Every finding on record at Abundant Hospice LLC

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AT IMMEDIATE JEOPARDY. This Condition of participation, which was also cited at Immediate Jeopardy, was not met as evidenced review of clinical records, observation, and interviews with the Administrator, Alternate Administrator, Director of Clinical Services, and Alternate Director of Clinical Services which revealed significant issues with the hospice's ability to assess and evaluate the patient's care environment related to patient safety: Failure to ensure the patient's right to be free from mistreatment and neglect, when the patient’s care environment was not assessed for safety risks (HPFC.2.D/L517). The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.52: Patient Rights. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient's right to be free from mistreatment and neglect, when the patient’s care environment was not assessed for safety risks. Agency policy PF.25 "Patient Care Site and Patient Safety Education," dated 02/01/2026, required in part "...the Interdisciplinary Group/Team (IDG/IDT) will...evaluate each case for ongoing risk and impact for patient...safety to determine if further action is needed. The determined plan of action will be discussed with the patient and/or family. All communication with the patient and/or family regarding safety concerns will be documented in the patient's medical record. The home environment will be re-evaluated for safety issues and/or hazards on an ongoing basis..." CLINICAL RECORD 2/HOME VISIT 2: During the home visit observation on 06/09/2026 with the Hospice Aide (HA) (Personnel Record 8), a flight of steep steps was ascended to reach the patient in his room above the garage, where the patient was found sitting in the recliner. The patient stood up, and the HA assisted the patient, who appeared unsteady, down the steps to the bathroom on the ground level of the finished garage. The bathroom door handle had a plastic lock protector, similar to a child-proof lock; however, the lock required a key. The Aide located the key underneath the laundry hamper to the right of the door. The key was used to access the bathroom. The Aide unlocked and opened the bathroom door. The Aide then assisted the patient with the step-up into the bathroom to shower the patient. Once the patient was showered and dressed, the Aide assisted the patient to step back down into the garage. The patient was observed to wobble and be unsteady as he held on to the Aide’s shoulder to steady himself in order to slide his feet into his shoes. The patient would not allow the aide to assist in any other manner but to help stabilize him. The patient was observed living in an apartment over the garage and did not have access to a bathroom unless he walked up and down the stairs. There was no bathroom upstairs in or next to the patient's room, and the patient did not have a bedside commode. A subsequent review of the clinical record revealed the patient resided at the home of his ex-wife and her husband. The hospice benefit election was dated 04/24/2026 with the diagnoses of senile degeneration of the brain and post-concussion syndrome. There was no 24/7 caregiver present with the patient. The family confirmed and was observed not being physically present at all times, and there was no way for the patient to call through phone, intercom, or lifeline if immediate assistance was needed. The Registered Nurse (RN) documented in the admission note dated 04/24/2026 that the patient had previously been in an independent living situation but had moved in with his ex-wife because he needed more care. The Social Worker (SW) documented on 04/28/2026 that the patient lacked access to a phone and was unable to make phone calls. The RN documented in the nursing visit note dated 05/28/2026 that, although the patient was able to ambulate, his cognitive deficit affected his judgment and balance. The RN documented in the nursing visit note dated 06/03/2026 that, due to increased "hunching over" while walking, the patient needed to be watched more closely during ambulation, with increased ataxia (poor muscle control and uncoordinated movements) impacting motor skills and balance. The patient required increased monitoring and fall prevention due to the center of gravity shifting forward, increasing his risk of falls "drastically." The SW documented on 06/08/2026 located the patient in his upstairs room with an unsteady stance and noted he was unbalanced on his feet, although he appeared comfortable and well-cared for. He was able to ambulate on his own "however he has a very unsteady stance when standing and often loses his balance when walking..." The Interdisciplinary Group (IDG) Meetings dated 05/13/2026 and 05/27/2026, the Registered Nurse documented the patient’s Palliative Performance Scale (PPS) of 50% (Ambulation-mainly sit/lie, Activity Level-can’t do any work, Self-Care-considerable assistance needed) and that the patient was a complete assist with 3 out of 6 ADLs (activities of daily living). The patient exhibited increased weakness and confusion. The Social Worker documented in the 05/27/2026 IDG meeting that the patient enjoyed his respite stay and was interested in adult daycare, as he enjoyed the activities during his respite stay. He continued to be supported by his ex-wife, and the SW would continue to support her and her current husband with education and information regarding disease progression but continue the current plan of care and monthly visits. The IDG documentation did not address the patient’s living conditions or assess the safety of the care environment. The clinical record did not include documentation that the patient had been assessed and evaluated to determine if the current care environment was safe for the patient, when the nurse and social worker documented increased unsteadiness with ambulation and assistance needed with activities of daily living. During the home visit observation on 06/08/2026, the patient was observed to be unsteady on his feet, with uncoordinated movements, no assistive devices were available, and the patient had no access to a bathroom without ambulating down a flight of steep stairs. There was no documented evidence that the patient had been assessed for his ability to ambulate the stairs safely or that he had to go downstairs to use the restroom. CLINICIAL RECORD 3/HOME VISIT 3: During the home visit observation on 06/09/2026 with the Licensed Master Social Worker (LMSW) (Personnel Record 6), the patient was bedbound with contractures (shortening and hardening of muscles and tendons, leading to limited joint movement) and unable to move in bed without assistance. The patient was observed to need total care. While talking with the LMSW, the son (primary caregiver) stated he "just couldn't" move, turn, and change the patient like he has done for years due to his own physical limitations. Respite was offered by the LMSW during the visit, but the patient's son was reluctant, as he felt his mother would react negatively. Subsequent review of the clinical record revealed that the patient resided at home with the son, who was the primary caregiver. The hospice benefit election was dated 03/11/2026 with a diagnosis of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The plan of care dated 04/13/2026 to 06/11/2026 included the identified problem of a deficit in self-care that included deficits in ambulation, transferring, dressing, toileting and bathing. Interventions included instructing the primary caregiver on safe care of a bed bound patient and the need for Hospice Aide services, which were being provided 5 times a week. The Registered Nurse (RN) documented on the admission assessment date 03/11/2026 the patient was bedbound, PPS 30% (Ambulation-bedbound, Activity Level-can’t do any work, Self-Care-total care); no skin condition or wounds; moderate risk for skin breakdown due to bedfast, potential friction/shear, completely immobile; incontinent bowel/bladder; has pure wick (urine collection system), and history of urinary tract infections; frail and cachectic (wasting syndrome); skin intact; occasional general pain, total assist all activities of daily living. The Registered Nurse documented on 05/06/2026 that the patient appeared clean and well cared for, despite an "unkempt environment (bugs throughout home and trash and dishes everywhere and very strong odor throughout home)." The nurse documented contact and coordination with the Social Worker (SW), who stated she had been "frequently keeping an eye on things." The Registered Nurse documented the presence of a wound on 05/13/2026. The wound assessment recorded a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with scant serosanguineous drainage and a mild odor. The Social Worker documented a visit on 05/14/2026 and noted the patient appeared comfortable and well cared for, but the son was upset that a large wound on the patient's back had reopened due to the "seriousness of it as reported by the assigned nurse." The Social Worker noted that the patient's son was aware of the patient's care needs. The Registered Nurse documented on 05/20/2026 that the son reported that the patient was having a bad day and had made multiple statements of just wanting to die, which he repeated in the nurse's presence. The patient was noted to be bedbound and contracted. The Interdisciplinary Group (IDG) Meeting dated 06/04/2026 included documentation indicating that the LMSW provided ongoing emotional support and connected the patient to resources, and that the patient remained bedbound with limited communication. "No further SW needs or concerns at this time. The patient will continue the current plan of care and monthly visits." The RN noted that the patient's Palliative Performance Score (PPS) was 30%...the patient required complete assistance with 6/6 ADLs. The patient was noted to have a "...stage 3 ulcer getting wound care weekly from RN..." The patient had dark, discolored urine with odor and sediment, and added that an antibiotic had been ordered 2 weeks previously, but the son never began the antibiotic as he decided she did not need it but finally agreed to start giving it at the previous day's nursing visit. The clinical record did not include documentation of an assessment of the patient’s care needs after the primary caregiver had made multiple statements of just wanting to die in the nurse’s presence. The primary caregiver had also referred to caregiver strain with the Social Worker, with no follow-up assessment documented. During the home visit observation, the patient was found to require total care, unable to turn self in bed or provide own self-care. During interviews with the Administrator (Personnel Record 1), the Alternate Administrator (Personnel Record 2), the Director of Clinical Services (Personnel Record 4), and the Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3) on 06/10/2026 and 06/11/2026, there was no documentation provided that ensured that the patients' safety had been addressed via assessment, intervention, plan of care updates, orders, or documented discussions with the Interdisciplinary Group (IDG). An interview was conducted with the Medical Director (Personnel Record 12) on 06/10/2026. During the interview, the patient’s living situation and mobility status (Clinical Record 2) were reviewed. The Medical Director did not demonstrate current awareness of the patient’s safety risks within the home environment at the time of the interview. When asked how the interdisciplinary team addressed safety concerns related to the patient’s living environment, the Medical Director stated that concerns were discussed during IDG meetings with participation from all disciplines. He described that the team collaborated to review the situation, identify potential risks, and develop interventions, including determining any additional steps necessary to address ongoing concerns.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patients drug profile contained the correct patient prescriptions, over-the-counter drugs, or supplements. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient resided at a Nursing Facility (NF). During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), a medication review was completed by comparing the patient’s hospice medication profile to the NF medication list. The hospice medication profile included Seroquel 100mg at bedtime for behavior/agitation, while the NF medication list included Seroquel 75mg at bedtime. The hospice medication profile included Lorazepam 1mg every 6 hours PRN (as needed) for agitation/behaviors. The NF medication list did not include Lorazepam. The hospice medication profile included Acetaminophen 650mg: 1-2 tablets every 8 hours PRN for pain, while the NF medication list included Acetaminophen 650mg 1 tablet every 8 hours PRN. The NF medication list included Cyanocobalamin 1000mcg daily as a supplement and the hospice medication profile did not include Cyanocobalamin. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The Registered Nurse documented in the nursing visit note dated 05/20/2026, patient with excoriated skin to the patient's thigh folds and noted that the Hospice Aide applied barrier cream and antifungal powder. The barrier cream and antifungal powder were not listed on the patient's medication profile and plan of care. During interviews on 06/10/2026 and 06/11/2026 with the Administrator (Personnel Record 1), the Director of Clinical Services (Personnel Record 4), and the Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the leaders could not provide evidence that the medication profiles for Clinical Record 1 and Clinical Record 3 included the current and correct medications and dosages.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as part of the initial comprehensive assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/24/2026 with diagnoses of senile degeneration of the brain, post-concussion syndrome, and depression. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During a review of the record and interview on 06/11/2026, the Alternate Director of Clinical Services (Personnel Record 3) could not provide evidence that the initial bereavement risk assessment had been completed for Clinical Record 2.

