Every finding on record at Universal Hospice Care LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed, for records in which a social worker was accepted, the agency did not ensure that the social worker, when requested, provided a full psychosocial assessment in the first 5 calendar days after the election of hospice care. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/17/2025 with a primary diagnosis of Parkinson's disease. The initial comprehensive assessment dated 01/17/2025 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 01/29/2025 when a visit was made on day 12, which was 7 days late. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/22/2025 with a primary diagnosis of Alzheimer's disease. The initial comprehensive assessment date 08/22/2025 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 08/29/2025 when a visit was made on day 7, which was 2 days late. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/18/2025 with a primary diagnosis of Alzheimer's disease. The initial comprehensive assessment dated 07/18/2025 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 07/25/2025 when a visit was made on day 7, which was 2 days late. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/03/2024 with a primary diagnosis of malignant neoplasm of prostate. The initial comprehensive assessment dated 09/03/2024 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 09/14/2024 when a visit was made on day 11, which was 6 days late. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/02/2024 with a primary diagnosis of Alzheimer's disease. The initial comprehensive assessment dated 05/02/2024 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 05/15/2024 when a visit was made on day 13, which was 8 days late. CLINICAL RECORD 12: The hospice benefit of election was 05/02/2025 with a primary diagnosis of Alzheimer's disease. The initial comprehensive assessment dated 05/02/2025 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 05/11/2025 when a visit was made on day 9, which was 4 days late. CLINICAL RECORD 14: The hospice benefit of election was 12/29/2025 with a primary diagnosis of chronic respiratory failure. The initial comprehensive assessment dated 12/29/2025 included documentation of a request for social work services. There was no documented contact in the clinical record from the social worker until 01/08/2026 when a visit was made on day 10, which was 5 days late. An interview and joint clinical record review was conducted with the Director of Patient Care Services on 04/23/2026 during which time she advised "a communication note should have been entered if the visit was going to be late." However, they were also working with the social worker on improving this issue.

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. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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 observation and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1: The patient elected the hospice benefit on 04/01/2026 with diagnosis of Alzheimer's disease. The patient resided in an assisted living facility (ALF). During the home visit observation with the Registered Nurse (Personnel Record 4) on 04/22/2026, a medication review was completed by comparing the hospice medication profile (printed on 04/21/2026) with the ALF medication list (printed on 04/22/2026). The following medication was listed on the hospice medication profile and was not listed on the ALF medication list: Prochlorperazine Maleate 10 mg, 1 tablet every 6 hours as needed (ordered 04/02/2026). The following medications were listed on the ALF medication list and were not listed on the hospice medication profile: Bisacodyl 10 mg, 1 suppository every 24 hours as needed (ordered 04/03/2026). Desonide ointment, topically every 12 hours as needed (ordered 11/19/2025). The hospice medication profile had Nystatin cream twice daily as needed (ordered 04/01/2026) and the ALF medication list had Nystatin cream twice daily scheduled (ordered 11/19/2025). An interview and joint clinical record review was conducted with the Director of Patient Care Services and the Registered Nurse Case Manager on 04/23/2026 during which time the Registered Nurse advised "she had given the updated medication list to the assisted living facility but had not followed up to make sure the changes had been implemented."

