Every finding on record at Well Care Hospice, Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form. The consent includes acknowledgement for patient rights. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form. The consent includes acknowledgement of advance directives discussion. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form. The consent form acknowledges patient education regarding patient rights including grievance/complaints procedures. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence of the appropriate documentation for release of confidential information. Patient #4: Patient admitted 9/21/25. There is no evidence of signed consent form, including no evidence of signed release of confidential information. Interview with staff confirms they are unable to locate/identify signed consent document.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #14: Patient admitted 6/21/24. SNF Resident's facility current medication profile observed during visit included extensive list of facility standing orders for medications. The hospice med profile does not include any reference to standing orders. There is no indication on either medication profile of intent to coordinate between the two providers when or before initiating either of the standing orders.

Upon patient record review, 4 of 19 (Patient #8, 9, 13, 16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: Patient admitted 11/19/25. Initial bereavement assessment documented by SC 11/25/25 Day 6 (Patient refused earlier visit). Patient #9: Patient admitted 12/15/25. Initial bereavement assessment documented by SC 12/29/25. (There is a 12/22/25 entry that says "Hospice Bereavement Visit" but there is no other documentation in coordination notes or in attachments.) Patient #13: Patient admitted 10/28/25. Initial bereavement assessment documented by RN documented 12/10/25 Patient #16: Patient admitted 10/31/25. Initial bereavement assessments 11/7/25.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #8: 1/29/26 RN identified new skin breakdown elbow and hip described as stage 2. MD notified and awaiting response. No follow up documentation of treatment order. No documented visits since then. 1/22/26 note eschar left great toe. Notified MD directed just watch. No follow up documentation related to toe on 1/29/26 recert visit.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #6: Patient admitted 12/04/25 with suprapubic catheter. There is no reference to problem, goals, interventions associated with catheter. Functional limitations lists bladder incontinence. Problem list includes general "need for SN to insert/maintain indwelling catheter - hospice" with no specific orders regarding catheter or site.

Upon patient record review, 2 of 19 (Patient #6, 15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: Patient admitted 12/4/25 with initial wound care order for hospice nurse to perform wound care to stage 2 wound on lower right extremity utilizing clean technique: cleanse with wound cleanser, apply Vaseline gauze and cover with ABD pad and Coban wrap, change every other day and PRN. Instruct caregiver in wound care. PRN is not qualified for dressing changes. Patient admitted 12//25 with suprapubic catheter with no specific orders regarding catheter or site. Patient #15: 9/6/2025 Order for in and out cath. Order does not specify size.

Upon client record review, 2 of 19 (Patient #3, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Patient admitted 12/4/25. 1/15 and 1/21/26 orders for volunteer coordinator to visit with PCG to assess for need and appropriateness of volunteer services- requested. No documented follow up at time of survey. Patient #6: Patient admitted 12/4/25 with initial wound care order for hospice nurse to perform wound care to stage 2 wound on lower right extremity. utilizing clean technique: cleanse with wound cleanser. Apply Vaseline gauze and cover with ABD pad and Coban wrap. Change every other day and PRN. Instruct caregiver in wound care. PRN is not qualified for dressing changes. 12/5/25 SN Visit documented wound care provided to include covering wound with ABD and wrapping with "fluff" rather than Coban.

Upon patient record review 1 of 19 (Patient #8) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #8: 1/29/26 RN identified new skin breakdown elbow and hip described as stage 2. MD notified and awaiting response. No follow up documentation of treatment order. No documented visits since then. 1/22/26 note eschar left great toe. Notified MD directed just watch. No follow up documentation related to toe on 1/29/26 recert visit. No evidence patient needs met.

Upon patient record review, 2 of 19 (Patient #4, 6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4: Patient had recent history of GI bleeding with no reference/alert included in Hospice Aide Care Plan. Patient #6: Patient admitted with suprapubic catheter. Hospice Aide Care Plan includes task related to output, but no reference/alert to suprapubic catheter.

Upon patient record review 2 of 19 (Patient #1,5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Hospice Aide Care plan assigns hair, nails, linen once/week. Hospice Aide performed every visit Jan 14, 16, 19, 21, 23, 2026 Patient #5: Hospice Aide Care Plan Shampoo and linens assigned weekly. Hospice Aide both tasks every visit: January 5, 7, 9; 14, 16,19, 23, of 2026 and linen change also on the 12th and 21st of January 2026.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation, Volunteer Hours tracking for Calendar Year 2025 demonstrates 4.22% Volunteer cost savings, less than 5% of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient client record review, 2 of 19 (Patient #4, 15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: 1/30/26 SN prn visit for in and out cath. SN failed to document details of procedure including implication, technique, catheter size, amount and appearance of urine return. Patient #15: 9/16/25 physician order for in and out catheter and c/s related to retention. SN documented SN performed in and out catheter per protocol. Obtained sample. Patient had dark yellow urine drained about 300cc. Patient tolerated procedure well. Interview with staff confirms there is no actual protocol in place for in and out catheterization procedure.

