SAMPLE — ILLUSTRATIVE TEST DATA, NOT A REAL FACILITY
Hospice · Metrics
Single-facility report
SAMPLE HOSPICE OF ANYTOWN
CCN 000000
123 Example Avenue, Anytown, XX 00000
Prepared as: Neutral reference
A structured, denominator-anchored reference of this facility's publicly reported metrics and public ownership and survey records.
How to read this report. Provenance-labeled throughout, denominators on every rate, caveats stated. Presented without advocacy for any party.
This report compiles and visualizes publicly available CMS data. It is not legal advice or legal strategy, and it is not a substitute for an attorney licensed in your jurisdiction. All derived metrics should be independently verified before submission to any administrative or judicial proceeding.
CMS-PUBLISHED read directly from a CMS file
PRODUCT-COMPUTED derived here from public sources, shown with its denominator
What this report does not establish
This report is built only from the CMS files named in the methodology section. The list below states what those files cannot show, so that the figures in this report are read for what they are. Each entry points to the section that covers it in full.
- That any patient was enrolled improperly, or that any care was poor
- This report makes no causal claim and asserts nothing about the eligibility of any individual patient. It is not a determination of wrongdoing.
- That a high live-discharge rate means poor clinical care
- The discharge rate measures how enrollments ended. The inspection record measures regulatory compliance. They are near-independent, and neither substitutes for the other.
- That a suppressed or absent figure is a zero
- Where CMS published nothing, this report says so and stops. A value shown as not published is unknown, not low and not zero.
- That an absent inspection record means a clean one
- If a subject does not appear in the survey export, its inspection record is not established here. Absence of a survey row is not a finding of zero citations.
- Any ranking, score or composite of this product's own making
- Every figure is either published by CMS or is a stated arithmetic operation on published figures. This report applies no flag rule and assigns no direction of its own.
- That the size band is a control group see 01
- The band is a comparator and nothing more. The rate is not adjusted by it, and no band-relative gap is computed.
- That this hospice's live-discharge rate has been independently validated see 01
- No public CMS file reports provider-level discharge status, so no outside source can confirm THIS hospice's rate. The national aggregate is a different matter: CMS publishes a claims-based national live-discharge rate, and the construction used here reproduces a national figure below it. The construction is therefore checkable in aggregate; the facility figure is not.
- That the two counts behind the rate are the same kind of thing see 01
- CMS publishes live discharges as a count of discharges and decedents as a count of beneficiaries. They are added here because that is how the two published figures combine into a rate, and a beneficiary dies once, so the two nearly coincide -- but a beneficiary can be discharged alive more than once in a window. The rate is close to, not exactly, live discharges over all discharges.
- That total Medicare dollars indicate anything about conduct see 02
- Total dollars mostly track how large a facility is. They are shown as scale and are not ranked.
- The legal entity behind this CCN, where CMS holds no enrollment record see 05
- Where the ownership release carries no match, the entity is not established by this report.
- The family experience, where CMS published no CAHPS scores see 07
- An absent CAHPS record is not evidence about the family experience, and it is not evidence of a good one.
00
At a glance
PRODUCT-COMPUTED
| Signal | This hospice | Read against | § |
|---|
| Live-discharge rate | 48.57% | national 16.08%; above by 32.49 points; median for similar discharge volume (Q2) 23.91% (see 01; not a control group) | 01 |
| Medicare dollars (over the measure window) | $9,088,000 | per-beneficiary spending at the 63rd national percentile (CMS-published); a measure of Medicare size, not conduct | 02 |
| Discharge-pattern components at/above CMS's 90th percentile | 2 of the 4 components CMS published | CMS-published percentiles; each component is shown individually with its national and state comparator in 03 | 03 |
| Hospice Care Index (CMS composite) | 9.0 / 10 | national 8.8; CMS's own 0 to 10 monitoring score; higher = fewer indicators in the worst-performing category | 04 |
| Ownership | for-profit; PRIVATE-EQUITY FLAGGED; chain of 10+ | CMS ownership flags, read directly | 05 |
| Case mix (largest deviation on the page) | dementia 34.0% | national 26.1% (1.9 SD from the national spread) | 06 |
| Family experience (CAHPS) | 4.0/5 stars | CMS-published; blind to discharge patterns | 07 |
| Inspections, condition-level | 3 | the most serious citation class | 08 |
| Inspections, citations per survey | 4.67 across 3 surveys | national median 3.0 — 68th percentile (raw count alone: 71st) | 08 |
Every row restates a figure from the section named beside it, with the comparator that figure is read against. This page adds no score, ranking, priority or conclusion, and none of the sections below do either: what a given value means for a given case is a judgment this report leaves to the reader who is qualified to make it.
