Every finding on record at Western Health Resources

It is required that the written Patient Bill of Rights includes the right to: receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of a patient discharged with an extended prognosis, the agency did not ensure the patient received information about the services covered under the hospice benefit, including the notice of termination of Medicare-covered services. The document "Notice Instructions for the Notice of Medicare Non-Coverage" (NOMNC) Center for Medicare and Medicaid Services (CMS)-10123 stated in part, "A Medicare provider/plan (Medicare Advantage plans and cost plans, collectively referred to as “plans”) must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare-covered services end, or the second to last day of service if care is not being provided daily." CLINICAL RECORD 15: A clinical record review conducted on 01/16/2026 revealed that the patient was discharged from hospice care with an extended prognosis on 04/18/2025, and a Notice of Medicare Non-Coverage (NOMNC) was signed on 04/18/2025. There was no evidence documenting that the patient received the NOMNC two days before discharge. During a joint clinical record review and interview on 01/14/2026, the Administrator/Director of Patient Care Services confirmed the NOMNC was signed on the day of discharge, stating, "They realized it should have been signed in advance, and they have been getting them signed at least two days ahead of time since then."

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; [and] 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; [and] 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 measures 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 clinical record review, observation, and interview. In 2 of 4 (50%) home visits observed and clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's medications. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 12/23/2025 for a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 01/14/2026, the hospice medication profile (printed on 01/13/2026) was compared to the SNF medication profile (printed on 01/14/2026). The hospice medication profile contained the following medication not listed on the SNF medication profile: "Albuterol Sulfate 2.5mg/3ml nebulizer, 1 vial every 4 hours as needed (ordered 12/30/2025). The last comprehensive nursing visit was dated 01/12/2026. Home Visit 4/Clinical Record 4: The patient elected the hospice benefit on 12/29/2025 for a diagnosis of malignant neoplasm of the bronchus or lung. The patient resided in a SNF. During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 01/14/2026, the hospice medication profile (printed on 01/13/2026) was compared to the SNF medication profile (printed on 01/14/2026). The SNF medication profile contained the following medication not listed on the hospice medication profile: "Cough drops. 1 every hour as needed (ordered 12/30/2025)." The last comprehensive nursing visit was dated 01/13/2026. During a joint clinical record review and interview on 01/14/2026, the Administrator/Director of Patient Care Services confirmed the findings, stating that for Home Visit 1/Clinical Record 1, they "Remembered the order being received during the IDG (interdisciplinary group) meeting, but appeared it didn't get sent over to the facility" and regarding Home Visit 4/Clinical Record 4, stated that "The nurses need to look at the printed facility medications, not just ask if they need refills."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 12 (17%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services included in the plan of care. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 12/29/2025 with a diagnosis of malignant neoplasm of the bronchus or lung. The patient resided in a skilled nursing facility (SNF). The plan of care ordered HA services twice weekly. The HA care plan dated 12/30/2025 assigned the HA the relevant tasks: Bathing-bed bath; assist with ADLs (activities of daily living); change linens; tidy room; assist with feeding; hair care; skin care; perineal care; oral care; ear care-weekly; nail care (no cutting)-weekly; dressing; ask if patient had any falls; incontinence care; observe skin integrity; apply lotion; apply barrier cream; float heels. All tasks were to be completed on every visit unless otherwise specified. During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 01/14/2026, the HA was observed soaking the patient's feet in a basin, applying lotion, and tidying the patient's room. The HA visit note dated 01/14/2026 documented, "Patient only allowed me to soak her feet and tidied up her room." The HA was not assigned the task to soak the patient's feet in a basin. CLINICAL RECORD 17: The patient elected the hospice benefit on 04/17/2025 with a diagnosis of cerebral atherosclerosis. The plan of care dated 04/17/2025 ordered HA services twice weekly. The HA care plan dated 04/17/2025 assigned the HA the relevant tasks: "Shower with assist every visit, use DME (durable medical equipment); assist with transfers, ADLs (activities of daily living), oxygen not necessary for safe bathing, change linens, ensure adherence to safe bathing techniques per plan of care, date of last BM (bowel movement); transfer client from chair/bed; transfer client to wheelchair; assist patient to dress; assist to toilet; shampoo; skin care; perineal care; shaving; oral care; ear care-weekly; denture care; nail care-no cutting-weekly; ask if patient has had any falls; back rub; incontinence care; observe skin integrity; apply lotion; apply powder; apply barrier cream; float heels." All tasks were to be completed on every visit unless otherwise specified. The HA visit note dated 05/05/2025 documented "Patient unable to get into shower, bed bath was done." During a joint clinical record review and interview on 01/14/2026, the Administrator/Director of Patient Care Services confirmed the findings. Regarding Home Visit 4, the Administrator stated that the "aide wanted to make sure she had performed a task for the surveyor to watch, but knew better than to do something not on the care plan." Regarding Clinical Record 17, the Administrator stated that the HA "should not have completed a bed bath without the care plan being changed."