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 IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, observation, and interviews with the Administrator, Alternate Administrator, Director of Nursing, and Alternate Director of Nursing which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure to ensure the Registered Nurse provided coordination of care and ensured continuous assessment of the patient and family needs (HCPC.19.I/L540); Failure to ensure the patient's primary caregiver received education and training as appropriate to their care responsibilities (HCPC.20.I/L544); Failure to ensure the individualized plan of care included complete treatment orders (HCPC.21.I/L549); and Failure to ensure the plan of care was revised with new/changed problems, interventions, and goals that reflected the changes documented in the assessment (HCPC.22.I/L553). The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary group, care planning, and coordination of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the Registered Nurse provided coordination of care and ensured continuous assessment of the patient and family needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The Registered Nurse (RN) documented on the admission assessment and nursing visits dated through 05/06/2026, no skin issues were identified. The RN documented on the nursing visit note dated 05/13/2026, a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm with a scant amount of serosanguinous drainage with mild odor. A treatment order was documented to cleanse the site with "skin prep," pack tunneling in the wound with plain packing strips, and cover with a foam dressing every 2 days. Review of the nursing visit notes dated 05/20/2026, 05/27/2026, and 06/03/2026 revealed the wound assessment and documentation did not change the wound size was documented with the same measurements of 1cm x 0cm x 5cm and the same description of the wound drainage. The wound assessments associated with these nursing notes included a wound assessment date of 05/13/2026. There was no documented evidence in the clinical record that the stage 3 pressure ulcer wound was assessed by the RN, except for initial assessment of the wound on 05/13/2026. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/24/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a personal care home. The Registered Nurse documented on the nursing visit note dated 05/18/2026, a stage 2 pressure wound on the patient's left buttock that measured 1.5cm x 1cm x 0cm. The nursing visits notes dated 05/27/2026 and 06/03/2026, included wound documentation dated 05/18/2026 and included the same wound measurements and staging as the 05/18/2026 nursing visit. The nurse made a visit on 06/10/2026, and the skin assessment included the same wound measurements as documented in the assessment dated 05/18/2026. During the interviews, the Alternate Director of Clinical Services (Personnel Record 3) on 06/10/2026 and the Director of Clinical Services (Personnel Record 4) on 06/11/2026 were unable to provide evidence demonstrating that nursing staff performed ongoing, comprehensive wound assessments or documented updated findings in the clinical record. Both clinical leaders were unable to identify or produce documentation reflecting reassessment of the patient’s wound beyond the initial entry. The only wound documentation in the reviewed clinical records was the original assessment, including the date the wound was first identified and the initial measurement. There was no evidence of subsequent or ongoing wound assessments, specifically, there were no updated measurements of length, width, or depth; no documentation addressing the presence or extent of tunneling or undermining; no description of wound bed characteristics (including granulation, slough, eschar, or hyper-granulation with quantified percentages); no assessment of wound edges or margins (e.g., defined versus undefined, maceration, etc.), and no ongoing evaluation of exudate/drainage (amount, type, color, consistency, or odor).

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's primary caregiver received education and training as appropriate to their care responsibilities. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the primary caregiver. On 05/13/2026, the Registered Nurse documented a wound assessment of a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with a scant amount of serosanguineous drainage and a mild odor. A treatment order was documented to cleanse the site with "skin prep," pack tunneling in the wound with plain packing strips and cover with a foam dressing every 2 days. The plan of care for the benefit period from 04/13/2026 to 06/11/2026 included an order for Skilled Nursing visits once a week and 3 PRN (as needed) visits/unscheduled visits. A problem of the patient being at risk for altered skin integrity due to bowel and bladder incontinence, bedbound status, and previous history of wounds was identified on 04/14/2026. The interventions included education of the primary caregiver on turning the patient every 2 hours, positioning techniques, and the importance of preventing skin breakdown. The documented goals were to minimize the risk of bedsores and to ensure the patient-maintained skin integrity. The wound care order specified dressing changes every 2 days; however, the nursing visit frequency was ordered once a week, leaving the patient's caregiver to manage the wound in the nurse's absence. There was no documented evidence in the clinical record that the primary caregiver was educated and demonstrated competency for wound care. During interviews with the Director of Clinical Services (Personnel Record 4) and the Alternate Director of Clinical Services (Personnel Record 3) on 06/10/2026 and 06/11/2026, the leaders were unable to provide evidence that the primary caregiver had been educated and demonstrated competency to provide wound care to the patient on the days the nurse did not provide a visit.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care included complete treatment orders. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The Registered Nurse documented on the nursing visit note dated 05/13/2026, a wound assessment for a stage 3 pressure ulcer measuring 1cm x 0cm x 5cm, with a scant amount of serosanguineous drainage and a mild odor. A treatment order was documented to cleanse the site with "skin prep," pack tunneling in the wound with plain packing strips and cover with a foam dressing every 2 days. The wound treatment order did not specify the wound site or who was responsible for wound dressing changes when the nurse was not present. There was no indication of what the wound should be cleaned with, as skin prep is not a cleanser but a product to protect skin from irritation caused by medical tape or dressings. The plan of care for the benefit period from 04/13/2026 to 06/11/2026 included orders for Skilled Nursing visits once a week and 3 PRN (as needed) visits/unscheduled visits; however, the plan of care was not updated to include a complete treatment order. During interviews on 06/10/2026 and 06/11/2026, the Director of Clinical Services (Personnel Record 4) and the Alternate Director of Clinical Services (Personnel Record 3) did not produce a clarification order for the wound treatment that included the location of the wound and the type of wound cleanser to be used.

A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the plan of care was revised with new/changed problems, interventions, and goals that reflected the changes documented in the assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. The NF clarification order dated 04/03/2026 included Occupational Therapy (OT) services four (4) times per week for 60 days for self-care, neuro-reeducation, splinting, manual therapy, pain modalities (hot/cold packs and Bio-Freeze), caregiver/patient education, and discharge planning. An additional NF clarification order dated 04/02/2026 prescribed Physical Therapy (PT) services four times per week for 30 days, including therapeutic exercise, therapeutic activity, neuro-reeducation, gait training, and wheelchair management. A further NF recertification order dated 06/02/2026 included Speech-Language Pathology (SLP) services three times per week for 60 days with treatment interventions to maintain and/or improve the patient’s current level of function. Despite the presence of these active therapy orders, the hospice plan of care and IDG (interdisciplinary group) documentation did not reflect incorporation of these services into patient-specific problems, measurable goals, or individualized interventions. The IDG note dated 04/09/2026 did not include documentation of therapy services or evidence of collaboration with the facility regarding therapy interventions, despite active NF therapy orders. There were no corresponding hospice orders for therapy services in the hospice clinical record, and no identified problems, goals, or interventions addressing the patient’s functional status, mobility needs, or therapy-related care. The IDG note dated 04/23/2026 referenced monitoring the patient’s decline and transition to memory care; however, there was no documentation addressing ongoing therapy services or integration of facility-based therapies into the hospice plan of care. The IDG note dated 05/07/2026 contained no reference to therapy services, functional status interventions, or coordination with the NF therapy team. The nursing visit note dated 06/05/2026 included documentation that the patient was “sitting upright in a chair in physical therapy” at the time of arrival, indicating ongoing therapy involvement; however, this was not reflected in the hospice plan of care, including updated problems, measurable goals, or coordinated interventions. The hospice plan of care was not consistently updated to reflect the patient’s current condition, ongoing therapy services, and individualized functional needs. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 04/24/2026 with diagnoses of senile degeneration of the brain, post-concussion syndrome, and depression. Observation of the patient’s home environment during the home visit observation revealed the patient resided in an upstairs room with access via flight of steep stairs above the garage. The Registered Nurse (RN) documented on the admission assessment dated 04/24/2026 the patient had experienced a recent decline that required a transition from independent living. The Social Worker (SW) documented an assessment on 04/28/2026 that the patient had a lack of phone access, an absence of an MPOA (medical power of attorney) due to impaired capacity, and an upstairs living arrangement with potential need for relocation. Subsequent nursing and social work documentation reflected the patient’s progressive decline and increasing safety concerns. On 05/28/2026, the RN noted impaired judgment and balance despite continued ambulation and on 06/03/2026, increased ataxia (uncoordinated movements), forward posturing, and elevated fall risk were documented. The SW described in a note dated 06/08/2026 an unsteady gait with frequent loss of balance in the upstairs environment. During the home visit observation on 06/09/2026 with the Hospice Aide (HA) (Personnel Record 8), a flight of steep steps was ascended to reach the patient in his room above the garage where the patient was found sitting in the recliner. The patient stood up and the HA proceeded to assist the patient who appeared to be unsteady down the steps to the bathroom that was located on the ground level of the finished garage. The door handle to the bathroom had a plastic lock protector, similar to a child-proof door lock; however, the lock required a key. The Aide located the key underneath the laundry hamper to the right of the door. The key was used to access the bathroom. The patient was observed to exhibit marked unsteadiness requiring hands-on support. The plan of care was not revised to include the patient’s increased risk of falls, unsteadiness of gait, and specific environmental hazards related to the steep stairs and lack of bathroom access without ambulating up and down stairs. The hospice plan of care did not reflect the patient’s progressive decline and hazardous environment through updated, individualized problems, goals and interventions. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The patient resided at home with a family member as the caregiver. The RN documented on the admission assessment dated 03/11/2026 the patient had transferred from another hospice provider. The patient was described as bedbound with a PPS of 30% (Ambulation-bedbound, Activity Level-can’t do any work, Self-Care-total care), completely dependent for activities of daily living, incontinent of bowel and bladder, and utilizing a Pure Wick (urinary collection system) with a history of urinary tract infections. The patient was noted to be frail and cachectic (wasting syndrome), with intact skin; however, the assessment identified moderate risk for skin breakdown related to immobility, incontinence, and potential for friction and shear. The patient also experienced occasional generalized pain. The hospice plan of care did not include patient-specific problems, measurable goals, and individualized interventions to address pressure injury prevention, incontinence management, infection risk, or pain management strategies consistent with the patient’s condition and level of dependence. During review of clinical records and interviews conducted on 06/09/2026, 06/10/2026, and 06/11/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the organization's leadership was unable to provide evidence that the patient's plans of care were consistently updated to reflect current needs, services, and care coordination.

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed with aide services provided, the agency did not ensure the aide plan of care included patient specific care instructions for the hospice aide. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/11/2026 with diagnoses of cerebral atherosclerosis, vascular dementia, and dysphagia (difficulty swallowing). The plan of care for the benefit period dated 04/13/2026 to 06/11/2026 included an order for Hospice Aide services at a frequency of five times per week. The current aide care plan dated 05/04/2026 assigned the aide routine personal care tasks to be completed during each visit, including incontinence care for bowel and bladder, perineal care, bed bath, shampooing and brushing hair, shaving using a safety razor, oral care, and nail care. The Registered Nurse documented on the 05/13/2026 nursing visit note, the patient was incontinent of bowel and bladder and identified a Stage 3 pressure ulcer located on the sacrum, measuring 1 cm x 0 cm x 5 cm with tunneling. The treatment order dated 05/13/2026 directed staff to cleanse the wound with skin prep, pack the tunneled area with plain packing strips, and cover with a foam dressing, with dressing changes every two days. The aide care plan did not include instructions for the aide related to the patient’s wound, wound dressing, and incontinence. There were no instructions provided to the aide regarding appropriate actions to take if the wound dressing became wet, loose, or soiled and how to care for the wound dressing while providing care to the patient. CLINICAL RECORD 17: The patient elected the hospice benefit on 07/29/2025 with a diagnosis of interstitial pulmonary disease. Review of the clinical record and plan of care for the benefit period from 10/27/2025 to 01/24/2026 revealed an order dated 12/02/2025 for the Hospice Aide to provide services twice a week. The current aide care plan dated 12/23/2025 assigned the aide to provide a shower at each visit. The Registered Nurse documented on the nursing visit note dated 12/30/2025, the patient was unable to stand and required maximum assistance with bathing, toileting, and dressing, and indicated this was a significant change in condition and care needs for the patient. There was no documented evidence that the aide care plan was updated after the Registered Nurse documented the patient’s decline in mobility and need for maximum assist with bathing, toileting, and dressing. During a review of records and interview on 06/11/2026, the Director of Clinical Services (Personnel Record 4) or the Alternate Director of Clinical Services (Personnel Record 3) did not provide evidence to show that aide care plans included directions to the aide for protection and observation of the patient's wound during care, or a change in assigned bathing as the patient's function deteriorated.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes: the volunteer’s duties and responsibilities; the person to whom they report; the person to contact if they need assistance and instruction; hospice goals, services, and philosophy; confidentiality and protection of the patient’s and family’s rights; family dynamics and psychological issues surrounding terminal illness, death, and bereavement; procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) volunteer personnel file reviewed, the hospice did not ensure hospice volunteer orientation and training include required elements. PERSONNEL RECORD 11: Volunteer date of hire 01/14/2026. There was no documented evidence in the personnel record that the volunteer was oriented and trained to the role of volunteer. During an interview with the Alternate Administrator (Personnel Record 2) on 06/11/2026, it was confirmed that a complete orientation record could not be produced for the volunteer. The only form located included the volunteer acknowledgment of drug testing, confidentiality, harassment, non-solicitation/illegal remuneration, non-discrimination, and abuse, neglect, and prevention policies.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure documentation of efforts to recruit and retain volunteers. During a review of the Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 06/11/2026, the discussion revealed a lack of an established, consistently implemented process for documenting volunteer recruitment and retention efforts. The VC was unable to describe a formal process for tracking or maintaining records related to volunteer retention, and no supporting documentation was provided upon request. While the VC described general recruitment strategies including social media postings, outreach to facilities to participate in group activities, and collaboration with hospice marketing staff. The efforts were not supported by systematic or ongoing documentation. The evidence produced consisted of three printed social media posts. No documentation or process was provided to demonstrate active monitoring, evaluation, or sustained efforts related to volunteer retention. A review of the Volunteer Program documentation, along with an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 06/11/2026, revealed that the agency lacks an established, consistently implemented process for documenting volunteer recruitment and retention efforts. The VC was unable to describe a formal process for tracking or maintaining records related to volunteer retention, and no supporting documentation was provided upon request. While the VC described general recruitment strategies—including social media postings, outreach to facilities to participate in group activities, and collaboration with hospice marketing staff—these efforts were not supported by systematic or ongoing documentation. The only evidence produced consisted of three printed social media posts. No documentation or process was provided to demonstrate active monitoring, evaluation, or sustained efforts related to volunteer retention. In addition, the VC demonstrated a lack of knowledge about integrating volunteer services into the patient’s overall plan of care. During the interview, the VC was unable to describe the process for developing or implementing volunteer-specific plans of care, including determining visit frequency, assigning volunteer activities, or aligning with patient needs and interdisciplinary care planning. The absence of both a structured recruitment and retention documentation process and a clear understanding of volunteer care planning requirements indicates potential for ineffective utilization and oversight of the hospice volunteer program.

