Every finding on record at Abigail Hospice LLC

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 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 clinical record review and interview. In 2 of 13 (15%) clinical records reviewed, it was revealed that the agency did not ensure that the drug profiles included the patient’s current prescription medications. CLINICAL RECORD 4: The initial nursing assessment, dated 06/06/2025, documented the patient had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was using oxygen continuously at 2 liters. The drug profile effective as of 06/06/2025 did not include the oxygen therapy. CLINICAL RECORD 8: The initial nursing assessment, dated 04/18/2025, documented the patient had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was using oxygen continuously at 2 liters. The drug profile effective as of 04/18/2025 did not include the oxygen therapy. The Director of Clinical Services stated in an interview on 08/13/2025 that these medications were not included on the drug profile.

It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. In-service training may be offered by any organization and is supervised by registered nurse. The hospice maintains documentation that demonstrates that requirements 1 and 2, above, have been met for each aide. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) hospice aide personnel records reviewed, it was revealed that the agency did not ensure that the hospice aide completed at least 12 hours of in-service training during a 12-month period. Personnel Record 6: The hospice aide with a date of hire of 02/14/2023, documented a total of 5 hours of in-service training for the calendar year 2024. During an interview on 08/14/2025 the Director of Clinical Services said the agency offers the on-line training courses, but she had not maintained records for hospice aide training and didn’t realize the aide hadn’t completed them.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group with 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 and interview. In 5 of 13 (38%) clinical records reviewed, in which aide services were accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/07/2024 with a diagnosis of other sequelae following unspecified cerebrovascular disease. The hospice aide plan of care included orders for the following relevant tasks: complete bed bath every visit and shower with chair every visit. The aide care plan did not provide additional instructions on when the bed bath or shower should be provided, nor did it include an identified decision maker. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/06/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The hospice aide plan of care included orders for the following relevant tasks: complete bed bath every visit and shower with chair every visit. The patient was also receiving continuous oxygen therapy. The hospice aide care plan did not provide additional instructions on when the bed bath or shower should be provided, nor did it include instructions on how to manage the oxygen use (i.e., could the hospice aide remove the oxygen canula for bathing, activity or dressing). There was not an identified decision maker. CLINICAL RECORD 6: The patient elected the hospice benefit on 04/10/2025 with a diagnosis of cerebrovascular disease. The hospice aide plan of care included orders for the following relevant tasks: complete bed bath every visit and shower with chair every visit. The hospice aide care plan did not provide additional instructions on when the bed bath or shower with chair should be provided, nor did it include an identified decision maker. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/13/2025 with a diagnosis of metabolic encephalopathy. The hospice aide plan of care included orders for the following relevant tasks to be provided at every visit: assist with transfer, scheduled repositioning, 2-person lift, ambulatory with assistance; complete bed bath; and shower with chair. The hospice aide care plan did not provide specific instructions on which tasks would be provided when (i.e. bed bound versus ambulation and bed bath versus shower), or the type of assistance required. There was no identified decision maker. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/18/2025 with a diagnosis of COPD. The hospice aide plan of care included orders for the following relevant tasks to be provided at every visit: complete bed bath, partial bed bath, shower with chair, assist with transfer, turn and position, 2-person assist, Hoyer lift and Sit to Stand transfer The hospice aide care plan did not provide specific instructions on which tasks would be provided when (i.e. bed bound versus Hoyer lift use versus Sit to Stand transfer versus 2 -person assist and bed bath versus shower). The patient also received continuous oxygen therapy. The hospice aide care plan did not include instructions on how to manage the oxygen use (i.e., could the hospice aide remove the oxygen canula for bathing, activity or dressing). There was no identified decision maker. The Director of Clinical Services reviewed the records on 08/13/2025 and stated the care plans did not provide the aide specific instructions or guidance on who was identified as the decision maker.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed, in which the hospice aide was accepted and provided care for greater than 14 days, the agency did not ensure that RN supervision was provided at least every 14 days. CLINICAL RECORD 8: For the benefit periods dated 04/18/2025-07/16/2025 and 07/17/2025-10/14/2025 the aide services were ordered and being provided twice weekly. A hospice aide supervisory visit was documented on 06/30/2025 with no additional supervisory visits documented as of the date of the review, 08/13/2025 (30 days overdue). CLINICAL RECORD 10: For the benefit periods dated 04/10/2025-07/08/2025 and 07/09/2025-10/06/2025 the aide services were ordered and being provided twice weekly. A hospice aide supervisory visit was documented on 06/24/2025 with the next supervisory documented on 07/16/2025 (8 days overdue). During the interview, on 08/13/2025, the Director of Clinical Services reviewed the records and stated that the aide supervision was not documented every 14 days.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of a hospice aide, the agency did not ensure that the registered nurse made an annual on-site visit to observe and assess each hospice aide while performing patient care. Personnel Record 6: For hospice aide with date of hire 02/14/2023, there is no documented annual in person assessment visit for calendar year 2024. Interview: The Director of Clinical of Clinical Services stated they have done in person supervisory visits with their hospice aide staff but do not monitor or document the information in the agency files. They were unable to provide documentation of in person hospice aide supervisory visits in patient medical records to corroborate.