01
Live-discharge rate
PRODUCT-COMPUTED
48.57 %
denominator: 210 discharges (102 live + 108 decedents)
National volume-weighted rate this window: 16.08%
Median rate, facilities of similar discharge volume (Q2, 1,351 facilities): 23.91% — a comparator, not a control group
| National rate by discharge volume | Facilities | Discharges | Median LD rate |
|---|
| Q1 smallest |
1,359 |
11–81 |
45.00% |
| Q2 |
1,351 |
81–222 |
23.91% |
| Q3 |
1,352 |
222–573 |
17.37% |
| Q4 largest |
1,354 |
573–61,829 |
13.07% |
The national rate beside this figure is not size-neutral. Live-discharge rate falls with discharge volume: nationally the smallest quartile of facilities has a median rate of 45.00% and the largest 13.07%. That gradient is not the case-mix confounder in another form. It survives holding dementia roughly constant, and within the lowest dementia quartile it still runs 22.0% against 9.2%. This facility's denominator places it in Q2 by volume (1,351 facilities), where the median rate is 23.91%. That band is a comparator and nothing more. It is NOT a control group. The facilities in it may share whatever this rate reflects, so treating the band as a baseline can absorb the variation the rate is measuring. The rate is not adjusted by it, and no band-relative gap is computed here. Smaller hospices transfer, revoke and discharge patients more often than larger ones, so the gradient may reflect ordinary operating differences. It may instead be part of what the rate is responding to. This data cannot settle which, and this product does not try to.
Derivation: live discharges / (live discharges + decedents) x 100. Medicare-FFS-scoped; 8-quarter rolling window; computed from CMS-published denominators. No public CMS file reports provider-level discharge status, so THIS hospice's rate has no external reconciliation. The national aggregate does: CMS publishes a claims-based national live-discharge rate in its Hospice Monitoring Report, and the same construction applied here runs below it. The measure denominator used here excludes an immediate transfer to another hospice, which CMS's all-reasons national rate includes; that accounts for much of the gap and the remainder is not attributed.
02
Medicare dollars at this facility
PRODUCT-COMPUTED
$9,088,000
= per-beneficiary spending $14,200 × beneficiaries 640 · window the measure's published two-year window (illustrative)
Per-beneficiary spending national percentile (CMS-published): 63 · national per-beneficiary spending, pooled the same way: $15,760
National median facility total, counted the same way (5,469 facilities): $4,432,125 — a measure of scale, not a ranking
Inputs: H_012_07_OBSERVED (per-beneficiary spending, CMS-published $) and H_012_07_DENOMINATOR (beneficiary count, the spending measure's own denominator). Total rounded to the nearest whole dollar. A claims-based Medicare spending figure over the measure window, computed the way CMS defines the Hospice Care Index indicator; it is Medicare dollars for the beneficiaries in that computation. It is not a total across all payers, and it is not a forward-looking figure. It is a measure of the facility's Medicare size, not of any finding.
The figure beside the total is CMS's own national percentile for this facility's per-beneficiary spending. It compares spending per patient, not total dollars, so facility size does not drive it. The national per-beneficiary figure is pooled the same way: total national Medicare dollars over total national beneficiaries. Total dollars are shown to give a sense of scale, with the national median per-facility total beside them for context. Total dollars mostly track how large a facility is, so they are not ranked.
