Every finding on record at Sun Tree Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 4 (25%) observed home visits, it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT3/CLINICAL RECORD 3: The patient elected the hospice benefit on 09/22/2025 for a diagnosis of Alzheimer's disease. The patient resided in an assisted living facility (ALF). During the observed home visit with the registered nurse (RN - Personnel Record 4) on 03/17/2026 the hospice medication profile (printed on 03/16/2026) was compared to the ALF medication profile (printed on 03/17/2026). The hospice medication profile listed the following medication(s) not listed on the ALF profile: "Losartan 100 mg tablet, take 1 daily (ordered 01/30/2026.) The following discrepancies were noted: the hospice medication profile included Bisacodyl 10 mg suppository, give one daily (ordered 09/25/2025) and the ALF medication profile listed Bisacodyl 10 mg suppository, give one daily as needed (ordered 10/21/2022); The hospice medication profile included Melatonin 5 mg tablet every 24 hours (ordered 09/25/2025) and the ALF medication profile listed Melatonin 5 mg tablet every 24 hours as needed (ordered 10/09/2023)." The most recent documented comprehensive nursing visit was on 03/09/2026. An interview and joint clinical record review was conducted with the Director of Patient Care on 03/19/2026 during which time she stated "Nurses should be reviewing medications during every visit."

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. 4 of 17 (24%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided patient-specific written instructions for the HA. CLINICAL RECORD 4/HOME VISIT 4: The patient resided in a skilled nursing facility (SNF) and the hospice benefit was elected on 12/17/2025. The HA care plan dated 12/17/2025 (updated 03/06/2026) included the following assigned tasks: "Assist to toilet, bathing (shower), shampoo, hair care, perineal care, shaving, oral care, nail care, dressing, lotion application, empty trash in patient area, change linens, PPE (personal protective equipment) precautions, fall precautions." All tasks were to be completed every visit with an aide visit frequency of three times weekly. During the observed home visit on 03/18/2026 with the HA (Personnel Record 7), the Aide explained the patient was observed to describe the patient's clothes in detail, allowing him to feel the clothing. The aide also took extra precautions to place the patient's hands on his walker when getting him up and taking him towards the bathroom. He then stated the patient was "considered fully blind." The aide stated he had learned this information "by working with the patient for a while." This information was not documented on the HA care plan. Additionally, the patient was observed to be bald, therefore shampoo and hair care needed to have specific instructions for care to be provided by the aide. CLINICAL RECORD 7: The patient resided at home and elected the hospice benefit on 06/06/2025. The HA care plan dated 01/29/2026 included the following assigned tasks: "Assist with ambulation, assist to toilet, routine catheter care, nail care, lotion application, offer fluids, empty trash, empty urinary drainage bag, fall precautions." All tasks were to be completed every visit with an aide visit frequency of twice weekly. A nursing visit dated 02/26/2026 documented "Indwelling suprapubic catheter due to be changed on 3/26/2026 however after discussion with daughter the decision was made to remove catheter." A nursing visit dated 03/03/2026 documented "Pain persists despite catheter removal." The task(s) of routine catheter care and empty drainage bag were not removed from the aide care plan when the catheter was removed from the patient. An interview was conducted with the Director of Clinical Services on 03/18/2026 and she advised the catheter had been replaced on 03/11/2026 "as she had just ordered supplies for it. Therefore, the patient was without a catheter from 02/26/2026 to 03/11/2026 and it remained on the aide care plan during that time." CLINICAL RECORD 14: The patient elected the hospice benefit on 02/09/2026. The HA care plan dated 02/09/2026 included the following assigned tasks: "Assist to toilet, assist with feeding, bathing (shower), shampoo, hair care, perineal care, oral care, nail care, dressing, lotion application, offer fluids, empty trash in patient area, change linens, fall precautions, aspiration precautions, oxygen precautions." All tasks were to be completed every visit with an aide frequency of twice weekly. The patient lived in a private home. The patient's initial Plan of Care (POC) with a start date of 02/09/2026 included the following: "Problem: Altered Nutrition/Hydration; Goal: Patient will maintain proper nutrition without choking, coughing or force feeding; Intervention: SN (skilled nurse) to educate family regarding feeding patient and use of ensure to maintain nutritional intake. SN to also educate family regarding offering soft foods and/or cutting up food thoroughly to avoid risk of dysphagia/aspiration-diet mechanical soft." This information was not documented in the aide plan of care, nor were specific instructions for feeding the patient documented for the aide. CLINICAL RECORD 18: The patient resided in a SNF and the hospice benefit was elected on 02/26/2026. The HA care plan dated 02/27/2026 included the following assigned tasks: "Turn and position in bed, assist to toilet, bathing (shower), shampoo, hair care, perineal care, shaving-at patient request, oral care, dressing, offer fluids, change linens, fall precautions, oxygen precautions." All tasks were to be completed every visit with the exception of shaving. The aide visit frequency was three times weekly. The aide care plan did not provide the aide with specific instructions for shaving for a patient with a diagnosis of senile degeneration of the brain who was described on admission (02/26/2026) by the nurse as "confused". An interview and joint clinical record review was conducted with the Director of Patient Care on 03/19/2026 during which time she stated the information "was probably passed along to the aides in the individual patient threads but wasn't documented in the charts and if the aides had to be changed out she could see where it could cause issues."