It is required that a hospice providing hospice care to residents of a SNF/NF or an ICF/IID follows the standards and requirements defined elsewhere in this manual related to providing care to a hospice patient that resides in a facility. THIS IS A CMS CONDITION LEVEL CITATION. This Condition was not met as evidenced by review of clinical records, document review, observation, and interviews with Administrator, Alternate Administrator, Director of Clinical Services, and Alternate Director of Clinical Services, which revealed significant issues with oversight and coordination of hospice care with facility staff for patients that reside in a Nursing Facility, including: Failure to ensure the hospice Registered Nurse coordinated care and updated the plan of care for the patient that resided in a Nursing Facility (HSRF.4.I/L762); Failure to ensure the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the agreed upon functions (HSRF.6.I/L774); Failure to ensure coordination of medical care for the patient that resides in a Nursing Facility (HSRF.8.I/L780); and Failure to ensure the Nursing Facility was provided with the required hospice information (HSRF.9.I/L781). The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.112: Hospices that provide hospice care to residents of a SNF/NF or an ICF/IID. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG); consultation about the patient’s/resident’s care with the facility staff; and coordination by the hospice Registered Nurse (RN) for the implementation of the plan of care for the patient/resident. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 1 of 1 (100%) clinical records reviewed for patients that reside in a nursing facility (NF), the hospice did not ensure the hospice RN coordinated care and updated the plan of care for the patient that resided in a Nursing Facility. Agency policy PC.125 "Hospice Care in a SNF/NF or ICF/IID," dated 11/12/2024, required in part, "...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC (plan of care) will be developed based on the patient/family's needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family...Change to the POC will be discussed with patient or representative and the facility representatives and approved by the Hospice prior to implementation...The Hospice will authorize services to be provided in the facility...Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to provide overall coordination of the Hospice care of the patient with the facility representatives, communicating with the facility representatives...maintain professional management responsibility and coordination of services furnished...according to the POC..." CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the patient was observed in the therapy room actively receiving Occupational Therapy services. The current hospice plan of care and active physician orders were compared to the NF plan of care and active physician orders. The NF plan of care and active orders indicated that the patient had ongoing restorative therapy services, including Physical Therapy four times per week for 30 days (order dated 04/02/2026), Occupational Therapy four times per week for 60 days (order dated 04/03/2026), and Speech Therapy services, with a recertification/clarification order dated 06/02/2026 and an original evaluation and treatment order dated 04/03/2026. These services remained active and were being delivered by the NF staff concurrently with hospice care. Clinical record review revealed the Registered Nurse was aware the patient received therapy services at the NF. The Registered Nurse documented on the nursing visit note dated 06/05/2026, “…Upon arrival patient sitting upright in chair in physical therapy….” The hospice clinical record did not include documentation of coordinated oversight, evaluation of appropriateness, or integration of these therapy services into the hospice plan of care. There was no documented evidence of interdisciplinary discussion, physician involvement, or consideration of how these therapies aligned with the patient’s hospice diagnosis, goals of care, or prognosis. During review of clinical records and interviews conducted on 06/10/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services (Personnel Record 3), the organization's leadership lacked knowledge of the Nursing Facility’s plan of care and the services that were provided to the hospice patient that resided in a NF. Home Visit Observation (HVO) 2 was conducted on 06/09/2026, including a review of the nursing facility (NF) plan of care and active physician orders, the hospice plan of care and active orders, interviews with the Director of Clinical Services (DCS) (Personnel Record 4) and the Administrator (Personnel Record 1), and review of the agency’s policies. This comprehensive review identified a lack of coordination and oversight of non-hospice services being provided to the patient (Clinical Record 1). Specifically, the NF plan of care and active orders indicated that the patient had ongoing restorative therapy services, including Physical Therapy (PT) four times per week for 30 days (order dated 04/02/2026), Occupational Therapy (OT) four times per week for 60 days (order dated 04/03/2026), and Speech Therapy (ST) services, with a recertification/clarification order dated 06/02/2026 and an original evaluation and treatment order dated 04/03/2026. These services remained active and were being delivered concurrently with hospice care. During the HVO conducted with the Chaplain (Personnel Record 7) on 06/09/2026, the patient was observed in the therapy room actively receiving Occupational Therapy services. In addition, documentation by the Registered Nurse (RN) on 06/05/2026 noted, “…Upon arrival patient sitting upright in chair in physical therapy…,” confirming the patient’s ongoing participation in therapy services. Despite clear evidence that the patient was receiving routine, restorative therapies, the hospice clinical record did not reflect coordinated oversight, evaluation of appropriateness, or integration of these services into the hospice plan of care. There was no documentation demonstrating interdisciplinary discussion, physician involvement, or consideration of how these therapies aligned with the patient’s hospice diagnosis, goals of care, or prognosis. Interviews with leadership (Personnel Records 1, 2, 3, and 4) demonstrated lack of knowledge regarding the NF’s plan of care and of services being provided to the hospice patient while at the NF. The lack of coordination and oversight of ongoing therapy services reflects a breakdown in the hospice agency’s responsibility to manage and direct all aspects of the patient’s care. The agency's policy "Hospice Care in a SNF/NF or ICF/IID (PC.125)" dated 11/12/2024, read in part that "...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC will be developed based on the patient/family's needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family...Change to the POC will be discussed with patient or representative and the facility representatives and approved by the Hospice prior to implementation...The Hospice will authorize services to be provided in the facility...Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to provide overall coordination of the Hospice care of the patient with the facility representatives, communicating with the facility representatives...maintain professional management responsibility and coordination of services furnished...according to the POC..."

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed for patients that reside in a Nursing Facility (NF), the hospice did not ensure the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the agreed upon functions. Agency policy PC.125 "Hospice Care in a SNF/NF or ICF/IID," dated 11/12/2024, required in part, "...The hospice responsibilities will include...providing medical direction and management of the patient...A Hospice POC (plan of care) will be developed based on the patient/family's needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or family and attending physician...The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. The POC will reflect the participation of the Hospice, the facility and the patient and family." CLINICAL RECORD 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. The Interdisciplinary Group (IDG) Plan of Care dated 06/04/2026, described a 79-year-old [patient] with a primary diagnosis of senile degeneration of the brain, exhibiting moderate cognitive impairment (FAST 6E), wandering behaviors within a locked unit, insomnia, increased somnolence, impaired mobility, fall risk, edema, incontinence, nutritional decline, and pain symptoms. Interventions outlined in the hospice plan of care focused on monitoring, medication education, and skilled nursing assessments across a range of clinical conditions, including cardiac status, respiratory status, depression, pain, urinary elimination, and nutritional intake. However, despite the patient residing in a nursing facility with 24-hour staff supervision, the plan of care did not specify how facility staff would participate in, support, or carry out these interventions. There was no documentation that specified communication pathways, delegation, or coordination strategies to ensure that interventions such as fall prevention, incontinence care, monitoring of wandering behaviors, medication administration, and response to changes in condition were implemented in the facility setting. Additionally, despite noted behavioral concerns (wandering, nighttime agitation, pulling at clothing/briefs) and safety risks. The plan of care did not include individualized, setting-specific interventions tailored to the locked NF unit environment. During an interview conducted on 06/10/2026 with the Administrator (Personnel Record 1), Alternate Administrator (Personnel Record 2), Director of Clinical Services (Personnel Record 4), and Alternate Director of Clinical Services/Alternate Administrator (Personnel Record 3), the leadership team was unable to demonstrate that the hospice plan of care was developed and implemented in coordination with the Nursing Facility.

It is required that the Interdisciplinary Group member ensure that the IDG communicates with the SNF/NF or ICF/IID medical director, the patient’s attending physician, and other physicians participating in the patient’s/resident’s care to coordinate the hospice care with the medical care provided by other physicians. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) clinical records reviewed for patients that resided in a Nursing Facility (NF), the hospice did not ensure coordination of medical care. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 12/05/2025 with diagnoses of senile degeneration of the brain, asthma, peripheral vascular disease, and osteoarthritis. The patient moved to a Nursing Facility (NF) on 03/31/2026. During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the current hospice plan of care and active physician orders were compared to the NF plan of care and active physician orders. The hospice plan of care listed the Associate Hospice Medical Director as the patient's attending physician, while the NF plan of care identified a different attending physician. The discrepancy was not addressed or reconciled within the clinical record, and there was no documentation that demonstrated coordination between the hospice and facility to clarify responsibility for medical oversight and order management. During an interview on 06/10/2026, the Administrator (Personnel Record 1) was unaware of the discrepancy in attending physician designation between the hospice plan of care and the nursing facility plan of care. The Director of Clinical Services (Personnel Record 4) reported that he visited the facility on 06/10/2026 but did not discover or report the discrepancy in the patient's listed attending physicians.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information, and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observation for a patient that resided in a Nursing Facility (NF), the hospice did not ensure the facility was provided with the required hospice information. HOME VISIT 1: During the home visit observation on 06/09/2026 with the Chaplain (Personnel Record 7), the hospice facility binder was reviewed. The binder included the patient’s hospice election form, out-of-hospital DNR (do not resuscitate), medication list, and a hospice plan of care dated 06/04/2026. However, at the time of review, the binder did not contain the physician’s certification of terminal illness and did not include the names and contact information of hospice staff involved in the patient’s care. During the home visit at the NF an interview was conducted with the NF Director of Nursing (DON). The NF DON provided printed copies of the nursing facility’s medication list and plan of care for the patient and did not indicate that additional hospice documentation existed within the facility’s system that would be necessary or available for review during the survey.

