Every finding on record at Stand by U Hospice Care Inc.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the agency's emergency preparedness (EP) plan revealed the agency did not ensure it was reviewed and updated at least every two (2) years. A review and interview were conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time it was revealed the EP plan was reviewed and updated in 2022, then not again until 2025. She advised it was "because we did not have any patients in 2023 and 2024, so we did not review our EP plan." A review of the agency's emergency preparedness (EP) plan revealed the agency did not ensure it was reviewed and updated at least every two (2) years. A review and interview was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time it was revealed the EP plan was reviewed and updated in 2022, then not again until 2025. She advised it was "because we did not have any patients in 2023 and 2024 so we did not review our EP plan."

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the patient was informed about the scope of services the hospice provides and any specific limitations on those services. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/17/2025 and requested the non-covered items addendum. A clinical record review on 11/25/2025 revealed that the electronic medical record (EMR) contained documentation indicating that this had been signed however the area where the non-covered items should be listed was not filled out. This should have been issued within five (5) days of the election of benefits, making it over two and half months outstanding. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/23/2025 and requested the non-covered items addendum. A clinical record review on 11/25/2025 revealed that the electronic medical record (EMR) did not contain documentation indicating that this had been completed or given to the patient. This should have been issued within five (5) days of the election of benefits, making it nine (9) months outstanding. A clinical record review and interview was conducted with the Administrator on 11/26/2025. She stated that "I didn't realize we needed to send them anything."

It is required that the hospice takes action to improve performance and assesses the success of the action after implementing it. This standard was not met as evidenced by document review and interview. A review of the agency's Quality Program revealed the agency did not ensure the agency took action to improve performance and assess the success of the action after implementing it at least annually. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she advised "they did not have Quality meetings or Performance Improvement Projects during 2023 or 2024 as there were not any patients. There was one in 2022 when there was a survey, and we had one again in 2025 because we had another survey coming." A review of the agency's Quality Program revealed the agency did not ensure the agency took action to improve performance and assesses the success of the action after implementing it at least annually. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she advised "they did not have Quality meetings or Performance Improvement Projects during 2023 or 2024 as there were not any patients. There was one in 2022 when there was a survey and we had one again in 2025 because we had another survey coming."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged live, revealed the agency did not ensure the discharge summary was forwarded to the patient's attending physician. Document 2: Agency Policy titled "Discharge Summary Policy No 1-026 dated April 2020" stated in relevant parts: "Procedure: 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued which may include the patient's current plan of care. A copy of the discharge summary will be provided to the patient's attending physician." CLINICAL RECORD 3: The patient elected to revoke their hospice Medicare benefit on 05/21/2025. The clinical record did not contain evidence of the discharge summary being forwarded to the patient's attending physician. An interview and joint clinical record review was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she said "they declined our services and I didn't realize we needed to fax something to the Dr."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the patient's discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Document 2: Agency Policy titled "Discharge Summary Policy No 1-026 dated April 2020" stated in relevant part: "Procedure: Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued which may include the patient's current plan of care. A copy of the discharge summary will be provided to the patient's attending physician." CLINICAL RECORD 3: The patient elected to revoke the hospice benefit on 05/21/2025. The discharge summary dated 05/21/2025 included the following note: "Visiting RN *** reported that patient wants to be discharge today because he is seeking further treatment with his doctor. Hospice physician notified and order to discontinue all medications and treatment, discharge patient per patient requests." The discharge summary did not include at least a summary of the patient's hospice stay including treatments, symptoms and pain management. An interview and joint clinical record review was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 during which time she stated, "I thought we just needed to obtain an order and write a note."

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of patients who resided in a skilled nursing facility revealed the agency did not ensure that hospice care of the patient/resident was stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/11/202 and was a resident of a skilled nursing facility (SNF) per documentation in the admission nurse's note. The patient remained a resident of the SNF until his discharge on 07/12/2025. A review of the clinical record on 11/25/2025 revealed that the clinical record did not contain documentation of a written plan of care that documented the collaboration between the hospice and the SNF. A joint clinical record review and interview was conducted with the Administrator/Director of Patient Care Services on 11/25/2025 in which she was unable to locate documentation of a written plan of care for facility coordination.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 5 (20%) clinical records reviewed, the patient's individual written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. The agency policy, Plan of Care #9-017, (Dated: 4/2020), stated in part, "The 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." Clinical Record 1: The patient was admitted on 10/1/22. There was a physician order dated 11/5/22 that stated to start wound care on "left hand skin tear - to cleanse with normal saline, gently pat dry and cover with dry dressing." The interdisciplinary group (IDG) POC dated 11/11/22 lacked a goal and interventions that included the specific wound care ordered. In an interview on 12/23/22, the Director of Patient Care Services (DPCS) and the DPCS designee reviewed and agreed with the above finding.

It is required that the hospice provides nursing care under the supervision of a Registered Nurse. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 2 (100%) clinical records reviewed of patients that had services provided by a Licensed Vocational Nurse (LVN), the record lacked evidence of the Registered Nurse completing a supervisory visit per agency policy. The agency policy, Agency Responsibilities/Supervision of Clinical Services #1-031, (Dated: 4/2020), stated in part, "Procedure: 7B. A monthly patient visit will be completed by a Registered Nurse to supervise licensed practical/vocational nursing services." Clinical Record 2: The patient was admitted on 10/30/22. The first LVN visit was on 11/7/22. The record lacked a LVN supervisory visit every 30 days. As of 12/23/22, no LVN supervisory visits had been completed. Clinical Record 1: The patient was admitted on 10/1/22. The first LVN visit was on 11/5/22. The record lacked a LVN supervisory visit every 30 days. As of 12/23/22, no LVN supervisory visits had been completed. In an interview on 12/23/22, the Director of Patient Care Services (DPCS), and the DPCS designee reviewed and agreed with the above findings.