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. A review of the volunteer program was conducted with the Volunteer Coordinator and Director of Patient Care Services on 03/19/2026, during which time it was noted that the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged 4.33%. The Volunteer Coordinator advised they had "Lost a lot of patients in the fall that had volunteers and steady volunteers traveling out of town to take care of their own family members. Recruitment had been down a bit as it was previously done via Volunteer Match however the name change stalled it out a bit." NOTE: the name change occurred due to acquisition by a corporate entity. She was "optimistic as the March numbers improving and were currently at 6.6%" A review of the volunteer program was conducted with the Volunteer Coordinator and Director of Patient Care Services on 03/19/2026, during which time the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged to 4.33%. The Volunteer Coordinator advised they had "Lost a lot of patients in the fall that had volunteers and steady volunteers traveling out of town to take care of their own family members. Recruitment had been down a bit as it was previously done via Volunteer Match however the name change stalled it out a bit." She was "optimistic as the March numbers improving and were currently at 6.6%"

It is required that the hospice maintains an emergency preparedness 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: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles and EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 12 (17%) personnel records reviewed, the hospice did not ensure the EP training was completed at time of hire and every 2 years. Clinical Record 11: The Volunteer was hired on 5/11/22. A review of the personnel record and inservice attendance records revealed no evidence of emergency preparedness training at hire. Clinical Record 5: The contracted Physical Therapist (PT) was hired on 1/1/2016. A review of the personnel record and inservice attendance records revealed no evidence of emergency preparedness training for 2021 and 2022. During interview 6/16/23, the Administrator stated, "We are unable to locate the missing emergency preparedness training". During interview 6/16/23, the Administrator stated, "We are unable to locate the missing emergency preparedness training".

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 document review, interview, and personnel record review. Organizational policy #7-001, "Infection Control Plan," stated in part, "...will educate all personnel on infection control policies, procedures and their responsibilities for implementation …New Personnel will receive a copy of the standards of practice in their orientation packets...Infection control inservices will be scheduled no less than annually, attendance will be mandatory and will be documented, records of inservice education will be maintained in the personnel file." In 2 of 12 (17%) personnel records reviewed, the hospice did not ensure infection control training was completed during orientation and annually as required by agency policy. Clinical Record 6: The Volunteer Coordinator was hired on 2/7/22. A personnel record review revealed no documented evidence that infection control education was completed at hire and annually per the policy. Clinical Record 5: The contracted Physical Therapist (PT) was hired on 1/1/2016. A personnel record review revealed no documented evidence that infection control education was completed in 2021 and 2022. During the interview on 6/16/23, the Administrator stated, "We are unable to locate the missing infection control inservices." Policy "Infection Control Plan", Policy No. 7-001, included in part, "(Name of hospice) will educate all personnel on infection control policies, procedures and their responsibilities for implementation as contained throughout this section", "New Personnel will receive a copy of the standards of practice in their orientation packets", and "Infection control inservices will be scheduled no less than annually, attendance will be mandatory and will be documented, records of inservice education will be maintained in the personnel file". During interview 6/16/23, the Administrator stated, "We are unable to locate the missing infection control inservices".

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 17: The patient elected hospice on 11/9/2022. The hospice aide care plan documented the hospice aide visit frequency as three times a week. A clinical record review revealed one hospice aide visit was missed the week of 2/13/2023. There was no evidence of a documented missed visit or communication with the physician regarding a change in the hospice aide visit frequency. During an interview on 6/16/2023, the Director of Nursing confirmed the missing hospice aide visit note and missed visit documentation and stated, "Appears the scheduler didn't plot the third visit for that week on the calendar."