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 record review and interview. In 3 of 6 (50%) clinical records reviewed, the agency did not ensure that interventions and goals identified in the comprehensive assessment were documented on the plan of care. Clinical Record 1: The patient elected the hospice benefit 08/02/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. In the spiritual assessment dated 08/04/2023 the Chaplain documented the patient was Christian, mostly Pentecostal and would benefit from prayer and meditation with monthly visits. The Chaplain documented the patient was very comfortable with death. During Chaplain visits dated 08/04/2023 and 09/01/2023 the Chaplain documented read scriptures, prayed, and did blessings with the patient. The Chaplain noted the patient was interested in bible reading and study. The plan of care dated 08/02/2023 through 10/30/2023 did not include interventions or measurable goals relate to the patient’s spiritual needs, including reading bible scriptures, prayer, and study. The spiritual section of the plan of care documented: "No areas of concern from the daughter. Chaplain will monitor for any changes." Clinical Record 2: The patient elected the hospice benefit 08/16/2023 with a terminal diagnosis of colon cancer. In the spiritual assessment dated 08/17/2023 the chaplain documented the patient had a strong faith and would enjoy monthly visits that included prayer and handouts on transitioning. The plan of care dated 08/16/2023 through 11/21/2023 did not include interventions or measurable goals relate to the patient’s spiritual needs. The spiritual section of the plan of care documented: "No areas of concern. The chaplain will continue to monitor the daughter and the patient for any changes." Clinical Record 4: The patient elected the hospice benefit 08/08/2023 with a terminal diagnosis of Alzheimer's disease. In the spiritual assessment dated 08/14/2023 the chaplain identified a need for chaplain services two times a month with a plan for spiritual/social conversation and to provide scripture reading and prayer. The plan of care dated 08/08/2023 through 11/05/2023 did not include interventions or measurable goals relate to the patient’s spiritual needs. The spiritual section of the plan of care documented: "No concerns with patient and family, chaplain will continue to monitor and assist in any necessary change to patient and family.” During an interview on 09/11/2023, the Alternate Administrator and Clinical Director stated the chaplain did not transition the identified problems to the plan of care and may need some education.

It is required that the inpatient hospice facility has Emergency Preparedness (EP) policies and procedures based on the hospice EP plan, including risk assessment and communication plans. The inpatient policies and procedures provide for safe evacuation from the hospice facility including consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance. This standard was not met as evidenced by document review and interview. Agency policy "Emergency Preparedness for the Inpatient Facility", Policy INPT 26, (no date), stated in part, “The Plan on Evacuation must include contracts with prearranged receiving facilities to provide hospice in-patient care, with at least one facility located at least 50 miles away.” Review of the hospice agency’s contracts revealed the hospice did not have a contract with a prearranged receiving facility to provide hospice in-patient care at least 50 miles away from the inpatient facility as required by the hospice’s inpatient facility policy and procedure. Review of the back-up contracted facilities for general inpatient and inpatient respite level of care revealed the backup inpatient facilities were not located at least 50 miles away for the inpatient facility. During an interview on 7/28/23, the Administrator confirmed the two back up inpatient contracts that were in place were not located at least 50 miles away from the inpatient facility. Review of the hospice contracts revealed a missing contract with a prearranged receiving facility to provide hospice in-patient care with at least one facility located at least 50 miles away", as required by inpatient facility policy and procedure. Review of the back-up contracted facilities for general inpatient and inpatient respite level of care revealed the back up inpatient facilities were not located at least 50 miles away". Policy "Emergency Preparedness for the Inpatient Facility", Policy INPT 26, (no date), included, “The Plan on Evacuation must include contracts with prearranged receiving facilities to provide hospice in-patient care, with at least one facility located at least 50 miles away”. During interview 7/28/23, the Administrator confirmed the two back up inpatient contracts that were in place were not located at least 50 miles away.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review, interview and observation. Life Safety Code 2012 Edition, EXISTING Health Care Facilities, 19.7.1.4 through 19.7.1.7: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. Review of the emergency preparedness binders revealed the hospice inpatient facility fire drills were not completed once per shift every quarter, as required by Life Safety Code 2012 Edition. The hospice inpatient facility nursing and hospice aide shifts are 7am to 7pm and 7pm to 7am, and the unit clerk shifts are 8am to 8pm and 8pm to 8am. Review of fire drill documentation revealed two hospice inpatient facility fire drills were completed 2nd quarter 2023 on 6/2/23 for nursing, hospice aide and unit clerk Day shift and 4th quarter 2022 for nursing, hospice aide and unit clerk Day shift. The agency provided no evidence that the hospice inpatient facility’s fire drills were completed once per shift every quarter for Night shift nurses, hospice aides and unit clerks for the 1st and 2nd quarters 2023. Additionally, there was no evidence the hospice inpatient facility fire drills were completed once per shift every quarter for Day shift nurses, hospice aides and unit clerks for the 1st quarter 2023. There was no evidence that the inpatient facility fire drills included the transmission of a fire alarm signal. No fire drills were conducted from 9:00 PM and 6:00 AM in which a coded announcement may be used instead of audible alarms. During an interview on 7/26/23, the Social Worker/Director confirmed only two fire drills were completed at the inpatient facility. The Social Worker/Director stated "There are no printouts that document a fire alarm was pulled at the inpatient facility during fire drills. We do not pull the fire alarm during fire drills at the inpatient facility." Review of the emergency preparedness binders at both the hospice program office and the hospice inpatient facility revealed the hospice inpatient facility fire drills were not completed once per shift every quarter, as required by Life Safety Code 2012 Edition. The first patient was admitted to the hospice inpatient facility 3/26/22 and the initial hospice inpatient facility site visit occurred 7/19/22. The nursing and hospice aide shifts are 7am to 7pm and 7pm to 7am, and the Unit Clerk shifts are 8am to 8pm and 8pm to 8am. During the time frame after 7/19/22, there was only two hospice inpatient facility fire drills which were completed 2nd quarter 2023 on 6/2/23 for DAYS and Unit Clerk shift and 4th quarter 2022 for DAYS and Unit Clerk shift. There was no evidence the hospice inpatient facility fire drills were completed once per shift every quarter for Night shift nurses and aides and Night shift unit clerks for 2nd and 3rd quarters 2022 and 1st and 2nd quarters 2023. Additionally, there was no evidence the hospice inpatient facility fire drills were completed once per shift every quarter for Day shift nurses and aides and Day shift unit clerks for 3rd quarter 2022 and 1st quarter 2023. Additionally, there was no evidence the inpatient facility Fire drills included the transmission of a fire alarm signal. No fire drills were conducted 9:00 PM and 6:00 AM in which a coded announcement may be used instead of audible alarms. During interview 7/26/23, the Social Worker Director presenting the fire drill binders located at the program office and hospice inpatient facility confirmed only two fire drills were completed at the inpatient facility. During interview 7/26/23, the Social Worker Director presenting the emergency preparedness program documents stated, "There are no print outs of a fire alarm was was pulled at the inpatient facility during a drills" and "We do not pull the fire alarm during fire drills at the inpatient facility". Life Safety Code 2012 Edition, EXISTING Health Care Facilities, 19.7.1.4 through 19.7.1.7: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.

It is required that the written Patient Bill of Rights includes the patients' right to choose his or her attending physician. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the clinical record included documentation that the patient or legal representative was given the right to choose an attending physician. Clinical Record 3: The patient elected the hospice benefit on 6/20/23, with a terminal diagnosis of Dementia. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. Clinical Record 6: The patient elected the hospice benefit on 6/7/23 with a terminal diagnosis of Alzheimer’s. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. Clinical Record 8: The patient elected the hospice benefit on 4/26/23 with a terminal diagnosis of Senile Degeneration of the Brain. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. Clinical Record 11: The patient elected the hospice benefit on 5/29/23 with a terminal diagnosis of Colon Cancer. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. Clinical Record 14: The patient elected the hospice benefit on 4/21/23 with a diagnosis of Alzheimer’s Disease. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. Clinical Record 17: The patient elected the hospice benefit on 6/29/23 with a terminal diagnosis of heart disease. Review of the hospice consent form revealed it had a section to document the patient's choice of their attending physician or if they chose not to have an attending physician. In the clinical record, the section of the patient’s signed consent form that included documentation of the patient’s choice of attending physician or if the patient chose not to have an attending physician was blank. There was no documented evidence in the clinical record that the patient/legal representative was given the choice to choose an attending physician. During interviews conducted during review from 7/24/23 through 7/28/23, the Clinical Director stated, "Yes, that section of the consent forms is blank and does not include the patient's choice of attending physician or if they choose not to have an attending physician." During interview 7/24/23 through 7/28/23, the Clinical Director stated, "Yes, that section of the consent forms is blank and does not include the patient's choice of attending physician or if they choose not to have an attending physician".

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the initial spiritual assessment as part of the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 19: The patient elected the hospice benefit on 8/20/22, with a terminal diagnosis of Congestive Heart Failure. A physician order written at the start of care dated 8/20/22 stated “Spiritual Counselor one time a month.” There was no documented evidence in the clinical record that a spiritual assessment was completed for the patient. During an interview on 7/28/23 the Clinical Director stated, "The initial spiritual assessment is not documented in the clinical record, and it is not mentioned in the IDG meeting notes or other entries in the clinical record to explain why the spiritual assessment was not completed." During interview 7/28/23, the Clinical Director stated, "The initial spiritual assessment is not documented in the clinical record and it is not mentioned in the IDG meeting notes or other entries in the clinical record to explain why the spiritual assessment was not completed".

It is required that the comprehensive assessment includes an initial assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 19: The patient elected the hospice benefit on 8/20/22. There was no documented evidence in the clinical record that an initial bereavement assessment was completed during the comprehensive assessment. During an interview on 7/28/23 the Clinical Director stated, "The initial bereavement assessment is not documented in the clinical record." During interview 7/28/23, the Clinical Director stated, "The initial bereavement assessment is not documented in the clinical record".