03
Discharge-pattern components
CMS-PUBLISHED
| Component | Observed | Base | Nat'l | State | CMS pctl | ≥90th |
|---|
| Early live discharges (% of live discharges) |
3.1 |
210 |
7.3 |
3.9 |
41 |
no |
| Late live discharges (% of live discharges) |
55.8 |
210 |
37.4 |
38.0 |
91 |
yes |
| Burdensome transitions, type 1 |
18.9 |
210 |
8.5 |
9.9 |
92 |
yes |
| Burdensome transitions, type 2 |
1.2 |
210 |
2.1 |
1.1 |
60 |
no |
Each component is CMS-published and shown on its own line against the national and state figures. This report combines them into no composite, score or flag: a count of components at or above CMS's 90th percentile is stated against how many CMS published, and nothing is inferred from it. Components CMS suppressed are shown as not published, never as zero and never as a passing value.
Base is the count of cases each percentage is computed over (CMS's own denominator for that component). A small base makes the percentage fragile — for example, a rate over a base of 3 moves by a third with a single case — so read every observed value against its base.
04
Hospice Care Index (CMS composite)
CMS-PUBLISHED
9.0 / 10
CMS Hospice Care Index · national 8.8 · state 8.9
The Hospice Care Index is CMS's own monitoring score. It is not a figure this product calculates. CMS builds it from ten indicators drawn from Medicare claims. A hospice earns one point for each indicator on which it does NOT fall in the worst-performing category, giving a score out of 10. A higher score therefore means fewer indicators in that category. This panel shows CMS's score with the national benchmark beside it.
| Indicator | Observed | Nat'l | State | CMS pctl |
|---|
| Continuous home care / general inpatient care provided (% days) |
0.6 |
0.5 |
not published |
62 |
| Gaps in nursing visits (% elections) |
51.0 |
52.4 |
not published |
47 |
| Early live discharges (% live discharges) · see discharge-pattern flag |
3.1 |
7.3 |
not published |
41 |
| Late live discharges (% live discharges) · see discharge-pattern flag |
55.8 |
37.4 |
not published |
91 |
| Burdensome transitions, type 1 (% live discharges) · see discharge-pattern flag |
18.9 |
8.5 |
not published |
92 |
| Burdensome transitions, type 2 (% live discharges) · see discharge-pattern flag |
1.2 |
2.1 |
not published |
60 |
| Per-beneficiary spending (U.S. $) · see the Medicare-dollars section |
14,200.0 |
19,227.0 |
not published |
63 |
| Nurse care minutes per routine home care day (minutes) |
18.0 |
19.9 |
not published |
45 |
| Skilled nursing minutes on weekends (% minutes) |
9.1 |
9.6 |
not published |
50 |
| Visits near death (% decedents) |
88.0 |
89.3 |
not published |
44 |
Each indicator is shown exactly as CMS publishes it: the observed value, the national and state benchmarks, and CMS's percentile. This report assigns no direction to any of them. Which end of the scale CMS treats as worst-performing varies from one indicator to the next, and CMS's Hospice Care Index documentation defines each one. The same value can also read differently to a quality reviewer and to a billing-integrity reviewer. This panel therefore reports the number and its benchmark, and leaves the reading to the reader. A suppressed value is shown as not published, never as zero. Four indicators (early and late live discharges, and the two burdensome-transition measures) also appear in the discharge-pattern section with their national and state comparators, and per-beneficiary spending appears in the Medicare-dollars section. They are repeated here so the index is complete. Note that the national figure on the per-beneficiary spending row is CMS's own benchmark for that indicator, which CMS builds as an average across hospices. The Medicare-dollars section shows a different national figure for the same measure, pooled as total national dollars over total national beneficiaries. Both are correct and they are built differently, so the two are never subtracted from one another.
05
Ownership & structure
CMS-PUBLISHED
Profit status
For-profit
Profit-status source
CMS enrollment record (PECOS); CMS's public Care Compare listing may state a different ownership type
Incorporation year
2016
Private-equity owner (CMS flag)
Yes
Chain (owner with 10+ hospices)
Yes
Cross-sectional association from public ownership records; no causal or liability claim.
Official change-of-ownership record (CMS-published): 1 transaction(s).
| Effective date | Type | Buyer (CCN) | Seller (CCN) | Published |
|---|
| 2024-05-15 |
CHANGE OF OWNERSHIP |
EXAMPLE HOSPICE HOLDINGS, LLC (000000) |
PRIOR OWNER, INC. (000001) |
2024-07-01–2026-04-01 |
CMS's official CHOW transaction file, as published: a formal change of ownership with an effective date and named buyer/seller. The record is the deduped union across quarterly files; a transaction CMS later dropped is kept and marked. A change of ownership is an event, not a finding.
