Every finding on record at Accurate Hospice Inc.

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for four of fourteen sampled patients (Patient 1, Patient 3, Patient 8, and Patient 10). This failure had the potential to result in patients identified hospice needs are not addressed promptly leading in the delay to develop the individualized plan of care identifying these needs and services for patients certified to receive hospice benefits. --- 1. During a record review of Patient 1’s medical record titled, Patient Information, indicated a start of care date of 8/9/2025 with a terminal diagnosis of Lare B-cell lymphoma (a type of cancer).   During a concurrent interview and record review on 8/27/2025, at 12:36 p.m., the Administrator/Director of Patient Care Services (DPCS), reviewed Patient 1’s electronic medical records (EMR) and paper medical records. The review indicated there was no spiritual assessment documented anywhere. The DPCS stated Patient 1 did not have a spiritual assessment because Patient 1 was a nun, lived in a convent, and had a lot of spiritual support. The DPCS stated the spiritual support was not documented and should have because the staff needed to be aware of what the spiritual needs were and that the HA was monitoring those needs.   2. During a record review of Patient 3’s medical record titled, Patient Information, indicated a start of care date of 7/21/2025, with a terminal diagnosis of Alzheimer’s disease (progressive memory loss).  During a concurrent interview and record review on 8/27/2025, at 2:03 p.m., the DPCS reviewed Patient 3’s EMR and paper medical records. The review indicated there was no spiritual assessment documented anywhere. The DPCS stated the reason why the spiritual assessment was not done was because Patient 3 had refused spiritual care services. The DPCS stated she had documented in the medical record a brief note about her spiritual needs, but the note was not a comprehensive spiritual assessment. The DPCS stated if patients declined SC services, the nurse should have completed ted the spiritual comprehensive assessment.  3. During a record review of Patient 8’s medical record form titled “Personal Information” undated, indicated a start of care date of 9/25/2024 with the terminal diagnosis of Alzheimer's Disease (progressive memory loss).  During a record review of Patient 8’s medical record form titled “RN (Registered Nurse) Initial Assessment” dated 9/25/2024, indicated under section “Spiritual/Religion” that Patient 8 and/or caregiver were asked and discussed about spiritual/existential concerns. The RN Initial Assessment form also indicated that the interdisciplinary team was notified and agreed with Patient 8’s plan of care and medications.   During a concurrent interview and record review on 8/28/2025 at 1:06 p.m., with the DPCS of Patient 8’s EMR and physical medical records, the DPCS stated that a comprehensive assessment consisted of a head to toe, spiritual, psychosocial assessments. The DPCS stated that the doctor, family, spiritual counselor (SC), medical social worker (MSW), and nurses are involved in the comprehensive assessment of the patients. The DPCS stated that the MSW saw Patient 8 on the 7th day after the patient's admission date on 9/25/2024 and also the SC did not see Patient 8. Patient 8’s EMR indicated there were no SC documentation since admission to 8/27/2025.  4. During a record review of Patient 10’s medical record form titled “Personal Information” undated, indicated a start of care date of 1/29/2025 with the terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries with plaque buildup) without angina pectoris (pain).  During a record review of Patient 10’s medical record form titled “RN Initial Assessment” dated 1/29/2025, indicated under section “Spiritual/Religion” that Patient 10 and/or caregiver were asked and discussed about spiritual/existential concerns and that Patient 10 was part of a religious and spiritual community and fairly religious. The RN Initial Assessment form also indicated that the interdisciplinary team was notified and agreed with Patient 10’s plan of care and medications.   During a concurrent interview and record review on 8/28/2025 at 1:15 p.m., with the DPCS of Patient 10’s EMR and physical medical records, the DPCS stated Patient 10’s admission date was on 1/29/2025 and has not been seen by the SC since admission. The DPCS stated that there was no documentation indicating Patient 10 refused SC services. The DPCS stated that Patient 10’s comprehensive assessment was not completed by all the IDG members. Patient 10’s EMR indicated there were no SC documentation from Patient 10’s admission date to present day, 8/27/2025. During an interview on 8/27/2025 at 1:12 p.m. with the Spiritual Counselor (SC), the SC stated that he worked for the HA for about 3-4 years. The SC stated that he (SC) currently has one patient assigned to him, Patient 9. The SC stated his last patient was discharged on 6/29/2025. The SC stated his duties included providing spiritual care for patients and their families, and initial spiritual assessments. The SC stated that he (SC) checks in on patients once a month.   During a record review of the agency’s form titled “The Plan of Care” revised 10/2019, indicated “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments… The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.”  During a record review of the agency’s form titled “Comprehensive Assessment” revised 10/2019, indicated “A comprehensive assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician.”