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) 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, observation, and interview. In 4 of 12 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the registered nurse provided patient specific written care instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan dated 04/02/2026 included an aide frequency of twice a week and assigned the aide the following tasks: "Incontinent care; record bowel movements; dress; bed bath; brush; shampoo; brush teeth; file nails; deodorant; apply lotion; visualize condition of skin and report to nurse, peri care; range of motion; change patient linens; tidy patient room; empty trash/light housekeeping; provide companion services; check vitals every visit." The tasks were to be completed on every visit. The nursing visit note dated 04/15/2026 included documentation that "Heel protectors were ordered, and education was provided to staff on the use of booties and the importance of frequent elevation of the feet due to severe edema. Medication technician verbalized understanding." The heel protectors and specific instructions for the heel protectors during aide tasks were not added to the hospice aide care plan and did not include specific instructions or parameters for the vital signs to report to the registered nurse. CLINICAL RECORD 2/HOME VISIT 2: The hospice aide care plan dated 03/18/2026 included an aide frequency of twice a week and assigned the aide the following tasks: "Foley catheter care, empty collection bag; incontinent care; record bowel movement; assist with dressing; encourage fluids; bed bath; shampoo hair; comb hair; brush teeth; clean nails; apply deodorant; apply lotion; visualize condition of skin and report to RN (registered nurse), peri care; ROM (range of motion);change linens; empty trash/light housekeeping; provide companionship." The tasks were to be completed every visit. During the home visit observation on 04/22/2026 with the Hospice Aide (HA) (Personnel Record 7), the patient was observed to have a wrist brace. The aide care plan did not notify the aide of the wrist brace nor give specific instructions for the brace during care. During an interview with the Registered Nurse (RN) (Personnel Record 4) and the Director of Patient Care Services on 04/22/2026, the RN stated "the sister brought in the brace and it was placed on the patient. It should have been on the aide care plan so she knows if she can take it off or not." CLINICAL RECORD 3: The hospice aide care plan dated 03/02/2026 included an aide frequency of twice a week and assigned the aide the following tasks: "Incontinent care; mechanical lift; dress; bed bath; comb; shampoo; shave; dentures; clean and file nails; deodorant; apply lotion; visualize condition of skin and report to nurse, peri care; oxygen; change patient linens; tidy patient room; empty trash/light housekeeping; check vitals every visit; report to case manager any skin breakdown; report pain scale over 3/10 or signs/symptoms of pain; report urine: changes in color, smell and/or amount any abnormal findings/changes in patients behavior." The tasks were to be completed every visit. The clinical record included a physician order dated 03/27/2026 for: "Coccyx area, pressure injury. Cleanse with wound wash, pat dry, crush 1-2 Flagyl pills and sprinkle onto wound bed, apply Medi honey, cover with sacral bordered dressing. Change every SNV (skilled nurse visit) and if soiled, wet or dislodged." The aide care plan did not notify the aide of the wound and did not provide specific instructions for the wound dressing during care or to notify the nurse if the dressing became soiled, dislodged or wet. CLINICAL RECORD 7: The hospice aide care plan dated 07/18/2025 included an aide frequency of twice a week and assigned the aide the following tasks: "Shower with shower chair; brush; shampoo; blow dry; dress; brush teeth; clean nails; deodorant; apply lotion; visualize condition of skin and report to nurse; peri care; oxygen; change linens; tidy room; empty trash/light housekeeping; provide companionship; vital signs." The tasks were to be completed every visit. The nursing visit note dated 07/18/2025 included documentation that the patient had "bilateral heel protectors." The heel protectors and specific instructions for the heel protectors during aide tasks were not added to the hospice aide care plan and did not include specific instructions or parameters for the vital signs to report to the registered nurse. An interview and joint clinical record review was conducted with the Director of Patient Care Services and the Registered Nurse Case Manager on 04/22/2026 during which time it was agreed the aide care plans "needed more details for the aide to follow during tasks."