Ownership-change history: 2 organizational-owner change event(s) across loaded quarters.
| From quarter | To quarter | Owners added | Owners removed |
|---|
| 2024-04-01 | 2024-07-01 | 2 | 0 |
| 2025-04-01 | 2025-07-01 | 1 | 1 |
Organizational-owner changes reconstructed from quarterly CMS ownership snapshots. This is a separate, PRODUCT-COMPUTED signal from the official transaction record above. It sees owner-set churn between snapshots (partial rosters included) and carries observation-quarter bounds rather than transaction dates, so it and the official file measure different things and are not expected to match one-to-one; the two are reconciled by this product's own quality-control layer. A change of control is a recorded event, not a finding; individual-officer churn is excluded.
Enrolled legal entity
EXAMPLE HOSPICE HOLDINGS, LLC
Organizational form
LLC
Incorporated
2016-03-02 in DE (outside its operating state)
CMS enrollment ID
O00000000000000
CMS associate ID
0000000000
The enrolled legal entity is the party CMS holds accountable, and it is often not the trading name at the top of this page. The enrollment and associate IDs are how CMS keys this hospice in its own systems. Incorporation state is shown because 618 of 6,066 hospices are incorporated outside the state they operate in -- a structural fact worth knowing, not a finding of any kind.
06
Case mix & scale
CMS-PUBLISHED
Average daily census
58.0
National average daily census PRODUCT-COMPUTED
65.3
Average daily census is the average number of patients this hospice had under care on any given day. It is a measure of size, not of quality: a larger hospice will accumulate more of everything, including citations.
| Primary diagnosis (% of patients) | This hospice | National mean | Hospices in that mean |
|---|
| Dementia | 34.0 | 26.1 | 4,647 |
| Cancer | 12.0 | 19.8 | 4,420 |
| Circulatory / heart disease | 22.0 | 23.3 | 4,650 |
| Respiratory disease | 11.0 | 9.7 | 3,673 |
| Stroke | 9.0 | 8.7 | 3,530 |
| Other conditions | 12.0 | 15.6 | 4,212 |
| Care setting (% of care) | This hospice | National mean | Hospices in that mean |
|---|
| Home | 71.0 | 66.3 | 6,142 |
| Assisted living | 20.0 | 18.4 | 6,091 |
| Nursing facility | 7.0 | 9.5 | 6,028 |
| Skilled nursing | 2.0 | 5.0 | 5,840 |
Case mix is a potential explanatory factor for a high live-discharge rate: dementia and debility trajectories are unpredictable and routinely outlast a six-month prognosis, so those patients are more often discharged alive, while cancer declines predictably. These shares are shown so section 01 is read in context. National figures are means across every facility CMS published this release and are PRODUCT-COMPUTED, not CMS-published benchmarks. Three constraints CMS places on these fields: each share counts a patient's PRIMARY diagnosis only, so a patient with dementia and cancer appears once; CMS suppresses any share above 75%, so the top of the distribution is censored and no facility can be shown as overwhelmingly one diagnosis; and these come from a single year of CMS's public use file, not the eight-quarter window behind the live-discharge rate, so the two describe overlapping but different periods.
07
Family experience (CAHPS)
CMS-PUBLISHED
CMS summary star rating
4.0 / 5
Would definitely recommend
88.0%
Overall rating 9-10
84.0%
Treated with respect
92.0%
Help with symptoms
76.0%
Family-experience (CAHPS) surveys sample decedents' families; live-discharged patients are outside the sampling frame, so CAHPS is structurally blind to discharge patterns. It neither confirms nor refutes the claims-based signals above.