It is required that all hospice care and services provided to patients and families follow the individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs. This standard was not met as evidenced by clinical record review and interview. In 10 of 19 (53%) clinical records reviewed, the agency did not ensure hospice care and services followed an individualized written plan of care established by the Interdisciplinary Group (IDG) in collaboration with the physician and patient/caregiver. Clinical Record 8: The patient elected the hospice benefit on 4/26/23, with a terminal diagnosis of Senile Degeneration of the Brain. The patient was in general inpatient level of care (GIP) from admission on 4/26/23 until the patient’s death on 5/1/23. A physician's order was obtained on 4/26/23 for admission to GIP, medications and discipline specific visit frequencies for nursing, social worker and spiritual counselor. The needs identified in the initial nursing assessment dated 4/26/23 were not specified on the IDG plan of care until the first scheduled IDG plan of care meeting dated 5/3/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 4/26/23 and not established by the IDG until the first scheduled IDG meeting dated 5/3/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 5/3/23, 2 days after the patient’s death. Clinical Record 9: The patient elected the hospice benefit on 3/14/23, with a terminal diagnosis of Cancer of the Stomach. The patient was admitted as General Inpatient (GIP) at the inpatient facility from admission on 3/14/23 through 3/15/23, and respite level of care from 3/16/23 until the patient’s death on 3/20/23. A physician's order was obtained on 3/14/23 for admission to GIP and medications. A physician order dated 03/16/23 changed the level of care from GIP to Respite. The needs identified in the initial nursing assessment dated 3/14/23 were not specified on the IDG plan of care until the first schedule IDG meeting dated 3/21/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 3/21/23, 7 days after the patient was admitted to GIP level of care and 1 day after the patient’s death. Clinical Record 10: The patient elected the hospice benefit on 4/8/23, with a terminal diagnosis of Cancer of the Mouth. The patient was admitted to GIP level of care from 4/8/23 until the patient’s death on 4/14/23. A physician's order was obtained on 4/8/23 for medications and admit to GIP. The needs identified in the initial nursing assessment dated 4/8/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 4/18/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 4/8/23 and not established by the IDG until the first scheduled IDG meeting on 4/18/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 4/18/23, 4 days after the death of the patient. Clinical Record 11: The patient elected the hospice benefit on 5/29/23, with a terminal diagnosis of Colon Cancer. The patient was admitted to routine hospice care at home from 5/29/23 until the patient expired on 7/11/23. A physician's order was obtained on 5/29/23 for medications and staff visit frequencies. The needs identified in the initial nursing assessment dated 5/29/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 6/9/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 5/29/23 and not established by the IDG until the first scheduled IDG meeting on 6/9/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 6/9/23, 11 days after the patient’s admission to hospice. Clinical Record 14: The patient elected the hospice benefit on 4/21/23, with a terminal diagnosis of Alzheimer’s Disease. The patient was admitted to routine hospice care at home. A physician's order was obtained on 4/21/23 for medications, wound care and staff visit frequencies. The needs identified in the initial nursing assessment dated 4/21/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 4/28/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 4/21/23 and not established by the IDG until the first scheduled IDG meeting 4/28/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 4/28/23, 7 days after the patient’s admission to hospice. Clinical Record 16: The patient elected the hospice benefit on 6/2/23, with a terminal diagnosis of heart disease. The patient was admitted to routine hospice care at home. A physician's order was obtained on 6/2/23 for medications, wound care and staff visit frequencies. The needs identified in the initial nursing assessment dated 6/2/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 6/9/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 6/2/23 and not established by the IDG until the first scheduled IDG meeting on 6/9/23. The clinical record contained no document evidence that the IDG prepared the Plan of Care until 6/9/23, 7 days after the patient’s admission to hospice. Clinical Record 15: The patient elected the hospice benefit on 11/30/22. The patient was admitted to routine hospice care at home. A physician's order was obtained on 11/30/22 for medications and staff visit frequencies. The needs identified in the initial nursing assessment dated 11/30/22 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 12/7/22. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 11/30/22 and not established by the IDG until the first scheduled IDG meeting 12/7/22. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 12/7/22, 7 days after the patient’s admission to hospice. Clinical Record 17: The patient elected the hospice benefit on 6/29/23, with a terminal diagnosis of heart disease. The patient was admitted to routine hospice care at home. A physician's order was obtained on 6/29/23 for medications, wound care and staff visit frequencies. The needs identified in the initial nursing assessment 6/29/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 7/7/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 6/29/23 and not established by the IDG until the first scheduled IDG meeting on 7/7/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 7/7/23, 8 days after the patient’s admission to hospice. Clinical Record 18: The patient elected the hospice benefit on 3/17/23, with a terminal diagnosis of Senile Degeneration of the Brain. The patient was admitted to routine hospice care at home. The needs identified in the initial nursing assessment dated 3/17/23 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 3/29/23. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 3/17/23 and not established by the IDG until the first scheduled IDG meeting on 3/29/23. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 3/29/23, 12 days after the patient’s admission to hospice. Clinical Record 19: The patient elected the hospice benefit on 8/20/22, with a terminal diagnosis of Congestive Heart Failure. The patient was admitted to routine hospice care at home. A physician's order was obtained on 8/20/22 for medications and staff visit frequencies. The needs identified in the initial nursing assessment dated 8/20/22 were not specified on the IDG plan of care until the first scheduled IDG meeting dated 8/31/22. The nursing care plan problems, goals and interventions were documented in the initial nursing assessment form dated 8/20/22 and not established by the IDG until the first scheduled IDG meeting on 8/31/22. The clinical record contained no documented evidence that the IDG prepared the Plan of Care until 8/31/22, 11 days after the patient’s admission to hospice. During an interview on 7/25/23 the Clinical Director stated, "The IDG does not prepare a plan of care on admission and the IDG plan of care is not completed until the first scheduled IDG meeting which could be 14 days (after the start of care). We scheduled the IDG meetings every 14 days. The care plan problems, goals and interventions are documented in the nursing assessment form on admission and then sent to the IDG plan of care for the IDG to prepare the plan of care only at the first scheduled IDG meeting."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) bereavement clinical records reviewed, the agency did not ensure the bereavement plan of care include the types of bereavement services to be offered and the frequency of service delivery. Clinical Record 11: The patient expired 7/11/23. The post death bereavement assessment dated 7/12/23 included documentation that the bereaved accepted bereavement services. At the time of review on 7/28/23, the clinical record contained no documented evidence that a bereavement plan of care was developed for the bereaved. The plan of care entry section on the bereavement assessment form and the bereavement plan of care form were blank. Clinical Record 8: The patient expired 5/1/23. The post death bereavement assessment was completed 5/5/23 and included the spiritual counselor to follow for bereavement services. The post death bereavement assessment form included a field for "plan of care" but did not include the frequency of bereavement services. The bereavement plan of care form included a section to complete for frequency of bereavement visits/services, but this section was blank. The clinical record contained no documented evidence that a complete bereavement plan of care was established that included frequency of bereavement services. Clinical Record 10: The patient expired 4/14/23. The post death bereavement assessment was completed 4/21/23 and included chaplain to follow and provide bereavement services. The post death bereavement assessment form included a field for "plan of care" but did not include the frequency of bereavement services. The bereavement plan of care form included a section to complete for frequency of bereavement visits/services, but this section was blank. The clinical record contained no documented evidence that a complete bereavement plan of care was established that included frequency of bereavement services. Clinical Record 12: The patient expired 4/27/23. The post death bereavement assessment was completed 4/27/23 and included "Will provide bereavement and staff calls." The post death bereavement assessment form included a field for "plan of care" but did not include the frequency of bereavement services. The bereavement plan of care form included a section to complete for frequency of bereavement visits/services, but this section was blank. The clinical record contained no documented evidence that a complete bereavement plan of care was established that included frequency of bereavement services. Clinical Record 13: The patient expired 7/1/23. The post death bereavement assessment was completed 7/10/23 and included “to provide letters” for bereavement services. The post death bereavement assessment form included a field for "plan of care" but did not include the frequency of bereavement services. The bereavement plan of care form included a section to complete for frequency of bereavement visits/services, but this section was blank. The clinical record contained no documented evidence that a complete bereavement plan of care was established that included frequency of bereavement services. During an interview on 7/25/23, the Clinical Director stated "The Bereavement Counselor is still learning how to use the bereavement section of the medical record. I opened the Bereavement plan of care forms, and they are all blank and not filled in. For Records 8, 10, 12 and 13, the bereavement counselor filled in a partial bereavement plan of care on the after-death bereavement assessment form and did not fill out the bereavement plan of care form. For Record 11, a bereavement plan of care is missing in the plan of care section on the bereavement assessment form and the bereavement plan of care form is blank." During interview 7/25/23, the Clinical Director stated, "The Bereavement Counselor is still learning how to use the bereavement section of the medical record", "I opened up the Bereavement plan of care forms and they are all blank and not filled in", "For Record #8, 10, 12 and 14, the bereavement counselor filled in a partial bereavement plan of care on the after death bereavement assessment form and did not include and did not fill out the bereavement plan of care form", and for Record #11, "A bereavement plan of care is missing in the plan of care section on the bereavement assessment form and the bereavement plan of care form is blank".

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) recertification clinical records reviewed, the agency did not ensure documentation of the physician’s review of the patient’s clinical information. Clinical Record 7: The patient elected the hospice benefit on 1/5/23 with a terminal diagnosis of Alzheimer’s Disease. The patient’s third benefit period was dated 7/4/23. The Medical Director signed the recertification statement on 6/21/23 for the third benefit period which included the completed physician narrative and checked the section that included review of the face-to-face visit documentation. Through the date of this review on 7/28/23, the face-to-face visit note for the third benefit period was not documented in the clinical record for the Medical Director to review. During an interview on 7/28/23 the Clinical Director stated, "We have tried to locate the missing face-to-face visit documentation. We have not obtained the face-to-face documentation from the nurse practitioner." During interview 7/28/23, the Clinical Director stated, "We have not obtained the face to face documentation from the nurse practitioner" and "We have tried to locate the missing face to face visit documentation".

It is required that hospice inpatient facilities dispose of controlled medications in compliance with hospice policy and in accordance with state and federal law and regulation. The hospice maintains current and accurate records of the receipt and disposition of all controlled medications. This standard was not met as evidenced by document review, interview and observation. Agency policy, INPT 8 "Dispensing and Administering Medications (no date), stated in part, “The Pharmacist must determine the medication records are in order and that an account of all controlled medications is maintained and reconciled. The Pharmacist and registered nurse must dispose of medications and prepare a record of the disposal”. There was no evidence that controlled medications at the inpatient facility are destroyed by the contracted pharmacist and a registered nurse and no evidence that an account of all controlled medications was maintained and reconciled, as required by inpatient facility policy and procedure. During interview 7/26/24, the Inpatient House Manager stated controlled medications no longer needed by the patient are destroyed by two registered nurses and not the pharmacist. There was no evidence that controlled medications at the inpatient facility are destroyed by the contracted pharmacist and a registered nurse and no evidence that the pharmacist determined that controlled medications was maintained and reconciled, as required by inpatient facility policy and procedure. During interview 7/26/24, the Inpatient House Manager stated controlled medications no longer needed by the patient are destroyed by two registered nurses and no pharmacist. Policy, "Dispensing and Administering Medications", Policy INPT 8, (no date), included, “The Pharmacist must determine the medication records are in order and that an account of all controlled medications is maintained and reconciled” and “The Pharmacist and registered nurse must dispose of medications and prepare a record of the disposal”.

It is required that the hospice patient’s inpatient clinical record includes a record of all inpatient services provided and all events regarding care that occurred at the facility. This standard was not met as evidenced by clinical record review and interview. In 8 of 8 (100%) applicable clinical records of patients that were in the inpatient facility and received aide services, there was no evidence the inpatient facility aides documented personal care services that were provided to the patients at the hospice inpatient facility. Clinical Record 4: The patient was in the hospice inpatient facility on General Inpatient (GIP) level of care from 7/25/23 through the date of review on 7/26/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day since 7/25/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 5: The patient was an inpatient the hospice inpatient facility on respite level of care from 2/3/23 through 2/7/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 2/3/23 through 2/7/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 6: The patient was in the hospice inpatient facility on respite level of care from 6/13/23 through 6/17/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 6/13/23 through 6/17/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 7: The patient was in the hospice inpatient facility on respite level of care from 5/22/23 through 5/26/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 5/22/23 through 5/26/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 8: The patient was in the hospice inpatient facility on GIP level of care from 4/16/23 through 5/1/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 4/16/23 through 5/1/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 9: The patient was in the hospice inpatient facility on GIP level of care from 3/14/23 through 3/15/23 and respite level of care from 3/16/23 through 3/20/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day 3/14/23 through 3/20/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 10: The patient was in the hospice inpatient facility on GIP level of care from 4/8/23 through 4/14/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 4/8/23 through 4/14/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. Clinical Record 16: The patient was in the hospice inpatient facility on respite level of care starting 7/24/23 trough date of review 7/26/23. Inpatient facility hospice aides had provided care and services to the patient 24 hours a day from 7/24/23 through 7/26/23. The clinical record contained no documented hospice inpatient facility aide notes or entries for aide services provided while the patient was admitted to the hospice inpatient facility. During an interview on 7/25/23, the Clinical Director stated, "We have hospice aides in our hospice inpatient facility that provide aide services to patients 24 hours a day, day shift and night shift. The hospice aides that are in the inpatient facility do not document aide services that they provided to the patient. We have identified the issue of no aide visit documentation; we have a PIP (Performance Improvement Project) in place to correct and some of the aides have already learned how to document in the clinical record. When a patient comes from home and transfers into the inpatient facility, the outpatient homecare aide also comes into the inpatient facility to provide care to the patient and the home outpatient aide does document aide services that are provided to the patient while the patient is in our inpatient facility."

