Every finding on record at Transitions Crown Point LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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, interview, and observation. In 1 of 16 (6%) clinical records reviewed for patients receiving hospice aide services revealed the agency did not ensure that the aide plan of care included all instructions for the hospice aide. CLINICAL RECORD 3: A home visit observation was conducted with the Hospice Aide (HA) (Personnel Record 4) on 10/08/2025. The patient had a Kerlex wrap on her left lower leg. The hospice aide placed a plastic bag over the dressing when she assisted the patient in the shower. The current aide plan of care dated 06/26/2025 did not include instructions for the aide to cover the leg dressing with a plastic bag or to keep the dressing dry. A review of the clinical record revealed that the patient sustained a skin tear to the left leg on 09/30/2025, requiring an emergency room visit, sutures, and twice-weekly wound care by the Registered Nurse. The aide plan of care was not updated after the patient sustained the injury. The Administrator (Personnel Record 1) was interviewed on 10/08/2025 and stated, "The aide plan of care should have been updated."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical record reviewed where the patient received hospice aide services revealed the agency did not ensure that the Registered Nurse (RN) documented an aide supervision no less frequently than every 14 days. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice on 01/17/2025. The Plan of Care dated 08/12/2025 included orders for hospice aide services with a frequency of twice weekly. There were documented aide supervisions on 08/25/2025, 08/31/2025, 09/08/2025, 09/14/2025, and 10/01/2025 (17 days). The Administrator (Personnel Record 1) was interviewed on 10/06/2025 and stated, "There was no documented aide supervision between 09/14/2025 and 10/01/2025. The visits for the nurse were switched and the aide supervision was missed." CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice on 08/07/2025. The Plan of Care (POC) dated 08/07/2025 included orders for hospice aide services with a frequency of five visits weekly. The HA was provided as ordered on the (POC). There was aide supervision documented by a Registered Nurse (RN) on 08/11/2025, 09/01/2025, and 09/09/2025. There was no further documented HA supervision through 10/05/2025. Documented aide supervision was greater than fourteen days from 09/09/2025 to 10/05/2025 (26 days). The Administrator (Personnel Record 1) was interviewed on 10/08/2025 and stated, "The RN's who visited the patient on 09/12/2025 and 09/26/2025 should have documented aide supervision."

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients with orders for volunteer services included on the Plan of Care revealed the agency did not ensure that services were provided as ordered by the interdisciplinary group. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 03/19/2025. The Plan of Care (POC) dated 03/19/2025 included an order for Volunteer services. There was no further documentation in the record that the Volunteer Coordinator contacted the patient to arrange for Volunteer services, nor was a Volunteer Plan of Care present in the clinical record. The Volunteer services were not provided as ordered. The Volunteer Coordinator (VC) (Personnel Record 8) and the Administrator (Personnel Record 1) were interviewed on 10/09/2025. The VC stated, "I did contact the patient, and she declined Volunteer services. The patient thought the volunteer would be able to assist more with personal care needs. I did not document the conversation in the notes."

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 which revealed the agency did not ensure that volunteer services were utilized for 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. Volunteer Program: The agency's volunteer program was reviewed, as well as the agency's documentation of volunteer cost savings. The agency's documented percentage of volunteer utilization was 0.86% in 2024. The agency has not utilized volunteer services for 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. The Alternate Administrator (Personnel Record 11) was interviewed on 10/08/2025 and stated, "We recently started a PIP to work on increasing the use of volunteers." The Volunteer Coordinator (Personnel Record 8) was interviewed on 10/09/2025 and stated, "I am working on getting more volunteers who would be able to visit patients." The agency did not ensure that volunteer services were utilized for 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.

Based on record review and interview, the agency failed to ensure the administrator reported directly to the governing body. The findings include: --- A review of a job description for the Administrator indicated the Administrator reported to the governing body. A review of the undated organizational chart indicated the Administrator reported to the Vice President of Operations. On 12/13/2024, at 1:53 PM, the Administrator indicated she reported directly to Corporate Staff 1, the Vice President of Operations.