08
Inspection record (CMS Form 2567 surveys)
CMS-PUBLISHED
Condition-level citations
3
Standard-level citations
11
Immediate Jeopardy findings
1
Surveyed by
State agency, ACHC
| Regulatory regime | Condition | Standard |
|---|
| Conditions of Participation (care delivery) | 3 | 9 |
| Life Safety Code (building & fire safety) | 0 | 2 |
| Emergency Preparedness | 0 | 0 |
QCOR cites three separate regimes and they are not interchangeable: Conditions of Participation govern care delivery, the Life Safety Code governs the building, and Emergency Preparedness governs planning. A fire-door finding is not a care finding. Totals above are the sum of this table.
| Compared with all hospices PRODUCT-COMPUTED | This hospice | National median | Percentile |
|---|
| Citations, raw count | 14 |
6.0 |
71st |
| Citations per survey (3 surveys) |
4.67 |
3.0 |
68th |
Comparison set: 7,446 hospices (all hospices nationally with a valid CCN and at least one survey in this CMS survey export, regardless of quality-release listing status; the national count excludes 1,611 citations across 275 surveys that CMS published under a placeholder CCN (PENDING), together with a further 79 placeholder surveys that recorded no citations, which cannot be attributed to any hospice and are counted in no figure here). Computed here across every facility in this export; CMS publishes no survey benchmark. Read the per-survey figure, not the raw count: what drives a facility's citation total is how often a surveyor visited (correlation 0.51), not how big it is (0.16). Medians and percentiles are used rather than averages because a handful of facilities carry very high counts and drag an average upward.
| Survey type | Surveys | Citations |
|---|
| Recertification | 2 | 10 |
| Complaint | 1 | 4 |
Survey type matters. A complaint survey means that someone (family, staff or a member of the public) filed a grievance a state agency judged worth inspecting. A recertification survey is routine and scheduled. The same citation carries different weight depending on what brought the surveyor through the door. Surveys are counted here even when they produced NO citations: a complaint that was investigated and substantiated nothing is part of this hospice's record.
| Survey end | Tag | Governs | Severity | Survey type | Description & surveyor findings |
|---|
| 2025-08-14 | L0555 |
Care delivery | Condition |
Complaint |
QUALITY ASSESSMENT / PERFORMANCE IMPROVEMENT (418.58) Based on record review and interview, the hospice failed to maintain an effective, ongoing, hospice-wide quality assessment and performance improvement program for 3 of 5 sampled quarters. Refer to tags: L-0522, L-0530. Points to 2 other citation(s) from the same survey, listed in this table: L0522, L0530. This citation records no finding of its own. |
| 2025-08-14 | L0530 |
Care delivery | Condition |
Complaint |
INTERDISCIPLINARY GROUP, CARE PLANNING (418.56) Based on record review, the interdisciplinary group did not review and update the plan of care at the required interval for 2 of 5 sampled patients. |
| 2024-11-07 | L0625 |
Care delivery | Condition |
Recertification |
HOSPICE AIDE SERVICES (418.76) No surveyor narrative published for this survey. |
| 2025-08-14 | L0522 |
Care delivery | Standard |
Complaint |
PLAN OF CARE (418.56) Based on record review, the plan of care did not include all services necessary for the palliation and management of the terminal illness for 1 of 5 sampled patients. |
| 2025-08-14 | L0552 |
Care delivery | Standard |
Complaint |
COORDINATION OF SERVICES (418.56) No surveyor narrative published for this survey. |
| 2024-11-07 | L0505 |
Care delivery | Standard |
Recertification |
PATIENT RIGHTS (418.52) Based on interview, the hospice did not provide written notice of patient rights to 1 of 5 sampled patients on admission. |
| 2024-11-07 | L0533 |
Care delivery | Standard |
Recertification |
CONTENT OF PLAN OF CARE (418.56) No surveyor narrative published for this survey. |
| 2024-11-07 | L0596 |
Care delivery | Standard |
Recertification |
NURSING SERVICES (418.64) Based on record review, a registered nurse did not complete the comprehensive assessment within 5 days of election for 1 of 5 sampled patients. |
| 2024-11-07 | L0629 |
Care delivery | Standard |
Recertification |
HOSPICE AIDE SUPERVISION (418.76) No surveyor narrative published for this survey. |
| 2024-03-19 | L0514 |
Care delivery | Standard |
Recertification |
PATIENT RIGHTS — COMPLAINT PROCESS (418.52) Based on record review, the hospice did not document investigation of 1 of 2 patient grievances filed during the review period. |
| 2024-03-19 | L0678 |
Care delivery | Standard |
Recertification |
ORGANIZATION AND ADMINISTRATION OF SERVICES (418.100) No surveyor narrative published for this survey. |
| 2024-03-19 | L0741 |
Care delivery | Standard |
Recertification |
PERSONNEL QUALIFICATIONS (418.114) Based on personnel file review, 1 of 4 sampled staff files did not contain evidence of a current license. |
CMS records a follow-up revisit as its own survey event. The same deficiency can therefore be cited once on an initial survey and again on a later revisit that verifies whether it was corrected. That repetition is a feature of CMS's record, not a duplicated count. Every survey in the export is listed and counted here; none is combined or removed, and CMS's published survey type is shown for each survey above.