Upon client record review, 2 of 19 (Patient #15, 16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #15, 16: There is no evidence of discharge summary of care sent to physician.

Upon client record review, 2 of 19 (Patient #15, 16) did not have evidence that the discharge summary includes all required information. Patient #15, 16: There is no evidence of discharge summary of care.

Based on clinical record review and staff interviews, the agency failed to report signs of possible neglect in a timely manner for 1 of 1 patient with an APS  [adult protective services] referral [#1]. The findings included: --- Patient # 1 had a Start of Care date of 5/21/25 with a terminal diagnosis of Hypertensive Heart Disease, Vascular Dementia and Alzheimer’s Disease. Review of the Plan of Care for the certification period 8/19/25-11/16/25 included orders for SN [Skilled nursing] 2 times a week 2 times a week for 13 weeks, hospice aide 2 times a week for 13 weeks, MSW [medical social worker] 1 time a month for 3 months, chaplain 1 time a month for 3 months. Review of the clinical record revealed the patient lived alone with her adult disabled child. The patient was the primary caregiver for her disabled adult child. Another one of the patient’s adult daughters was noted to be the contact person for the agency, this daughter lived out of town and visited with the patient when possible. Further review of the clinical record revealed the clinicians [SN, MSW, and chaplain] documented numerous times their concern the patient's basic needs were not being met. An APS [adult protective services] report was not filed until 10/9/25. The documentation included: On 8/22/25, RN # 1 documented “residence unsuitable for hospice care-patient lives alone 90% of the time and is the PC [primary caregiver] for her disabled adult child...” Review of the clinical record revealed the physician had ordered the patient an antibiotic on 8/26/25 for possible cellulitis of right lower leg. During the visit on 8/28/25, it was revealed the caregiver had not picked the antibiotic up at the pharmacy and the patient had not received the medication as ordered. RN # 1 also expressed concern over the patient’s nutritional status and documented there were 5 unopened meals [meals on wheels] in the patient’s refrigerator.Review of the SN visit dated 9/10/25 revealed the following information, “...Patient states she eats 3 meals a day, 100% but on further assessments SN found multiple means on wheels trays unopened in the patient’s refrigerator for a total of 9...Patient is sleeping at night or wakes up frequently in the night and rummages through doors [sic]. Patient lives 90% alone with the exception of her disabled daughter. Patient’s caregiver comes in [sic] sees patient Thursday night and stays through Saturday nights several times a month. Upon assessment patient’s pill planner is full. Patient is unsure if she is [sic] taking her pills this week."On 9/10/25 the MSW made a routine visit and documented, " “...Pnt [patient] daughter calls and informs MSW that she visits weekly and spends the nights at times...Pnt daughers [sic] reports she provides care for her mom. Ptn daughter does report confusion, issues with recollections, and ptn being unable to do certain IADLS [instrumental Activities of Daily Living]...” RN # 1 documented the following information for the 9/19/25 visit, “...CG [caregiver] stated patient has not been sleeping at night but has been running through the house and rummaging through things. CG is only available Monday through Saturday night to be with the patient and not able to watch her during the day 2 [sic] work obligations. Per CG patient is still not taking her medications as ordered. Medications are commonly found left in the pill planner...SN and CG discussed patient’s safety and patient being left alone 70-90% of the time. CG head [sic] verbal understanding but had no way to have somebody in the home to help monitor patient’s [sic] when she is not available...” On 9/24/25 SN # 1 documented, "“...Patient continuing to have redness and irritation to bilateral lower extremities. Triamcinolone Cream could not be found during the visit...Call daughter...instructed her on helping mother with daily bathing keeping legs moisturized and elevating, applying cream at least twice a day...Daughter verbalized understanding but will be difficult as she is only in town for the weekends...”  On 9/26/25 Chaplain # 3 documented the following information, “...Patient was alert and oriented x 1 [aware of self]. SN reported that patient was confused and could not find the bathroom in her own home...Patient is confused about many details...Patient requires assistance with most ADLs since last visit. Chaplain observes patient’s increased confusion and forgetfulness...”RN # 1 made a visit on 9/30/25 and documented, “...Upon environmental assessment patient’s male [sic] planner still had all the weeks pills in it and patient could not recall [sic]  she taken any of her medication...SN expressed concern to patient about her not getting enough nutrition...Patient’s lower extremities are red and inflamed...”On 10/7/25 RN # 1 documented, “...SN told CG that her [patient] staying in the home and is [sic] confused state was a safety risk not just for her but also for her disabled daughter..” The RN also entered a note with the following documentation dated 10/7/25, “RN called MSW to discuss some concerns for pnt and residing alone. Pnt is not taking medication, there has been a decline in pnts mobility, pnt is not eating, pnt is exhibiting mor [sic] aggression, delusions and paranoid behaviors...”On 10/8/25 MSW # 2 documented the following information, “...Pnt denied seeing a RN or aide in a long time. She was unable to recall who MSW was as well. When MSW talked about her daughter [primary caregiver]  she stated she also hadn’t seen her in a long time as well. Daughter and SN had just visited with pnt...Pnt is not taking any of her medication because patient reports she honestly forgets to...” Further review of the clinical record revealed MSW called APS [adult protective services] on 10/9/25 to file a report related to the patient. The MSW documented, "MSW informed ____ [name of daughter] she made report to be helpful. ...MSW explained..._____ [patient # 1] not being able to care of [sic] herself is self neglect and neglect for ______ [adult disabled daughter]..." On 10/14/25 a communication note was noted for the director which stated, “...On Friday, 10/10/25, patient’s daughter ______ [name] called...Director followed up with a meeting with patient’s care team on Monday morning...concerns about patient’s declining mental and physical capacity while being alone with her adult daughter with disabilities most of the time. She is not taking her medications correctly, wanders in the woods at night, and allows team members into the home despite not remembering who they are... Team plans to meet with daughter on Friday...”During an interview with the vice president of compliance on 12/10/25 at approximately 9:30 am, the vice president of compliance confirmed the staff should have filed an APS report sooner. The vice president stated, "I think the staff was on the fence about making a report to APS. The daughter had told my staff all these things that she would do and then didn’t follow through on any of the things.”