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 clinical record review, observation, and interview. In 4 of 12 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care. CLINICAL RECORD 2/HOME VISIT 2: The hospice aide care plan dated 03/18/2026 assigned the aide the following tasks: "Foley catheter care, empty collection bag; incontinent care; record bowel movement; assist with dressing; encourage fluids; bed bath; shampoo hair; comb hair; brush teeth; clean nails; apply deodorant; apply lotion; visualize condition of skin and report to RN (registered nurse), peri care; ROM (range of motion);change linens; empty trash/light housekeeping; provide companionship." The tasks were to be completed every visit with an aide frequency of twice weekly. During the home visit observation on 04/22/2026 with the Hospice Aide (HA) (Personnel Record 7), the patient did not have a Foley catheter, and the aide did not perform Foley care, empty collection bag, brush teeth, and change linens. The aide removed an arm brace from the patient's wrist which was not listed on the aide care plan. During an interview with the Registered Nurse (RN) (Personnel Record 4) and the Director of Patient Care Services on 04/22/2026, the RN stated "the sister brought in the brace and it was placed on the patient. It should have been on the aide care plan so she knows if she can take it off or not." CLINICAL RECORD 4: The hospice aide care plan dated 03/18/2026 assigned the aide the following tasks: "Shower with shower chair; brush; shampoo; blow dry; dress; brush teeth; clean nails; deodorant; apply lotion; visualize condition of skin and report to nurse; peri care; oxygen; change linens; tidy room; empty trash/light housekeeping; provide companionship; vital signs; patient may refuse showers, please report to RN." The tasks were to be completed every visit with an aide frequency of twice weekly. The hospice aide documented on the aide visit note dated 04/17/2026, "Patient refused shower but provided bed bath during visit." The hospice aide documented on the aide visit note dated 04/14/2026, "Patient refused shower so provided bed bath." The hospice aide documented on the aide visit note dated 04/10/2026, "Patient refused the shower but also facility the water during my visit shut off for emergency purposes so provide bed bath." The aide did not provide a shower as ordered in the aide care plan. CLINICAL RECORD 5: The hospice aide care plan dated 02/01/2026 assigned the aide the following tasks: "Incontinent care; shower with shower chair; brush; comb; shampoo; blow dry; dress; brush teeth; clean nails; deodorant; apply lotion; visualize condition of skin and report to nurse; peri care; oxygen; change linens; tidy room; empty trash/light housekeeping; provide companionship; vital signs." The tasks were to be completed every visit with an aide frequency of twice weekly. The aide documented on the aide visit note dated 04/15/2026, "patient refused shower, bed bath given." The aide documented on the aide visit note dated 04/01/2026, "patient refused shower, bed bath given." The aide documented on the aide visit note dated 03/04/2026, "patient refused shower, bed bath given." The aide did not provide a shower as ordered in the aide care plan. CLINICAL RECORD 7: The hospice aide care plan dated 07/18/2025 assigned the aide the following tasks: "shower with shower chair; brush; shampoo; blow dry; dress; brush teeth; clean nails; deodorant; apply lotion; visualize condition of skin and report to nurse; peri care; oxygen; change linens; tidy room; empty trash/light housekeeping; provide companionship; vital signs." The tasks were to be completed every visit with an aide frequency of twice weekly. The aide documented on the aide visit note dated 04/10/2026, "provided a bed bath as facility had no water." The aide documented on the aide visit note dated 04/01/2026, "bed bath done during visit." The aide did not provide a shower as ordered in the aide care plan. An interview and joint clinical record review was conducted with the Director of Patient Care services and the Registered Nurse Case Manager on 04/22/2026 during which time, the Director advised she "thought the aide was providing showers per the aide plan of care." She had spot checked a few of the clinical records and saw the aide documenting showers were performed." However, she agreed these records said bed bath when the care plans said shower.

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. The hospice did not ensure volunteer hours equaled five percent of the total patient care hours of all paid hospice employees. A review of the volunteer program was conducted with the Administrator and the Director of Clinical Services on 04/23/2026 as the Volunteer Coordinator was not available. Documentation of the volunteer percentage for the last twelve (12) months (April 2025 to March 2026) averaged to 1.29%. The Director of Clinical Services advised the first few months of 2026 "had shown an increase of volunteer hours but there was still room for improvement." A review of the volunteer program was conducted with the Administrator and Director of Clinical Services on 04/23/2026 as the volunteer coordinator was not available, during which time the volunteer percentage for the last twelve (12) months (April 2025 to March 2026) averaged to 1.29%. The Director advised the first few months of 2026 "had shown an increase of volunteer hours but there was still room for improvement."

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. 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 personnel record review and interview. In 1 of 8 (13%) personnel records reviewed, the agency did not ensure criminal background checks were obtained within 3 months of the date of employment. PERSONNEL RECORD 5: Social Worker date of hire 06/07/2023. Personnel record review revealed no documented evidence of a criminal background check completed upon hire or within 3 months of hire. An interview was conducted with the Administrator on 04/21/2026 during which time she stated she believed a "Home health surveyor told her last year during a survey that employees only had to be checked through the OIG (Office of Inspector General) and not the live scan."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) records revealed the hospice did not ensure that the hospice aide reported changes in the patient's needs to the registered nurse as it related to the plan of care. Clinical Record 4: The hospice aide care plan dated in benefit period (BP) 3/23/23-6/20/23, directed the hospice aide to provide a shower every Wednesday. On Friday 3/24/23, 3/31/23, 4/7/23, 4/14/23, and 4/21/23 the HA documented that a shower was provided. There was no documentation as to why the shower was provided on Friday or that the RN was notified. An interview with the DPCS on 5/24/2023 confirmed this finding.