Inspection records measure regulatory compliance across three separate regimes: care delivery (Conditions of Participation), building and fire safety (Life Safety Code), and Emergency Preparedness. Only the first speaks to care. Discharge patterns measure something different: how enrollments ended. The two are near-independent: neither substitutes for the other, and a high live-discharge rate does not carry information about clinical care.
09
Live-discharge rate over time
PRODUCT-COMPUTED
| Release | 2023-05-24 | 2024-05-22 | 2025-05-21 | 2026-05-20 |
|---|
| This hospice, LD rate (%) | 41.2 | 44.8 | 47.1 | 48.57 |
| National, same release PRODUCT-COMPUTED | 14.77 | 14.87 | 15.34 | 16.08 |
| Gap to national (points) | +26.43 | +29.93 | +31.76 | +32.49 |
| CMS measurement window | 04/01/2019-12/31/2019; 07/01/2020-09/30/2021 | 01/01/2021-12/31/2022 | 01/01/2022-12/31/2023 | 01/01/2023-12/31/2024 |
Presented as a trend. 8-quarter rolling windows overlap across annual snapshots, inflating run-lengths; trends are descriptive.
Official CHOW effective date(s): 2024-05-15. The marked date(s) are official CHOW effective date(s) for this hospice, placed on the timeline as context. No before/after change is computed against them: each rate above is measured over a multi-year window and consecutive windows overlap, so a rate cannot be cleanly attributed to either side of a transaction date.
Each column is measured over a different CMS window, and they are not the same shape: the earliest excises the first half of 2020 under the COVID reporting exemption, so it is a split period rather than a continuous one. Read the gap to national rather than the facility line on its own, because the national rate moved over these releases too. One release is shown per year, taken from the same point in the year wherever the publication schedule allows, so that consecutive years are compared on a like-for-like footing. The most recent column is the release this report is drawn from, which is why it matches the headline figures above; when that release falls in a different part of the year, the final gap between columns is longer or shorter than the others and the dates shown say so.
10
Trajectory — signals over time
PRODUCT-COMPUTED
Live-discharge rate PRODUCT-COMPUTED
national basis: pooled (patients)
| Release | Value | National | Gap | Denominator | CMS window |
|---|
| 2023-05-24 |
41.20% |
14.77% |
+26.43 |
196 patients |
04/01/2019-12/31/2019; 07/01/2020-09/30/2021 |
| 2024-05-22 |
44.80% |
14.87% |
+29.93 |
203 patients |
01/01/2021-12/31/2022 |
| 2025-05-21 |
47.10% |
15.34% |
+31.76 |
208 patients |
01/01/2022-12/31/2023 |
| 2026-05-20 |
48.57% |
16.08% |
+32.49 |
210 patients |
01/01/2023-12/31/2024 |
Medicare $ per beneficiary PRODUCT-COMPUTED
national basis: pooled (dollars / beneficiaries)
| Release | Value | National | Gap | Denominator | CMS window |
|---|
| 2023-05-24 |
$13,100 |
$13,249 |
-149 |
610 beneficiaries |
04/01/2019-12/31/2019; 07/01/2020-09/30/2021 |
| 2024-05-22 |
$13,800 |
$14,288 |
-488 |
625 beneficiaries |
01/01/2021-12/31/2022 |
| 2025-05-21 |
$14,000 |
$14,849 |
-849 |
632 beneficiaries |
01/01/2022-12/31/2023 |
| 2026-05-20 |
$14,200 |
$15,760 |
-1,560 |
640 beneficiaries |
01/01/2023-12/31/2024 |
Hospice Care Index composite PRODUCT-COMPUTED
national basis: median across hospices (computed here, not CMS's published national)
| Release | Value | National | Gap | Denominator | CMS window |
|---|
| 2023-05-24 |
8.0 / 10 |
9.0 |
-1.0 |
1 hospice |
04/01/2019-12/31/2019; 07/01/2020-09/30/2021 |
| 2024-05-22 |
8.0 / 10 |
9.0 |
-1.0 |
1 hospice |
01/01/2021-12/31/2022 |
| 2025-05-21 |
9.0 / 10 |
9.0 |
+0.0 |
1 hospice |
01/01/2022-12/31/2023 |
| 2026-05-20 |
9.0 / 10 |
9.0 |
+0.0 |
1 hospice |
01/01/2023-12/31/2024 |
Citations per survey PRODUCT-COMPUTED