Observed in Document Review. During discussions with leadership, it was noted that of the clinical nursing staff 5 RNs are contracted staff who see the majority of patient visits. The Director of Hospice is the only nursing staff member who is a direct employee. This was confirmed with leadership.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the goals on the plan of care were not individualized, not measurable and not timed. Some examples of goals were as follows:A nursing care plan will be established, Comfort kit will be provided, Pt will exhibit signs of symptom reduction or relief., Indwelling catheter will remain in patient, Pt/Cg will verbalize/demonstrate appropriate pain management, Pt/CG will verbalize/demonstrate appropriate compliance with medication regime, Pt will maintain optimal cardiac function within the constraints of the disease, MSW will establish plan of care, adequate bowel elimination. These examples were noted in record review for home visits #1, 2 and 3 and discussed with the hospice director and PI nurse. however they were present in all of the records. In another example, record review # 2 the patient had documented pain of 10/10 however there was no measurable or timed goal for pain and no goal for establishing advance directives despite a documented need and desire of family for advance directive. In another example, in record review #1 there was no goal for a new problem of facial cellulitis. This was confirmed by the hospice director and PI nurse assisting with record review.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the plan of care was not revised to meet the patient's needs. For example, in record review #1 the patient developed facial cellulitis and was started on an antibiotic and anti-inflammatory and a change to pureed diet. The plan of care was not revised to reflect the patient's new problems, interventions or goals. Additionally, over the next three weeks the patient's intake decreased from 100 % to 50 % to 25% and on the most current visit note documentation stated that the patient had not taken any food or drink for the past four days. There was no increase in skilled nursing visits which remained one time per week and no updates to the plan of care with interventions or goals. In another example, in record review #2 the patient had a diagnosis of cancer of the rectum with metastasis and with a physician stated prognosis of weeks however, although the patient was a high fall risk there were no interventions or goals to address falls. There was no medical social worker goal to assist establishing an advance directive although this was identified as a need and desire of patient and family. Lastly, the patient condition continued to decline and aide visits were increased to five times per week due to caregiver burden however the plan of care was not updated and the aide was not assigned to perform any bath only skin, oral and hair care and assist to bedside commode. In another example, record review #3 it was documented that the patient was frequently found by the hospice staff covered in feces and urine, found on the floor, and that the caregiver was overwhelmed. Additionally, adult protective services were called however no changes were made to the frequency of skilled nursing visits which remained at one time per week. The social worker was scheduled to see the patient every three weeks and the chaplain monthly. There were no other updates to the plan of care to indicate the increased needs of the patient. This was validated by the hospice director and PI nurse assisting with the record review. Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the plan of care did not contain all orders. For example, in record review for home visit #1 the patient had been receiving wound care however during the visit the RN stated that no wound care was needed and that the wound was now left open to air. There was no order to discontinue the wound care. This was validated by the hospice director assisting with record review. Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the plan of care was not specific to patients individualized needs. For example every plan of care listed protocols for care including, may insert 16-18 fr, 5-10 cc balloon foley catheter for urinary retention if needed, may irrigate with 30-60 cc of NS or H2O PRN for obstruction and apply skin prep to bilateral heels BID and after bathing. Discussion with the hospice director indicated that these were considered orders and would not necessitate further supplemental orders to initiate.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that care was not provided per the plan of care. For example, in review of record for home visit #1 it was noted that the oxygen order was for 2L/nc however the patient was using 3L/nc per the wife. Additionally, the plan of care stated that wound care was to be provided and there was no wound care provided during the visit. In another example, in record review #5 and #6 the chaplain visits were not made and the ordered frequency and there was no documentation to explain the reasons for the missed visits. This was observed by the PI nurse present on the visits.