Based on record review and interview, the agency failed to evidence they had a written agreement for the services provided by Entity 1 and failed to evidence administrative oversight of services provided by Entity1. The findings include: --- 1.The personnel record for Registered Nurse (RN) 1 indicated their criminal history was ordered by Entity 1 on 5/28/2024. 2. The personnel record for RN 2 indicated their background check was ordered by Entity 1 on 12/10/2020. 3.The personnel record for Social Worker 1 indicated their background check was ordered by Entity 1 on 8/7/2023. 4.On 12/13/2024, beginning at 1:44 PM, the Administrator indicated the personnel files were maintained by their corporate office, indicated the hospice did not maintain the personnel files of their employees. The Administrator indicated Corporate Person 2, from Entity 1, completed the criminal history backgrounds for agency personnel and indicated she does not receive a copy of the agencys personnel criminal history report. The Administrator indicated if there was a criminal infraction on the criminal history report, Corporate Person 2, not the Administrator, makes the decision if an applicant could be hired. 5. On 12/13/2024, at 11:52 AM, during the entrance conference, the Administrator indicated Entity 1 had a call center where the agencys incoming phone calls were answered and triaged. The Administrator indicated Entity 1 answers the phone calls for the hospice via their call center. 6. A review of a contract with Entity 1 dated 3/12/2022 failed to evidence services were provided under written agreement for the answering and triaging of the agencys phone calls, nor conducting the agencys personnel criminal history checks, and maintenance of the agencys personnel files.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice maintains written policies and procedures concerning advance directives with respect to all adult individuals receiving care by or through the hospice. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by document reviews and interviews. Review of the written documents provided at the time of admission to the hospice program revealed the hospice did not inform and distribute its complete policy and procedure on advance directives to patients and/or their representatives. Document 1 - The agency's admission handbook provided to patients and families was reviewed and revealed general information and education on advance directives. The agency provided the purpose and policy statement of their advance directive policy on page 28 of the handbook, but not the procedures section of the policy that included 12 paragraphs. Document 2 - The agency policy, no. 9-007, "Advance Directives", stated in part under the subtitle, "Procedure": "(1) Upon admission, the clinician/technician will provide information regarding a patient's right to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining, the right to execute Advance Directives, and applicable organization policies. Written information designed for this purpose will be provided to the adult patient. The clinician/technician will document in the clinical/service record that the information was provided and document all discussions concerning Advance Directives... (2) If the patient lacks a decision-making capacity, the admitting clinician/technician will provide information and direct inquiry about Advance Directives to the patient's representatives. The clinician/technician will document that the patient's representative received information and his/her name and response will be noted in the clinical record... (3) If conditions are such that is not practical to provide information to the patient or his/her representative at the time of admission, such information will be provided as soon as feasible after admission....". Interview with the Administrator on 11/8/2022 confirmed the entire agency's policy for advanced directives was missing from the admission handbook. The Administrator and Chief Clinical Officer stated on 11/10/2022 that the whole policy with procedure was provided to the three active patients and families on 11/9/2022 with signature confirmation of receipt. They stated the whole policy that includes the procedures was updated in the handbook prior to the end of the site visit review.