national basis: pooled (citations / surveys)
| Release | Value | National | Gap | Denominator | CMS window |
|---|
| 2026-03-01 |
4.67 |
4.38 |
+0.29 |
3 surveys |
2021-10-01 to 2026-03-26 |
The store holds a single CMS survey export (one cumulative file), so citations per survey is a single point, not a trend; it will become a series as further exports are ingested. A suppressed period elsewhere is shown as a gap, never a zero and never interpolated.
Descriptive only. Each signal is shown beside the national figure counted the same way, with the gap to it; read the gap, not the raw line, because the national rate moves across these releases too. Nothing here attributes a change to conduct, and no signal is combined with another.
Each release measures a different multi-year CMS window and consecutive windows overlap (the 8-quarter rolling window), so a run of rising values is partly the windows sharing quarters, not four independent years. Read the gap to national.
Presented as a trend. 8-quarter rolling windows overlap across annual snapshots, inflating run-lengths; trends are descriptive.
A
Appendix — building & emergency-preparedness findings
CMS-PUBLISHED
These citations are counted in every total, benchmark and percentile in the inspection-record section. They are moved here, not discounted. They govern the building and emergency planning rather than patient care, which is why they are separated from the findings a care or billing review reads.
Some citations above carry no surveyor narrative. CMS publishes narratives per survey rather than per citation, so an unnarrated citation usually means the whole survey was published without text. Those citations are real and are counted in every total, benchmark and percentile above. The omission is CMS's, not ours.
| Survey end | Tag | Governs | Severity | Survey type | Description & surveyor findings |
|---|
| 2024-11-07 | K0293 |
Fire & building safety | Standard | Recertification |
EXIT SIGNAGE (NFPA 101) Based on observation, an exit access door on the second floor was not marked by a readily visible sign. |
| 2024-11-07 | K0225 |
Fire & building safety | Standard | Recertification |
STAIRWAYS AND SMOKEPROOF ENCLOSURES (NFPA 101) No surveyor narrative published for this survey. |
B
Appendix — measurement windows & survey dates on one time axis
CMS-PUBLISHED
| Date or window (as published) | Event | Release |
|---|
| 01/01/2021-12/31/2022 | Live-discharge measurement window | 2024-05-22 |
| 2025-08-14 | CMS survey | not applicable |
| 01/01/2023-12/31/2024 | Live-discharge measurement window | 2026-05-20 |
This appendix repeats, on one time axis, the live-discharge measurement windows from the live-discharge-over-time section and the survey dates from the inspection section. It places them side by side to save a manual cross-reference; it states no relationship between them. Overlap or closeness in time here is not a finding, and no window is matched to any survey.
11
Methodology & provenance
Why facility counts differ
Different sections count different things, so their facility totals differ on purpose. Each one is the set of hospices that actually had the figure being described: the live-discharge quartiles count hospices with BOTH discharge denominators published; the national facility median counts only hospices whose own rate is computable; the care-setting and incorporation figures count hospices that published those particular fields; the survey comparison set counts every hospice with a valid CCN and at least one survey in the CMS survey export, which is a different file with a different release date. A hospice missing from one of these counts is missing from that measure only. None of these totals is the "right" one and none is a correction of another; each figure names the count it was computed over so the two can always be read together.