It is required that a hospice that provides inpatient care directly in its own facility must demonstrate compliance with all standards. THIS IS A CMS CONDITION LEVEL CITATION. This Condition was not met as evidenced by review of clinical records, document review, observation, and interviews with Administrator, Clinical Director, House Manager, and Maintenance, which revealed significant issues with the inpatient facility systems, processes and care environment in the following areas: Failure to ensure the hospice patient's inpatient clinical record includes a record of all services provided and all events regarding care that occurred at the inpatient facility [HSIC.5.D/L713]; Failure to ensure the inpatient hospice facility addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property [HSIC.8.I/L824]; Failure to ensure emergency preparedness plan provided for a safe evacuation plan that included contracts with prearranged facilities to provide hospice inpatient care at least 50 miles away from the inpatient facility [HSIC.10.D/E20]; Failure to ensure the hospice operated inpatient care facility complied with all applicable federal, state and local health safety codes [HSIC.14.I/L827]; Failure to ensure the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills [HSIC.15.I/E39]; Failure to ensure a program for inspection, testing, and maintenance of fire extinguishers, sprinkler systems, and smoke detectors, and preventative maintenance programs for electrical, HVAC (heat, ventilation and air conditioner), sprinkler, and security systems [HSIC.18.I/L827]; Failure to ensure a policy and procedure for when the sprinkler system in the inpatient facility is shut down for more than 10 hours in a 24 hour period [HSIC.19.I/L827]; Failure to ensure corridor doors and doors to rooms containing flammable/combustible materials in the inpatient facility are provided with positive latching hardware [HSIC.20.I/L827]; Failure to ensure each patient room is equipped with a device used for calling for assistance [HSIC.23.I/L830]; Failure to ensure an adequate supply of hot water and plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients [HSIC.24.I/L832]; Failure to provide a sanitary environment by following current standards of practice [HSIC.25.I/L834]; Failure to ensure patient meals are served at the proper temperature [HSIC.28.I/L838]; Failure to ensure patient meals are obtained, stored, prepared, distributed, and served under sanitary conditions [HSIC.28.I/L839]; Failure to ensure the hospice inpatient facility disposes of controlled medications in compliance with hospice policy and in accordance with state and federal law and regulation, and maintains current and accurate records of the receipt and disposition of all controlled medications [HSIC.32.I/L698] and Failure to ensure inpatient facility staff received training on the restraint policy during orientation [HSIC.43.I/L857]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.110, Hospices that provide inpatient care directly. The collective deficient practices illustrated systemic process failures that had the potential to affect all patients receiving inpatient hospice care and services from the agency.

It is required that the inpatient hospice facility addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by document review, interview and observation. Agency policy INPT 23 "Physical Environment" (no date), stated in part, "The hospice must maintain a safe physical environment free of hazards for patients, staff and visitors.” Tour of the hospice inpatient facility on 7/26/23 accompanied by the Inpatient House Manager, Clinical Director, Administrator and Maintenance. Observed in the main hallway of the inpatient facility were two unlocked cabinets along the hallway wall that contained medicated creams, antifungal creams, ointments, mouth wash and lotions. There was no evidence that the hospice inpatient facility addressed the real or potential threats to the health and safety of patients, hospice staff, visitors and others, as required in the inpatient facility policy. Patients, family members and visitors had direct access to the unlocked cabinets with medicated creams, antifungal creams, ointments, mouth wash and lotions. There was no evidence the inpatient facility maintained a safe physical environment free from hazards for patients and visitors. During interview 7/26/23, the Clinical Director stated, "We could place a lock on those cabinets since we don't have another location for medical supplies other than the hallway cabinets". Tour of the hospice inpatient facility on 7/26/23 accompanied by the Inpatient House Manager, Clinical Director, Administrator and Maintenance. Observed in the main hallway of the inpatient facility were two unlocked cabinets along with side of the hallway wall that contained medicated creams, antifungal creams, ointments, mouth wash and lotions. There was no evidence that the hospice inpatient facility addressed the real or potential threats to the health and safety of patients, hospice staff, visitors and others, as required in the inpatient facility policy. Patients, family members and visitors had direct access to the unlocked cabinets with medicated creams, antifungal creams, ointments, mouth wash and lotions. There was no evidence the inpatient facility maintained a safe physical environment free from hazards for patients and visitors. Policy "Physical Environment", Policy INPT 23, (no date), included, "The hospice must maintain a safe physical environment free of hazards for patients, staff and visitors”. During interview 7/26/23, the Clinical Director stated, "We could place a lock on those cabinets since we don't have another location for medical supplies other than the hallway cabinets".

It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: The applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and The Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. This standard was not met as evidenced by document review, interview and observation. The inpatient facility was located on the first floor of a two-story free-standing building and the hospice inpatient facility was operational for the care of patients and staff use only on the first floor. Observation of the second floor revealed no furniture, staff or patients and only the electrical room upstairs is operational. During tour of the inpatient facility along with Maintenance, Administrator, House Manager and Clinical Director, the soiled linen storage area was observed to be located in a non-sprinklered wooden shed approximately 6 feet out the side exit door under a patio cover attached to the inpatient facility and located adjacent to the inpatient facility's generator. The fire extinguisher was located on the outside left side on the shed, did not contain a fire extinguisher inspection tag and there were no other records of the fire extinguisher being inspected. The shed was observed to contain 8 to 10 bags of soiled linen located directly on the floor with each soiled linen bag approximately 13-20 gallons with a total greater than 64 gallons of soiled linen. Located around the sides and back of the soiled linen bags was a waist high level of stacked and folded cardboard boxes, a large box of paper cups, a shelf containing paint cans, a bed mattress with a fabric cover, a patient walker, and two unsecured fire extinguishers located on the floor. The door to the wooden shed containing the soiled linen with other flammable and combustible items did not include a positive self-latching door and lock. There were no life safety code inspection reports completed by the hospice's Maintenance department except a log for hot water temperatures that were tested in the inpatient facility. There were quarterly life safety code inspection reports from the contracted fire safety company for 2022 and 2023. The City Fire Department inspection reports located at the inpatient facility and presented by the Director of Psycho/Social were completed in 2022 and 2023 which included, "deficiencies corrected" with a list of the following identified deficiencies on the back of the forms: "Use of space heater, hanging sprinkler head, ceiling Exit signage illumination not working, and fire extinguisher needed near generator". There was no evidence that the soiled linen was stored in a location free of flammable and combustible items which met the Life Safety Code 2012 requirements. There was no evidence the soiled linen area, which was greater than 64 gallons of soiled linen, was located in a Hazardous Room that was protected by fire barrier walls and ceiling having 1-hour fire resistance rating with a positive, self-latching door. There was no waiver present for current location of the soiled linen. During interview 7/26/23, the Inpatient House Manager stated, "Those paper cups in boxes next to the soiled linen bags are not to use, they are trash. We store the soiled linen here and it is picked up weekly. The walker was given to the hospice from one of the patients and we are just storing it here until we donate it, and we do not use that mattress." During an interview 7/26/23, Maintenance worker stated, "I have another shed which is not on site at the inpatient facility and I will move the paint cans to the other shed. We are not using those extinguishers that are located on the floor of the soiled storage area." During an interview 7/26/23, the Administrator stated, "The inpatient building was built in the 1950's as a dental office, a Hospice Inpatient Facility was started in the same building by another hospice in the 1990's and we purchased and started our hospice inpatient facility last year." During an interview 7/26/23, Maintenance stated, "The second floor of the inpatient facility building is not used since we do not have a fire escape in place from the second floor." The electrical room on the second floor of the inpatient facility was observed to contain a paint can. During interview 7/26/23, Maintenance for the inpatient facility stated he removed the paint can from the electrical room. Observation in the sprinklered Janitor's closet located on the first floor revealed an opening in the ceiling over the floor sink. There was no evidence that the janitor's room ceiling was protected by a fire barrier having 1-hour fire resistance rating. The facility Maintenance worker stated he fixed the opening in the ceiling, and it was observed to be corrected before leaving the inpatient facility. Additionally, the lock on the door to the Janitor's room was broken. The lock was repaired during the day and was then observed to be a locking, positive self-latching door. During interview 7/27/23, the Administrator stated, "We removed all the flammable items, trash, mattress, cardboard boxes, paint cans and fire extinguishers on the floor from the soiled linen room, and we are getting a linen container to place soiled linen bags into to get the linen off the floor. We will be checking with Life Safety Code department at the State to determine if soiled linen can be stored in a different room in the inpatient facility, either one of the hall shower rooms or the room where we are currently store emergency food and water. We are in the process of contacting fire extinguisher inspection company to get the fire extinguisher inspected that is located on the wall outside the soiled linen area next to the generator." NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.2.2.1: Hazardous Areas are protected by a fire barrier having 1-hour fire resistance rating (with ¾ hour fire rated doors). Doors shall be self-closing or automatic closing. NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.3.2: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.3.2.1.3: The doors shall be self-closing or automatic closing. 19.3.2.1.5: Hazardous areas shall include Boiler and fuel-fired heater rooms, Paint shops, Rooms with soiled linen in volume exceeding 64 gal (242 L), Rooms with collected trash in volume exceeding 64 gal (242 L), Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous. The inpatient facility was located on the first floor of a two-story free standing building and the hospice inpatient facility is operational for the care of patients and/or or staff use only on the first floor. Observation of the second floor revealed no furniture, staff or patients and only the electrical room upstairs is operational. During tour of the inpatient facility along with Maintenance, Administrator, the House Manager and Clinical Director, the soiled linen storage area was observed to be located in a non-sprinklered wood shed approximately 6 feet out the side exit door under a patio cover attached to the inpatient facility and located adjacent to the inpatient facility's generator. A fire extinguisher was located on the outside left side on the shed, did not contain a fire extinguisher inspection tag and there were no other records of the fire extinguisher being inspected. The shed was observed to contain 8-10 bags of soiled linen located directly on the floor with each soiled linen bag approximately 13-20 gallons with a total greater than 64 gallons of soiled linen. Located around the sides and back of the soiled linen bags was a waist high level of stacked and folded cardboard boxes, a large box of paper cups, a shelf containing paint cans, a bed mattress with a fabric cover, a patient walker, and 2 unsecured fire extinguishers located on the floor. The door to the wood shed containing the soiled linen with other flammable and combustible items did not include a positive self latching door and lock. There were no life safety code inspection reports completed by the hospice's Maintenance department except a log for hot water temperatures that were tested in the inpatient facility. There were quarterly life safety code inspection reports from the contracted fire safety company for 2022 and 2023. The City Fire Department inspection reports located at the inpatient facility and presented by the Director of Psycho/Social were completed in 2022 and 2023 which included, "deficiencies corrected" with a list of the following identified deficiencies on the back of the forms: "Use of space heater, hanging sprinkler head, ceiling Exit signage illumination not working, and fire extinguisher needed near generator". There was no evidence that the soiled linen was stored in a location free of flammable and combustible items which met the Life Safety Code 2012 requirements. There was no evidence the soiled linen area, which was greater than 64 gallons of soiled linen, was located in a Hazardous Room that was protected by fire barrier walls and ceiling having 1-hour fire resistance rating with a positive, self latching door. There was no waiver present for current location of the soiled linen. During interview 7/26/23, the Inpatient House Manager stated, "Those paper cups in boxes next to the soiled linen bas are not to use, they are trash", "We store the soiled linen here and it is picked up weekly", "The walker was given to the hospice from one of the patients and we are just storing it here until we donate it", and "We do not use that mattress". During interview 7/26/23, Maintenance worker stated, "I have another shed which is not on site at the inpatient facility and I will move the paint cans to the other shed" and "We are not using those extinguishers that are located on the floor of the soiled storage area". During interview 7/26/23, the Administrator stated, "The inpatient building was built in the 1950s as a dental office, a Hospice Inpatient Facility was started in the same building by another hospice in the 1990's and we purchased and started our hospice inpatient facility last year". During interview 7/26/23, Maintenance stated, "The second floor of the inpatient facility building is not used since we do not have a fire escape in place from the second floor". Additionally, the electrical room on the second floor of the inpatient facility was observed to contain a paint can. During interview 7/26/23, Maintenance for the inpatient facility stated he removed the paint can from the electrical room. Additional observation in the sprinklered Janitor's closet located on the first floor revealed an opening in the ceiling over the floor sink. There was no evidence that the janitor's room ceiling was protected by a fire barrier having 1-hour fire resistance rating. The facility Maintenance worker stated he fixed the opening in the ceiling and it was observed to be corrected before leaving the inpatient facility. Additionally the lock on the door to the Janitor's room was broken. The lock was repaired during the day and was then observed to be a locking, positive self-latching door. During interview 7/27/23, the Administrator stated, "We removed all the flammable items, trash, mattress, cardboard boxes, paint cans and fire extinguishers on the floor from the soiled linen room, and we are getting a linen container to place soiled linen bags into to get the linen off the floor", "We will be checking with Life Safety Code department at the State to determine if soiled linen can be stored in a different room in the inpatient facility, either one of the hall shower rooms or the room were we are currently store emergency food and water" and "We are in the process of contacting fire extinguisher inspection company to get the fire extinguisher inspected that is located on the wall outside the soiled linen area next to the generator". NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.2.2.1: Hazardous Areas are protected by a fire barrier having 1-hour fire resistance rating (with ¾ hour fire rated doors). Doors shall be self-closing or automatic-closing. NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.3.2: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. NFPA 101, Life Safety Code 2012, EXISTING Health Care Facilities, 19.3.2.1.3: The doors shall be self-closing or automatic-closing. 19.3.2.1.5: Hazardous areas shall include Boiler and fuel-fired heater rooms, Paint shops, Rooms with soiled linen in volume exceeding 64 gal (242 L), Rooms with collected trash in volume exceeding 64 gal (242 L), Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous.