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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 2 of 2 (100%) home visits where the current medication profile was reconciled with the current medications in the home setting, it was observed that the agency had not updated the medication profiles for accuracy. Document 7 - Agency policy, no. 2-004 "Medication Profile", stated in part: "... (7) A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the additions of a new medication... (8) During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes but will not be limited to: (A) using the medication profile to evaluate the use of the drugs in the home setting. (B) Using the medication profile to teach purpose of medication, dosages, routes administration times, side effects, and contraindications. (C) Using the medication profile as a communication tool for other clinicians involved in care... (12) Deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified." Home Visit 2 - During a home visit with the registered nurse (RN) (Staff 8) on 11/9/2022, while the RN was conducting a reconciliation of medications, the patient verbalized only taking the diuretic medication, Spironolactone 50 mg, as needed. The medication, "Spironolactone 50 mg orally", with a start date of 10/6/2022, was listed as scheduled to be taken daily on the current medication profile. Documentation in the clinical record (Record 9) included a physician order dated 10/6/2022 for "Spironolactone 50 mg by mouth daily for fluid retention". Review of the medication profile was documented as conducted by the RN during visits made on 10/6/2022, 10/19/2022 and 10/25/2022. The registered nurse (Staff 8) updated the order for Spironolactone to "as needed (PRN)" on 11/9/2022 after the observation visit was discussed and confirmed. Home Visit 3 - During home visit with the CNA (Staff 7) on 11/10/2022, the patient granted permission to review medications. Medication bottles, which were stored in a basket, were reviewed and compared to the current medication profile provided by the agency. The medication, Pantoprazole 40mg by mouth daily, was found in the basket but not documented on the medication profile. Also, the medication, Omeprazole 20mg by mouth daily, was documented on the medication profile with a start date of 8/10/2022 and was not found in the basket. Review of the clinical record (Record 10) included documentation that the last medication profile review by the registered nurse was completed on 9/3/2022 for the current recertification benefit period dated 10/24/20222-12/22/2022. During interview on 11/10/2022, the Director of Nursing (Staff 8) confirmed that the patient was switched to Omeprazole and the Pantoprazole was discontinued. During interview with Director of Nursing (Staff 8) on 11/10/2022, they confirmed the medication profiles for Record 9 and Record 10 were not updated and accurate.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Medical supplies and appliances necessary to meet the needs of the patient; and includes the documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 1 of 3 (33%) home visits where medical supplies were provided by the agency, all the medical supplies were not included on the plan of care. Clinical Record 9 - The patient elected the hospice benefit on 3/2/2022. The current recertification plan of care dated 10/18/2022, for the benefit period of 10/28/2022-12/26/2022, included documentation of, "Medline Supplies DME-Oxygen supplies and DME-Respiratory supplies". Documentation of the medical supplies provided by the hospice, that included gloves, incontinence briefs and wipes, were missing on the plan of care. Supplies were added to plan of care, updated on 11/9/2022 by the registered nurse (Staff 8), after discussion of the home visit observation (Home Visit 2).

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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. 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 a review of clinical records, document reviews and interviews. In 6 of 6 (100%) death records reviewed with bereavement care plans, the agency did not include on the bereavement care plans all of the bereavement services, as described in the agency's policy, and the frequencies the bereavement services would be provided. The agency used generic templates for each risk level (low, medium or high) for the respective bereavement care plans but did not include documentation of the frequency each bereavement service was to be scheduled or provided. Document 5 - The agency's policy, no. 9-023 "Bereavement Services", stated in part: "... (8) Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. (9) After three (3) weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. (10) Within three (3) to five (5) weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver... (11) If a person is noted as experiencing normal grief, the bereavement counselor will make contact with the bereaved person for ongoing assessment and support at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death." Clinical Record 1 - The patient with election of benefit dated 8/19/2022 and date of death of 9/20/2022, had a bereavement care plan dated 8/21/2022, modified 9/30/2022, that documented the bereaved as low risk. The care plan did not contain documentation of the frequencies the documented bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event", were to be provided. Additionally, the care plan was missing other services that were documented in the agency's policy (Document 5) which included contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. Clinical Record 2 - Patient with election of benefit dated 8/19/2022 and date of death of 10/23/2022, had a bereavement care plan dated 8/23/2022, modified 10/26/2022, that documented the bereaved as low risk. The care plan did not contain documentation of the frequencies for the bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event" that were to be provided. Additionally, the care plan was missing