Live-discharge derivation
live discharges / (live discharges + decedents) x 100
Scoping caveat
Medicare-FFS-scoped; 8-quarter rolling window; computed from CMS-published denominators. No public CMS file reports provider-level discharge status, so THIS hospice's rate has no external reconciliation. The national aggregate does: CMS publishes a claims-based national live-discharge rate in its Hospice Monitoring Report, and the same construction applied here runs below it. The measure denominator used here excludes an immediate transfer to another hospice, which CMS's all-reasons national rate includes; that accounts for much of the gap and the remainder is not attributed
CAHPS blindness
Family-experience (CAHPS) surveys sample decedents' families; live-discharged patients are outside the sampling frame, so CAHPS is structurally blind to discharge patterns. It neither confirms nor refutes the claims-based signals above.
Signal independence
Inspection records measure regulatory compliance across three separate regimes: care delivery (Conditions of Participation), building and fire safety (Life Safety Code), and Emergency Preparedness. Only the first speaks to care. Discharge patterns measure something different: how enrollments ended. The two are near-independent: neither substitutes for the other, and a high live-discharge rate does not carry information about clinical care.
Survey release cycle
CMS publishes survey (Form 2567) data on its own release cycle, independent of the provider-measures release; this report always shows the most recent survey export available as of the generation date above.
No active flag rule
This report applies no flag rule, score or composite of its own. Every figure it shows is either published by CMS or computed from CMS-published values with its denominator stated. Two candidate rules were built and tested against the data; both were rejected, and both are published below with the evidence that retired them.
Rejected rule (published): >=2 of 4 discharge-pattern components at/above CMS's 90th percentile, live-discharge denominator >= 20. — Rejected: it flags no more hospices than chance would. An early version of this test seemed to show a signal, 363 flagged against 308 expected, but it was run the wrong way. It shuffled the data across all 6,312 hospices in the pivot, including 845 that have no published percentiles, which understated how many flags chance alone produces and created a false signal. Run correctly, on the hospices the rule actually applies to (all four components published, with a live-discharge denominator of at least 20), it flags 206 against 204.8 expected by chance, a statistical tie. Combining the four components adds nothing, because their correlations cancel out. The rule also paired early and late live-discharge percentages, which are two shares of the same total and so cannot both run high, the same defect that sank the early-and-late rule. All four components stay in the report, each shown with its CMS percentile and its national and state comparators. Only the combined flag is withdrawn.
How this rule was tested. Among the 4,417 hospices this rule could apply to (hospices with all four component percentiles published and a live-discharge denominator of at least 20), 206 have at least 2 of these 4 components at or above CMS's 90th percentile. If the four components were unrelated to one another, chance alone would put about 205 over the same bar (give or take 10). The real count is 206, the same as chance would produce (+0.12 standard deviations). The rule therefore separates nothing that chance does not, which is why it is published here as rejected and no longer appears as a flag anywhere in this report. This is a test of the RULE, run across hospices; it says nothing about any one facility.
Rejected rule (published): worst-decile on early AND late live discharge simultaneously. — Early% and late% are shares of the same denominator (live discharges) and are mechanically anti-correlated; the joint rule flagged ~1 facility vs ~6 expected under independence. Statistically incoherent -- this is published as a rejected rule, and never shipped on any reports.
This report presents publicly reported metrics and public ownership/survey records with denominators and caveats. It makes no causal claim. It asserts nothing about the eligibility of any individual patient. It is not a determination of wrongdoing. The analytical body of this report is a function of the CMS releases named above and nothing else. Who commissioned it makes no difference to a single figure in it.
Reproducibility manifest. Illustrative sample. A real report lists the exact CMS releases used, with checksums, and is a pure function of those inputs.
| Family | Release date | Checksum |
|---|
| pdc_provider | 2026-05-20 | sample |
| ownership_all_owners | 2026-04-01 | sample |
| ownership_enrollments | 2026-04-01 | sample |
| qcor_2567 | 2026-03-01 | sample |
| cahps | 2026-05-20 | sample |
| chow | 2026-04-01 | sample |
| baseline_national | 2026-05-20 | sample |
| baseline_state | 2026-05-20 | sample |
| zip_service_area | 2026-05-20 | sample |
Code version sample · template report.html.j2/1 · generated 2026-08-19T01:57:02+00:00