It is required that the rooms of the hospice inpatient facility are designed and equipped for nursing care, as well as for the dignity, comfort, and privacy of the patient. Each patient room is equipped with a device used for calling for assistance that is easily activated, functioning, and accessible to the patient. This standard was not met as evidenced by interview and observation. Tour of the inpatient facility along with Maintenance, Administrator, the House Manager and Clinical Director revealed the patient call device was broken and non-functioning in the two shower rooms located in the hallway and in each of the patient bathrooms. The hospice had a functional portable call device for patient use which was located on each patient's bedside table. During interview 7/26/23, the Inpatient House Manager and Clinical Director stated the patient call device system was not operational, a portable call device was placed on each patient's bedside table and confirmed the missing patient call devices in the two shower rooms in the hallway and each patient's bathroom. Tour of the inpatient facility along with Maintenance, Administrator, the House Manager and Clinical Director revealed the patient call device was broken and non-functioning in the two shower rooms located in the hallway and in each of the patient bathrooms. The hospice had a functional portable call device for patient use which was located on each patient's bedside table. During interview 7/26/23, the Inpatient House Manager and Clinical Director stated the system patient call device system was not operational, a portable call device was placed on each patient's bedside table and confirmed the missing patient call devices in the two shower rooms in the hallway and each patient's bathroom.

It is required that each patient room in the hospice facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review, interview and observation. There was no evidence the water temperature for patient use at the plumbing fixtures was maintained at or below 110 degrees, as required by the inpatient facility policy. Review of the maintenance hot water temperature logs completed at the inpatient facility since August 2022 revealed the hot water for patient's use was documented 110 to 120 degrees. All hot water temperature checks were greater than 110 degrees except one check was 110 degrees. The maintenance logs had a column headed "corrective action taken" and all temperatures greater than 110 degrees stated "NA" with no correction action taken. During interview 7/26/23, the Administrator stated that Maintenance did not know what to write in the corrective action column. There is only one hot water heater at the inpatient facility which provides hot water for patient use as well as hot water supply for the kitchen's mechanical dishwashing machine. Agency policy INPT 10 "Plumbing Facilities” (no date), stated in part, “The recommended water temperature at the plumbing fixtures should be maintained at or below 110 degrees”. There was no evidence the water temperature for patient use at the plumbing fixtures was maintained at or below 110 degrees, as required by the inpatient facility policy. Review of the maintenance hot water temperature logs completed at the inpatient facility since August 2022 revealed the hot water for patient's use was documented 110 to 120 degrees. All hot water temperature checks were greater than 110 degrees except one check was 110 degrees. The maintenance logs had a column headed "corrective action taken" and all temperatures greater than 110 degrees stated "NA" with no correction action taken. During interview 7/26/23, the Administrator stated that Maintenance did not know what to write in the corrective action column. There is only one hot water heater at the inpatient facility which provides hot water for patient use as well as hot water supply for the kitchen's mechanical dishwashing machine. Policy "Plumbing Facilities”, Policy INPT 10, (no date), included, “The recommended water temperature at the plumbing fixtures should be maintained at or below 110 degrees”.

It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met as evidenced by document review, interview and observation. There is no evidence that dishes and utensils used for hospice patients are sanitized. There was no evidence that the hot water utilized for sanitizing in the kitchen's dishwashing machine at the inpatient facility met the State's requirements of 180 degrees Fahrenheit for sanitizing. There is only one hot water heater at the inpatient facility which is for patient use, as well as providing hot water for the kitchen and dishwashing machine. The hot water temperature logs range from 110 to 120 degrees since 7/19/22. The dishwashing machine is a standard, non-commercial machine with no internal regulator to increase hot water temperatures and no chemicals are utilized to sanitize dishes and utensils. The Inpatient Facility has no inpatient policies and procedures for sanitizing dishes and utensils that are used for patients, either by hot water of 180 degrees Fahrenheit or chemical sanitizing procedures. (State) Administrative Code, Title 26, Part I, Chapter 554: "Hot water for laundry and kitchen use must be normally 140 degrees Fahrenheit except that dish sanitizing, if done by hot water, must be 180 degrees Fahrenheit". Two Ice machines utilized for patient use were not cleaned or sanitized according to the manufacturer's manual procedures. There is no evidence the two ice machines located in the kitchen and hallway were cleaned and sanitized since 7/19/22. Review of the two ice machine cleaning logs documented only the air filter was changed at least two times a month. During interview 7/26/23, the Inpatient House Manager stated, "Maintenance cleans the ice machines". During an interview on 7/26/23, Maintenance staff stated, "I do not clean and sanitize the ice machines; I only change the air filters". The Inpatient House Manager presented a procedure manual for the cleaning and sanitizing for the two ice machines and confirmed the cleaning and sanitizing of the two ice machines had not been performed after initial site visit 7/19/22. Tour of the inpatient facility kitchen revealed two utensils' drawers were not clean and sanitary. Two drawers in the kitchen of the inpatient facility were observed to be soiled and contain food crumbs along with the forks, knifes, spoons and other utensils that are for patient use. During interview 7/26/23, the Inpatient House Manager stated the contracted housekeeping company cleans the inpatient facility daily to include the kitchen area. There is not evidence that dishes and utensils used for hospice patients are sanitized. There was no evidence that the hot water utilized for sanitizing in the kitchen's dishwashing machine at the inpatient facility met the State's requirements of 180 degrees Fahrenheit for sanitizing. There is only one hot water heater at the inpatient facility which is used for patient use and hot water for the kitchen and dishwashing machine. The hot water temperature logs range from 110 to 120 degrees since 7/19/22. The dishwashing machine is a standard, non-commercial machine with no internal regulator to increase hot water temperatures and no chemicals are utilized to sanitize dishes and utensils. No inpatient policies and procedures for sanitizing dishes and utensils that are used for patients, either by hot water of 180 degrees Fahrenheit or chemical sanitizing procedures. During interview 7/26/23, the Administrator stated she did not have a dietitian and uses the dietitian at the contracted food preparation company approves patient menus. (State) Administrative Code, Title 26, Part I, Chapter 554: "Hot water for laundry and kitchen use must be normally 140 degrees Fahrenheit except that dish sanitizing, if done by hot water, must be 180 degrees Fahrenheit". Two Ice machines utilized for patient use were not cleaned or sanitized according to the manufacturer's manual procedures. There is no evidence the two ice machines located in the kitchen and hallway were cleaned and sanitized since 7/19/22. Review of the two ice machine cleaning logs documented only the air filter was changed at least two times a month. During interview 7/26/23, the Inpatient House Manager stated, "Maintenance cleans the ice machines". During interview 7/26/23, the Maintenance stated, "I do not clean and sanitize the ice machines; I only change the air filters". The Inpatient House Manager presented a procedure manual for the cleaning and sanitizing for the two ice machines and confirmed the cleaning and sanitizing of the two ice machines had not be performed after initial site visit 7/19/22. Tour of the inpatient facility kitchen revealed two utensils drawers were not clean and sanitary. Two drawers in the kitchen of the inpatient facility were observed to be soiled and contain food crumbs along with the forks, knifes, spoons and other utensils that are for patient use. During interview 7/26/23, the Inpatient House Manager stated the contracted housekeeping company cleans the inpatient facility daily to include the kitchen area.