other services that were documented on the agency's policy (Document 5) which included contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. Clinical Record 5 - Patient with election of benefit dated 8/18/2022 and date of death of 9/30/2022, had two (2) bereavement care plans dated 8/19/2022 and modified 10/4/2022, which documented both bereaved as low risk. The care plans did not contain the frequencies the documented bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event" were to be provided. Additionally, the care plans were missing other services that were documented on the agency's policy (Document 5) which included the contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. Clinical Record 6 - Patient with election of benefit dated 8/22/2022 and date of death of 9/30/2022, had a bereavement care plan dated 8/24/2022, modified 10/3/2022, that documented the bereaved as low risk. The care plan did not contain the frequencies the documented bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event" were to be provided. Additionally, the care plan was missing other services that were documented in the agency's policy (Document 5) which included the contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. Clinical Record 8 - Patient with election of benefit dated 3/3/2022 and date of death of 3/6/2022, had a bereavement care plan dated 3/6/2022, modified 3/6/2022, that documented the bereaved as medium risk. The care plan did not contain the frequencies the documented bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event" were to be provided. The care plan was missing other services, per the agency's policy (Document 5), which included the contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. Clinical Record 7 - Patient with election of benefit dated 2/28/2022 and date of death of 3/5/2022, had a bereavement care plan dated 3/9/2022, modified 3/9/2022, that documented the bereaved as low risk. The care plan did not contain the frequencies the documented bereavement service interventions of "initial sympathy card letter, standard bereavement form letters, information/referral to community resources, quarterly correspondence, cards/newsletters, and memorial annual event" were to be provided. Additionally, the care plan was missing other services, per the agency's policy (Document 5), which included the contacts at three (3), six (6) and nine (9) months after the patient's death and at the anniversary of the patient's death. During interview with the Bereavement Coordinator (BC) (Staff 2) on 11/8/2022, they provided an internal form titled, "Bereavement Risk Levels and Care Plans", that outlined the services with the frequency each intervention was to be provided for each risk level of low, medium and high. The BC confirmed documentation of the frequency for bereavement service interventions was missing from the documented care plans and that phone calls and assessments needed to be included to match the outline of the internal form and the agency's policy (Document 5). During the exit conference on 11/10/2022, the Administrator (Staff 3) stated that the bereavement care plan templates were updated to include the frequencies of each bereavement service. The agency contained generic templates for each risk level (low, medium or high) for the respective bereavement care plans without documented frequencies for each bereavement service scheduled or provided.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 8 (12%) records reviewed of patients receiving hospice aide services, revealed the hospice did not ensure that the hospice aide notified the registered nurse of assigned tasks that were not completed per the hospice aide care plan. Clinical Record 5 - Patient with election of hospice benefit dated 8/18/2022 had a hospice aide care plan dated 8/18/2022. The aide care plan assigned tasks to be completed at every visit and included: Transferring patient from bed to chair/chair to bed; shampoo; nail care; and change linens. Documentation on the Hospice aide visit note dated 9/29/2022 stated that the assigned tasks of transferring patient from bed to chair/chair to bed and shampoo were not completed as they were "not required this visit". Also, the area of the aide visit note labeled, "Hospice nurse contacted if unable to provide care plan service", was documented as not completed due to "not required this visit". The Hospice aide visit note dated 9/28/2022 documented the assigned tasks of transferring patient from bed to chair/chair to bed, shampoo, nail care and change linens was not completed as they were "not required this visit". The area labeled on the note, "Hospice nurse contacted if unable to provide care plan service", was documented as not completed as it was "not required this visit". The Hospice aide visit note dated 9/27/2022 documented the assigned tasks of transferring patient from bed to chair/chair to bed, shampoo and nail care were not completed as they were "not required this visit." The area labeled, "Hospice nurse contacted if unable to provide care plan service", was documented as not completed due to "not required this visit". The record was missing documentation that the aide had notified the registered nurse of the noncompleted tasks.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document reviews and interviews. In 1 of 1 (100%) contract reviewed, the agency did not ensure that all contracted employees, who have direct patient contact or access to patient records, completed criminal background checks. Contract 1 - Review of the contract, with an effective date of January 28, 2022, titled, "Residential Hospice Care Agreement of Services to Residents of Nursing Facilities", revealed it did not include the requirement clause requiring criminal background checks for contracted personnel with direct access to hospice patients or their records. Interview with the Chief Clinical Officer on 11/10/2022 confirmed the criminal background check clause was missing from the contract during a joint contract review.