Observed in Tracer Visit. In 1 of 1 home visits conducted, where equipment was disinfected it was noted that the RN did not perform disinfection per standards of practice. For example, the RN was observed cleaning the equipment with Sanicloth and after wiping the equipment placing it directly back into the nursing bag with gloved hands. There was no dry or contact time. Additionally, the wipes had been repackaged into an unlabeled ziploc baggie with no label or biohazard sticker. This was observed by the PI nurse present on the visit. Observed in Tracer Visit. In 1 of 1 home visits conducted, where disinfection of equipment was performed it was noted that the RN did not follow bag technique. For example, in home visit #1 the RN was observed wearing gloves to clean equipment and placing the equipment back into the bag, then picking up the next piece of equipment and cleaning it and placing it back into the bag with the same gloves. This was done multiple times and was observed by the PI nurse present on the visit.

Observed in Tracer Activities. During discussions with leadership it was noted that of the clinical nursing staff 5 RN's are contracted staff who see the majority of patient visits. The Director of Hospice and the Clinical Supervisor are the only nursing staff members who are direct employees. This was confirmed with leadership.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted in record review of home visit #2 that the hospice aide plan of care had not been updated since the start of care in April 2021. The patient condition had declined and was no longer receiving the bath type (shower) listed on the plan of care as observed during the visit with the hospice aide. This was observed by the PI nurse present on the visit. In another example, in record review for home visit #1 the caregiver stated that the patient was receiving a bed bath during the aide visits however the plan of care listed shower as the type of bath to be provided.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that in review of record for home visit #1 the aide care plan stated a shower to be given every visit however the caregiver stated that a bed bath was given every visit.

Observed in Document Review. In review of documents and discussion with the volunteer coordinator it was noted that for 2021 there were no volunteer hours and for 2022 the level of activity for volunteers was .50% of the paid patient care hours. There was no blanket waiver in place and there was no process documented for meeting this requirement during the PHE. This was confirmed by leadership.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.64 and 418.102

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that there were no documented competencies for the Medical Director. This was confirmed by the HR staff member and hospice director.

Observed in Regulatory Review. During discussion with hospice director and compliance manager it was noted that there was no contractual agreement in place for an alternate Medical Director.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that the documentation in the record was not accurate. For example, in review of records for home visits #1 and #2 the aide documented on every visit note that she was performing a shower however she was observed providing a bed bath in home visit #2 and the caregiver in home visit #1 stated that only a bed bath had been given. This was confirmed by the PI nurse present on the visits and during record review. In another example in record review #4 it was noted that the RN documented a supervisory visit for the aide on 2/7/23 however the aide services had been discontinued on 1/9/23. In another example in record review #3 the aide documented in a narrative note that a shower was provided to the patient and on the same note checked off bed bath as given. In record review #2 the medical social worker documented that the patient had a wound however upon further review of the record and all skilled nursing notes there was no documentation of a wound.

Observed in Patient Home. In 1 of 3 patient records reviewed, it was noted that the medication profile was not updated to contain all medications the patient was currently taking. For example, in home visit #1 the following medications were on the list however not being taken, Ipratropian nasal spray, timolol and lantoplast eye drops. In the home it was noted that the patient was taking Robitussin which was not on the list and there was a PRN medication for Furosemide 20 mg, take 1-4 tabs PRN for shortness of breath, call physician for dose. This was observed by the PI nurse present on the visit.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted in home visit #1 that the back up oxygen tank was unsecured and standing against a wall. This was observed by the PI nurse present on the visit.

Observed in Document Review. During review of contract for the HME provider it was noted that there was no stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was confirmed by the hospice director.