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview and observation. Agency policy INPT 9 "Meal Service and Menu Planning" (no date), stated in part, “The hospice will furnish meals to each patient that are consistent with the patient’s plan of care, nutritional needs, and therapeutic diet, attractive, and served at the proper temperature; and obtained, stored, prepared, distributed and serviced under sanitary conditions”. Review of the food temperature logs revealed no evidence the hot food was served at the proper temperature, as required by inpatient facility policy. Since January 2023, the following hot food temperature checks were not documented: 7/21/23-7/23/23, 5/3/23, 4/22/23-4/24/23, 4/15/23-4/19/23, 3/25/23-3/26/23, 3/18/23-3/20/23, 3/11/23-3/12/23, 2/28/23-3/2/23, and 1/29/23-2/1/23. During interview 7/26/23, the Clinical Director and Inpatient House Manager stated the contracted food company prepares each patient meal and then delivers the prepared meals to the kitchen daily to be stored in the refrigerator in the kitchen until heated and served to patients. Before each meal, the trained Food Handler nurses and aides place the prepared meal containers in the large food heater unit located in the kitchen. Then the nurses and aides remove the heated food from the containers, plate the food and serve to patients. The refrigerator and freezer in the kitchen contain food for patient use, as needed. Review of the food temperature logs revealed no evidence the hot food was served at the proper temperature, as required by inpatient facility policy. Since January 2023, the following hot food temperature checks were not documented: 7/21/23-7/23/23, 5/3/23, 4/22/23-4/24/23, 4/15/23-4/19/23, 3/25/23-3/26/23, 3/18/23-3/20/23, 3/11/23-3/12/23, 2/28/23-3/2/23, and 1/29/23-2/1/23. During interview 7/26/23, the Clinical Director and Inpatient House Manager stated the contracted food company prepares each patient meal and then delivers the prepared meals to the kitchen daily to be stored in the refrigerator in the kitchen until heated and served to patients. Before each meal, the trained Food Handler nurses and aides place the prepared meal containers in the large food heater unit located in the kitchen. Then the nurses and aides remove the heated food from the containers, plate the food and serve to patients. The refrigerator and freezer in the kitchen contains food for patient use, as needed. Policy "Meal Service and Menu Planning", Policy INPT 9, (no date), included, “The hospice will furnish meals to each patient that are consistent with the patient’s plan of care, nutritional needs, and therapeutic diet, attractive, and served at the proper temperature; and obtained, stored, prepared, distributed and serviced under sanitary conditions”.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review, interview and observation. Agency policy INPT 9 "Meal Service and Menu Planning" (no date), stated in part, “To ensure that the hospice will furnish meals to each patient that are consistent with the patient’s plan of care, nutritional needs, and therapeutic diet, attractive, and serviced at the proper temperature; and obtained, stored, prepared, distributed and serviced under sanitary conditions”. Observation of the freezer in the kitchen revealed no evidence that food for patient use was stored in the freezer under sanitary conditions, as required by inpatient facility policy. Fish food was stored in the freezer along with un-labeled and not dated individual patient food items of two small ice cream containers and one container of soup. During interview 7/26/23, the Inpatient House Manager stated the small refrigerator in the hallway was identified to be utilized for specific patient food items brought into the inpatient facility by family members. During interview 7/26/23, Maintenance staff stated he can store the fish food at a different location other than the freezer in the inpatient facility that is utilized for patient food storage. There were no procedures in place to prevent cross contamination from the potentially soiled clothing worn of direct patient care nurses and aides and then handling, storing, preparing, and placing hot food onto plates for serving to patients. During interview 7/26/23, the Inpatient House Manager stated the nurses and aides are trained as food handlers, provide direct patient care contact during the shift, and then handle, heat up, plate food and serve food to patients with no protection over their patient care work clothes to prevent contamination of food, equipment and utensils. During an interview on 7/26/23, the Inpatient House Manager stated a procedure is in place for the nurses and aides to wash their hands and wear gloves when handling food for patients. Additionally, there were no procedures in place for hair restraint to prevent the head hair from nurses and aide food handlers from getting into patient food when handling, storing, preparing, placing hot food onto plates and serving food to patients. During interview 7/26/23, the Inpatient House Manager stated no hair restraint is wore on the head to prevent head hair from nurses and aide food handlers from getting on the food for patients. (State) Department of State Health Services, Sanitation and Food Safety, revised 2/21/2017, 228.43, "(State) Food Establishment Rules requires that food employees wear hair restraints that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment and utensils. (State) Department of State Health Services, Sanitation and Food Safety, revised October 2015, Food Establishment Rules, 228.41. Outer Clothing, Clean Condition. Food employees shall wear clean outer clothing to prevent contamination of food, equipment and utensils. Observation of the freezer in kitchen revealed no evidence that food for patient use is not stored in the freezer under sanitary conditions, as required by inpatient facility policy. Fish food was stored in the freezer along with un-labeled and not dated individual patient food items of two small ice cream containers and one container of soup. During interview 7/26/23, the Inpatient House Manager stated the small refrigerator in the hallway was identified to be utilized for specific patient food items brought into the inpatient facility by family members. During interview 7/26/23, Maintenance stated he can store the fish food at a different location other than the freezer in the inpatient facility that is utilized for patient food storage. There were no procedures in place to prevent cross contamination from the potentially soiled clothing worn of direct patient care nurses and aides and then handling, storing, preparing, and placing hot food onto plates for serving to patients. During interview 7/26/23, the Inpatient House Manager stated the nurses and aides are trained as food handlers, provide direct patient care contact during the shift, and then handle, heat up, plate food and serve food to patients with no protection over their patient care work clothes to prevent contamination of food, equipment and utensils. During interview 7/26/23, the Inpatient House Manager stated a procedure is in place for the nurses and aides to wash their hands and wear gloves when handling food for patients. Additionally, there were no procedures in place for hair restraint to prevent the head hair from nurses and aide food handlers from getting into patient food when handling, storing, preparing, placing hot food onto plates and serving food to patients. During interview 7/26/23, the Inpatient House Manager stated no hair restraint is wore on the head to prevent head hair from nurses and aide food handlers from getting on the food for patients. Policy, "Meal Service and Menu Planning", Policy INPT 9, (no date), included, “To ensure that the hospice will furnish meals to each patient that are consistent with the patient’s plan of care, nutritional needs, and therapeutic diet, attractive, and serviced at the proper temperature; and obtained, stored, prepared, distributed and serviced under sanitary conditions”. (State) Department of State Health Services, Sanitation and Food Safety, revised 2/21/2017, 228.43, "(State) Food Establishment Rules requires that food employees wear hair restraints that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment and utensils. (State) Department of State Health Services, Sanitation and Food Safety, revised October 2015, Food Establishment Rules, 228.41. Outer Clothing, Clean Condition. Food employees shall wear clean outer clothing to prevent contamination of food, equipment and utensils.

It is required that all patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion as part of orientation. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 3 (67%) applicable personnel records of inpatient facility patient care staff that were hired after 7/19/22, there was no evidence clinical staff received training on the inpatient facility restraint policy during orientation, as required in policy and procedure. Agency policy INPT 22 "Restraint or Seclusion Training" (no date), stated in part, “All patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. All staff designated by the hospice as having direct patient care responsibilities, including contract or agency personnel, must demonstrate the competency in restraint or seclusion prior to assessment, or care of a patient in restraint or seclusion. These competencies must be demonstrated initially as part of orientation at hire and as often as needed, but no less than annually.” Personnel Record 3: Inpatient House Manager with date of hire 6/26/23. Review of personnel record and in-service/training records revealed training on the inpatient facility's restraint and seclusion policy was not completed as part of orientation at hire, as required by inpatient facility policy. Training was completed on the restraint and seclusion policy on 7/25/23. Personnel Record 9: Inpatient Facility RN with date of hire 3/20/23. Review of personnel record and in-service/training records revealed training on the inpatient facility's restraint and seclusion policy was not completed as part of orientation at hire, as required by inpatient facility policy. Training was completed on the restraint and seclusion policy on 7/25/23. Policy "Restraint or Seclusion Training", Policy INPT 22 (no date), included, “All patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion”, "All staff designated by the hospice as having direct patient care responsibilities, including contract or agency personnel, must demonstrate the competency in Restraint or seclusion prior to assessment, or care of a patient in restraint or seclusion” and “These competencies must be demonstrated initially as part of orientation at hire and as often as needed, but no less than annually”.

Based on record review and interview, the Supervising Nurse failed to ensure that care was provided according to the patient's plan of care (POC) for two of three of patients (Patients #2 and #3), whose records were reviewed, in that: 1. Patient #2 did not receive Skilled Nurse (SN) visits as ordered in the POC. 2. Patient #3 did not receive SN visits as ordered in the POC. This failure placed Patients #2 and #3 at risk of not having their needs met and could result in negative client outcomes, which could also affect the agency's other 30 active patients. The findings included: Review of Patient #2 electronic clinical record (ECR) revealed an (interdisciplinary group/plan of care) IDG/POC dated 02/02/22 for benefit period 12/20/21-02/17/22 which included orders for skilled nurse (SN) visits of 2 times a week plus four prn (as needed) visits for symptom management. Continued review of the IDG/POC dated 02/02/22, under "Summary/Comments" read in part: "IDG meeting held today...POC's have been updated and discussed with the IDT (interdisciplinary team) to ensure individualized care...Agency will continue to provide care per the POC discussed..." Review of Patient #2's ECR revealed the following skilled visits made: Week of 12/26/21 only one SN visit was made on 12/28/21. Week of 01/02/22 only one SN visit was made on 01/04/22. Week of 01/09/22 only one SN visit was made on 01/12/22. Week of 01/16/22 only one SN visit was made on 01/18/22. Week of 01/23/22 only one SN visit was made on 01/25/22. Week of 01/30/22 only one SN visit was made on 02/02/22. Continued review of Patient #2's ECR included the following physician's orders: 12/27/21: change certified nurse aide (CNA) frequency, 1 weekly to 3 X weekly (one time a week to 3 times a week). 02/02/22 Chaplain 1 X/monthly (one time per month). 02/09/22 Verbal orders: recertify CTI (Certificate of Terminal Illness). Continued review of Patient #2's ECR did not reveal physician's orders for change in SN visit frequencies to once a week. Review of Patient #3's ECR revealed an IDG/POC dated 02/02/22 for benefit period 01/07/22 - 03/07/22 which included orders for SN visits of 2 times a week plus four prn visits for symptom management. Continued review of the IDG/POC dated 02/02/22, under "Summary/Comments" read in part: "IDG meeting held today...POC's have been updated and discussed with the IDT (interdisciplinary team) to ensure individualized care...Agency will continue to provide care per the POC discussed..." Review of Patient #3's ECR revealed the following skilled visits made: Week of 01/02/22 only one SN visit was made on 01/05/22. Week of 01/09/22 only one SN visit was made on 01/12/22. Week of 01/16/22 only one SN visit was made on 01/21/22. Week of 01/23/22 only one SN visit was made on 01/27/22. Week of 01/30/22 only one SN visit was made on 02/03/22. Continued review of Patient #3's ECR included the following physician's orders: 01/03/22: "Written Recertification for certification period 01/07/22 - 03/07/22. Continued review of the ECR did not reveal physician's orders for change in SN visit frequencies to once a week. In an interview and concurrent record review on 02/15/22 at 3:46 p.m., the Administrator/Supervising Nurse stated, "that the nurses are not putting in orders to change the SN visit frequencies to once a week and the SN visit frequencies were not being updated in the patient's record to once a week." Review of the agency's policy (LD. 6) titled, "Responsibilities of the Supervising Nurse", revised dated 01/01/18 read in part: "The responsibilities of the supervising nurse include, but are not limited to...Ensuring that a patient's POC is executed as written."

Based on personnel record review and interview, the agency failed to ensure that two of two Hospice Aides (HA F and HA G) whose personnel records were reviewed, were trained, observed, and evaluated by a RN prior to providing patient care. This failure could result in the Hospice Aides providing unsafe or incompetent care to agency patients. The findings Included: During the Entrance Conference on 02/10/22 at 3:07 p.m., with the Administrator/Supervising Nurse, the Surveyor requested and received a list of the Agency's Active Employees with their hire dates. Review of the Agency's active Employee list provided by the Administrator/Supervising Nurse revealed four hospice aides. Review of HA F's personnel record revealed a document titled, "Hospice/Home Health Aide Job Description" signed and dated on 12/06/21 by HA F's and by the (human resource coordinator) HRC on 12/7/21, that read in part: "Job Qualification - Education - Has successfully completed the Training program and Competency evaluation that complies with regulations...Skills: "...Must pass Aide Competency Evaluation Skills Checklist...and written skills test." Continued review of HA F's personnel record revealed an Agency form titled "Hospice Aide Competency Evaluation and Written Exam" it was signed and dated on 12/06/21 by HA F and also signed and dated by the HRC on 12/07/21 and not by a Registered Nurse. The space titled "Scored by" (which was where the signature was required) was left blank. Review of HA G's personnel record revealed a document titled, "Hospice/Home Health Aide Job Description" signed and dated on 10/28/21 by HA G's and by the HRC on 10/29/21, that read in part: "Job Qualification - Education - Has successfully completed the Training program and Competency evaluation that complies with regulations...Skills: "Must pass Aide Competency Evaluation Skills Checklist...and written skills test." Continued review of HA G's personnel record revealed an Agency form titled "Hospice Aide Competency Evaluation and Written Exam" it was signed and dated by HA G on 10/28/21 and also signed and dated by the HRC on 10/29/21 and not by a Registered Nurse. The space titled "Scored by" (which was where the signature was required) was left blank. In an interview and concurrent record review conducted on 02/15/22 at 2:47 p.m., with the Administrator/Supervising Nurse and the HRC, the surveyor presented the above findings. The Administrator/Supervising Nurse and the HRC agreed with the following: -Hospice Aide Competency Evaluation and Written Exam for 2021 for HA F and HA G were not signed by an RN as required by regulation. The Administrator/Supervising Nurse stated that, "Competency A and B must be signed off by an RN." Review of the agency's policy (HR. 9) titled, "Hospice Aide / Homemaker Competency Evaluation", revised date of 01/01/18, read in part: "The Competency evaluation and skills checklist, administered by a Registered Nurse (RN)...The RN will sign date and include direct observation of the RN of all required skills. "