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 agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services that equal at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the volunteer program with the Administrator and Volunteer Program Manager on 01/15/2026 revealed the volunteer percentage for the last twelve (12) months (January 2025 to December 2025) averaged 1.54%. The Volunteer Coordinator reported that they "Recently on-boarded several new volunteers who have become very active." The Volunteer Coordinator has been in the role since May 2025. A review of the volunteer program was conducted with the Administrator and Volunteer Program Manager on 01/15/2026, during which time the volunteer percentage for the last twelve (12) months (January 2025 to December 2025) averaged to 1.54%. The Volunteer Coordinator was given that role in May 2025 and the percentages have been improving since she has been in her position, however still fell below the required 5%. The Volunteer Coordinator reported she has "recently on boarded several new volunteers who have become very active."

It is required that the record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 12 (8%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) visit note included the care and services provided. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 12/29/2025 and resided in a skilled nursing facility (SNF). The HA care plan dated 12/30/2025 assigned the HA the relevant tasks: Bathing-bed bath; assist with ADLs (activities of daily living); change linens; tidy room; assist with feeding; hair care; skin care; perineal care; oral care; ear care-weekly; nail care (no cutting)-weekly; dressing; ask if patient had any falls; incontinence care; observe skin integrity; apply lotion; apply barrier cream; float heels. All tasks were to be completed on every visit unless otherwise specified. The HA visit note dated 01/14/2026 documented "yes" to completing the task: perineal care." During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 01/14/2026, the HA was not observed providing perineal care. During an interview, the Clinical Manager/Alt Administrator [Personnel Record 3], present for the duration of the home visit, confirmed the finding, stating that the HA had issues during the observed visit with documenting in the electronic medical record (EMR), and that the visit note was completed upon the return to the agency. During a joint clinical record review and interview on 01/14/2026, the Administrator/Director of Patient Care Services confirmed the findings, stating, "It must have been her clicking boxes too quickly when she checked the perineal care as completed."

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 clinical record review, document review, and interview. In 3 of 11 (27%) clinical records reviewed, the individualized written plan of care lacked patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy #AP-147, "Care Planning and Coordination of Services (Revised: 12/2019)", stated in part, "Policy: The Agency establishes a written, individualized plan of care for each patient which addresses needs identified in the assessment process. The plan of care has specific goals... B. 2. This plan should be based and developed upon the evaluation by the core IDG staff involved..." Clinical Record 8: The patient elected the hospice benefit on 12/29/22. The Chaplain frequency was 2m2 and 3 prn visits for spiritual needs, including emotional support per the interdisciplinary group (IDG) plan of care (POC) dated 12/29/22. The IDG POC dated 2/20/23 lacked goals and interventions for the Chaplain. Clinical Record 6: The patient elected the hospice benefit on 1/6/23. The Chaplain frequency was 2m2, and 3 prn visits for spiritual needs including emotional support per IDG POC dated 1/6/23. The IDG POC dated 1/6/23 lacked goals and interventions for the Chaplain. Clinical Record 11: The patient elected the hospice benefit on 11/9/22. The Chaplain frequency was 1m1 and 3 prns visits for spiritual needs including emotional support per IDG POC dated 11/9/22. The IDG POC dated 11/9/22 lacked goals and interventions for the Chaplain. Upon interview on 3/1/23, the Administrator reviewed and agreed with the Chaplain was seeing the patient's but the IDG POC lacked goals and interventions for the Chaplain.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group (IDG), and included in the plan of care (POC). This standard was not met as evidenced by clinical record review, document review, and interview. Agency Policy #AP-127, "Standard Policy: Certified Home Health Aide (Revised: 11/2018)", stated in part, "Policy: A. The CHHA provides services that are: 1. Ordered by the physician; 2. Included in the plan of care." In 3 of 7 (43%) clinical records reviewed for the patient's that elected to receive Hospice Aide services, the hospice aide did not provide services as ordered by the IDG and were included in the Hospice Aide POC. Clinical Record 2: The patient elected the hospice benefit on 12/7/22. The Aide POC dated 2/23/23 assigned a shower. On the Aide visit note dated 2/27/23, the aide did not follow the Aide POC and completed a sponge bath. Clinical Record 8: The patient elected the hospice benefit on 12/29/22. The Aide POC dated 12/29/22 assigned a shower with assist every visit, using a bath bench. On the Aide visit note dated 2/23/23, the aide did not follow the Aide POC and completed a bed bath. Clinical Record 3: The patient elected the hospice benefit on 2/15/23. The Aide POC dated 2/15/23 assigned a shower. On the Aide visit note dated 2/22/23, the aide did not follow the Aide POC and completed a sponge bath. Upon interview on 3/1/23, the Administrator reviewed and agreed the Hospice Aide did not follow the bathing task as ordered on the Hospice Aide POC.

