to missing documentation.

Based on record review, and staff interview, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on patients hospice plan of care for two patients (P) (P#2, P#5) of 17 sampled patients (P#1, P#3, P#4, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17). --- The Findings include: 1. Clinical record reviewed for P#6 for certification period 12/16/2022 to 3/15/2023. Review of the plan of care for P#6 revealed admitted to hospice services on 12/16/2022, with a primary diagnosis of chronic obstructive pulmonary disease (COPD), unspecified, (chronic inflammatory lung disease that causes obstructed airflow from the lungs) with the following comorbidity (the simultaneous presence of two or more diseases or medical conditions in a patient): type one diabetes mellitus (a disease in which the body does not make enough insulin to control blood sugar levels) with diabetic neuropathy (type of nerve damage that can occur if you have diabetes). Record review revealed the agency failed in providing coverage for payment for the following medications used to manage the comorbidity: type one diabetes mellitus with diabetic neuropathy, unspecified; Insulin lispro pen (used to improve blood sugar control in adults and children with diabetes mellitus) inject six units subcutaneous three times daily, Humulin regular (a short-acting insulin that starts to work in 30 minutes and lasts for several hours to control your blood sugar levels), inject six units subcutaneous three times daily, and Lantus insulin (a long acting insulin) pen inject 30 units at bedtime used to lower blood sugar. The hospice agency failed to pay for the three insulin medications. 2. Clinical record reviewed for P#8 for certification period 4/7/2022 to 6/5/2022. Review of the plan of care for P#8 revealed admitted to hospice services on 4/7/2022 with a primary diagnosis of heart failure (the heart muscle cannot pump enough blood to meet the bodys needs for blood and oxygen). The record revealed the agency failed in providing coverage for payment for the medication used to manage the co morbidity of type one diabetes mellitus with diabetic neuropathy, unspecified, Humalog insulin inject 12 units subcutaneous before meals per sliding scale three times daily, and Levemir insulin inject 30 units subcutaneous two times daily to lower blood sugar. The hospice agency failed to pay for the two insulin medications. In an interview at the agencys office with the Executive Director (ED) on 4/3/2023, at 2:30 p.m., revealed that she was unaware of why the agency did not pay for the medications related to the listed co morbidities on the plan of care for P#8. The agency failed to provide the needed medications related to the co morbidities.