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. A review of the volunteer program documentation revealed that the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The cost savings report documented an annual savings of 0.45% for 2023. For 2024, the average total was 3.67%. The first quarter of 2025 was 10.80%, the second quarter 4.22% with a savings of 7.51% for the year 2025 to date. During interview, on 08/14/2025, the Chaplain/Volunteer Coordinator stated that current volunteers are in place to provide hours and that current recruitment and retention efforts will continue. During the review of the volunteer program binder, the agency did not ensure that a cost saving of 5% or over was accomplished for the agency. The binder contained cost savings of 0.0% in the first and second quarters of 2023, 0.69% the third quarter and 1.1% the fourth quarter with an annual savings of 0.45% for 2023. For 2024, the first quarter was 0.2.65%, the second quarter was 2.63%, the third quarter 2.57% and the fourth quarter 6.81% with a savings of 3.67% for 2024. The first quarter of 2025 was 10.80%, the second quarter 4.22% with a savings of 7.51% for the year 2025 to date. Currently their volunteer census has dropped and they do not anticipate maintaining the 2025 numbers for the rest of the year. The process improvement plan is in place, as well as documentation of recruitment and retention efforts, which continue from the team.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by interview and personnel record review. In 3 of 8 (38%) personnel records reviewed, it was revealed that the agency did not ensure competency evaluations were completed in accordance with the agency policy. Agency Policy No. 3-005, Hospice Annual Core Competence, stated in part, "Hospice will implement an objective, measurable system to evaluate competency. The performance criteria lists the required behavior personnel must demonstrate to be deemed proficient in the skills required. 1. Hospice Personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process. 2. If hospice personnel are not required to perform a specific aspect of care or task as a routine part of their job responsibilities, the performance criteria is simply labeled 'N/A" by a qualified evaluator. .3. Hospice Personnel are deemed proficient only when 100% of the applicable performance criteria are demonstrated." PERSONNEL RECORD 2: The Director of Clinical Services and Registered Nurse/Case Manager had a date of hire of 02/14/2022. For 2023, the personnel record included skills competency evaluations for both positions however, the Administrator who does not have a nursing degree, signed as the evaluator. There were blank copies of competencies, filed in the record, for both positions for 2024. PERSONNEL RECORD 5: The Medical Social Worker (MSW) and Bereavement Coordinator had a date of hire of 05/15/2023. The record lacked evidence of an annual competency evaluations for either position. PERSONNEL RECORD 7: The Registered Nurse (RN) had a date of hire of 02/19/2024. The record lacked documented evidence of an initial competency evaluation. The RN was working independently and assigned a primary case load. On 08/14/2025, the Director of Clinical Services and Administrator confirmed the missing and blank forms. At the time of the exit conference, they were unable to provide documentation that the competency evaluations had been completed within the agency policy timeframes. The Director of Clinical Services and Administrator scheduled competency reviews for those that were missing, and the RN was removed from independent patient care until the competencies could be completed. Hospice Annual Core Competence Policy No. 3-005: "Hospice will implement an objective, measurable system to evaluate competency. The performance criteria lists the required behavior personnel must demonstrate to be deemed proficient in the skills required. 1. Hospice Personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process. 2. If hospice personnel are not required to perform a specific aspect of care or task as a routine part of their job responsibilities, the performance criteria is simply labeled 'N/A" by a qualified evaluator. .3. Hospice Personnel are deemed proficient only when 100% of the applicable performance criteria are demonstrated." On interview the administrator stated they are revising their policy to reflect their current practice of completing a competency review on hire, 90 days and annually.