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 and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency Policy #AP-127, "Standard Policy: Certified Home Health Aide (Revised: 11/2018)", stated in part, "Policy: C3. The CHHA will contact the Case Manager to notify of patient status changes and to receive additional instructions as deemed appropriate by the Registered Nurse, who may change the plan of care/assignment sheets as appropriate. The CHHA is not a skilled professional and is not authorized to make changes to the plan of care." In 3 of 7 (43%) clinical records reviewed for the patient's that elected to receive Hospice Aide services, the hospice aide did not notify the Registered Nurse of the change in the patient's needs related to the IDG ordered Hospice Aide plan of care (POC). Clinical Record 2: The patient elected the hospice benefit on 12/7/22. The Aide POC dated 2/23/23 assigned a shower. On the Aide visit note dated 2/27/23, the aide documented a sponge bath was completed. The record lacked evidence of the Hospice Aide notifying the Registered Nurse (RN) with the patient's current status and request to change the bathing task. Clinical Record 8: The patient elected the hospice benefit on 12/29/22. The Aide POC dated 12/29/22 assigned a shower with assist every visit using a bath bench. On the Aide visit note dated 2/23/23, the aide documented a bed bath was completed. The record lacked evidence of the Hospice Aide notifying the RN with the patient's current status and request to change the bathing task. Clinical Record 3: The patient elected the hospice benefit on 2/15/23. The Aide POC dated 2/15/23 assigned a shower. On the Aide visit note dated 2/22/23, the aide documented a sponge bath was completed. The record lacked evidence of the Hospice Aide notifying the RN with the patient's current status and request to change the bathing task. Upon interview on 3/1/23, the Administrator reviewed and agreed the Hospice Aide did not notify the Registered Nurse with the patient's current status and request to change the bathing task.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. Agency Policy #AP-111, "Discharge and Transfer (Revised: 6/2019)", stated in part, "Policy: 5a. If the care of patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward to the receiving facility a copy of: 1. The hospice discharge summary." In 1 of 1 (100%) clinical records reviewed for patients that revoked hospice services and were transferred to the hospital, the hospice did not forward a copy of the hospice discharge summary to the receiving facility (hospital). Clinical Record 7: The patient elected the hospice benefit on 11/23/22. The patient revoked hospice services on 12/5/22 and was transferred to the hospital to pursue aggressive treatment. The record lacked evidence that the discharge summary had been forwarded to the receiving facility (hospital). The clinical record had multiple coordination notes that addressed communication between the hospice Registered Nurse, the hospital, the physician, and the son. Upon interview on 3/2/23, the Administrator reviewed and agreed the discharge summary was not forwarded to the hospital.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed for a patient who revoked hospice and was transferred to the hospital, the hospice did not forward the patient's attending physician a copy of the hospice discharge summary. Agency Policy #AP-111, "Discharge and Transfer (Revised: 6/2019)", stated in part, "Policy: 5b. If patient is discharged, the hospice must forward to the patient's attending physician a copy of: 1. The hospice discharge summary." Clinical Record 7: The patient elected the hospice benefit on 11/23/22. The patient revoked hospice on 12/5/22 and was transferred to the hospital to pursue aggressive treatment. The clinical record had multiple coordination notes that addressed communication amongst the hospice RN, the hospital, the physician, and the son. The record lacked evidence that the discharge summary had been forwarded to the attending physician. Upon interview on 3/2/23, the Administrator reviewed and agreed the discharge summary was not forwarded to the patient's attending physician.