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient's attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient's record includes a signed copy of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's clinical record included a signed copy of the notice of the patient's rights. CLINICAL RECORD 1/HOME VISIT 1: The election of benefit was signed by the power of attorney (POA) on 10/07/2024. The two-page form, signed by the POA, did not include acknowledgement of the patient rights. During the home visit, completed on 08/12/2025, it was confirmed that the patient had received a copy of the patient rights/bill of rights. The record lacked evidence of signed copy of the notice of patient rights. Upon review of the election of benefit form that was included in this record the Director of Clinical Services report that the agency’s election of benefit was a 3-page form and they were missing page 2. CLINICAL RECORD 2/HOME VISIT 2: The election of benefit was signed by the power of attorney (POA) on 11/12/2024. The two-page form, signed by the POA, did not include acknowledgement of the patient rights. During the home visit, completed on 08/12/2025, it was confirmed that the patient had received a copy of the patient rights/bill of rights. Upon review of the election of benefit form that was included in this record the Director of Clinical Services report that the agency’s election of benefit was a 3-page form and they were missing page 2. During an interview on 08/13/2025, the Director of Clinical Services, reported that they investigated this and discovered that the election of benefit forms used in October and November last year (2024) were missing the middle page which included the bill of rights acknowledgement.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records, interviews and observations. In 1 of 9 (11%) records reviewed it was revealed that the agency did not ensure that the plan of care (POC) met the needs of the patient identified in the comprehensive assessment.. Clinical Record 2 Patient elected the benefit on 9/8/22 with terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and co-morbidity of Heart Failure. Review of record revealed that the patient had new edema documented in the Registered Nurse (RN) comprehensive assessment on 9/29/22. On 10/12/22 the physician was notified of continued edema and medication changes made. The plan of care effective 9/8/22-12/6/22 did not contain any problems or interventions related to cardiac status, or fluid overload/edema. Home Visit 3 (Record 2) During this home visit it was observed that the patient had 3-4+ bilateral lower extremity edema and the RN (staff 5) remarked this was an issue that patient had been experiencing. Staff 5 In an interview with Director of Clinical Services on 10/25/22 it was confirmed that the care plan did not address the cardiac disease or edema, and it should have.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 9 (11%) records reviewed it was revealed that the agency did not ensure that a correct physician order was present for all medications. . Clinical Record 1 Patient elected the hospice benefit on 8/4/22 with the terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Initial comprehensive assessment, completed on 8/4/22, documented the patient was on continuous oxygen at 4 liters. The nursing visit dated 8/9/22 documented that the oxygen was decreased to 2.5 liters continuously. A physician order, effective 8/4/22 to current, was written for oxygen at 2 liters continuously via nasal cannula. Staff 5 In an interview with the Director of Clinical Services, conducted on 10/25/22, it was confirmed that the oxygen order was for 2 liters since admission, and that new orders should have been written to reflect what the patient was administering. The agency was unable to produce any other physician orders to correlate with the oxygen dosage changes documented within the nursing assessments.

It is required that organization policy and procedure states the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. This standard was not met as evidenced by a review of document reviews, interviews and personnel records. In 1 of 1 (100%) of personal records reviewed, that contained a medical exemption for the COVID-19 vaccine, revealed the agency did not ensure that the medical exemption included a statement signed and dated by a licensed practitioner, who was not the individual requesting the exemption.. Agency Policy Stated in relevant part "For staff members who request a medical exemption from vaccination, all documentation confirming recognized clinical contraindications to COVID-19 vaccines, and which supports the staff member's request, must be signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice." Staff 6 On the medical exemption from COVID-19 vaccination form, dated 3/8/22, the signature for the person requesting exemption and the licensed practitioner recommending exemption were the same. The exemption form stated: "Please attach a statement from your medical provider recommending that you be exempt or receive accommodation from our COVID-19 vaccine mandate. The medical professional must identify his place of employment or practice and sign and date the statement." In that section the individual wrote, "see above, self-provided as a physician." Staff 1 In an interview with the administrator on 10/24/22 it was confirmed that the individual requesting exemption was the same person providing medical documentation of the reason for the request and that the agency policy was clear that was not acceptable.