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for two of fourteen sampled patients (Patient 1 and Patient 3).  This failure resulted in patients not being accurately evaluated which resulted in the delay in identifying patients' progress and/or decline in response to care. --- 1.  During a record review of Patient 1’s medical record titled, Patient Information indicated a start of care date of 8/9/2025 with a terminal diagnosis of Lare B-cell lymphoma (a type of cancer).  During a record review of Patient 1’s record titled, IDG meeting, dated 8/9/2025 and 8/20/2025, indicated the SC was in the meeting. However, there was no SC input documented to indicate participation in the update of the comprehensive assessment for Patient 1.  During an interview on 8/27/2025, at 12:36 p.m., the Administrator/Director of Patient Care Services (DPCS), stated Patient 1 did not have a spiritual assessment because Patient 1 was a Nun (a member of a religious community), lived in a convent, and had a lot of spiritual support. The DPCS stated the spiritual support was not documented and should have because the staff needed to be aware of what the spiritual needs were and that the HA was monitoring those needs. During an interview on 8/27/2025 at 1:12 p.m. with the Spiritual Counselor (SC) stated he currently has one patient assigned to him, Patient 9. The SC stated that his last patient was discharged on 6/29/2025. The SC stated his duties included providing spiritual care for patients and their families, and initial spiritual assessments. The SC stated he participated in the IDG meetings every two weeks via online. The SC stated the last in person IDG meeting was conducted “sometime earlier this year”. The SC stated that during and sometimes after the IDG meeting he logs into the HAs Electronic Medical Record (EMR) system to document and sign his notes. The SC stated that recently, he has signed his notes late and that his documentation was behind two or three meeting behind. The SC stated that his signature validates his interactions, as well as confirms and validates his documentation.   2. During a record review of Patient 3’s medical record titled, Patient Information, indicated a start of care date of 7/21/2025, with a terminal diagnosis of Alzheimer’s disease (progressive memory loss).   During an interview a on 8/27/2025, at 2:03 p.m., the DPCS stated the reason why the spiritual assessment was not done was because Patient 3 had refused spiritual care services. The DPCS stated she had documented in the medical record a brief note about her spiritual needs, but the note was not a comprehensive spiritual assessment. During a record review of Patient 3’s record titled, IDG meeting, dated 7/21/2025, 8/6/2025, and 8/20/2025, indicated the SC was in the meeting. However, there was no SC input documented to indicate participation in the update of the comprehensive assessment for Patient 3.  During a record review of the agency’s form titled “The Plan of Care” revised 10/2019, indicated “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments… and will be reviewed on a regular basis but no less than every fifteen (15) days.”

Based on interview and record review the Hospice Agency (HA) failed to ensure three of fourteen sample patients (Patient 9, Patient 10, and Patient 11) plans of care included their identified problems with goals and interventions to provide continuous assessment to manage their care.  This failure had the potential to result in patients not being assessed, which can cause failed treatments to manage their care and needs. --- 1. During a record review of Patient 9’s medical record form titled “Personal Information” undated, indicated a start of care date of 6/6/2025 with the terminal diagnosis of senile degeneration of brain (gradual loss of cognitive function).  During a record review of Patient 9’s medical record form titled “Plan of Care Order” dated 6/6/2025, indicated Patient 9 had a cerebrospinal fluid drainage system (VP Shunt -an implanted devise under the skin that diverts spinal fluid from the brain or spinal cord) and a pacemaker (an implanted electronic devise under the skin that helps regulate the hearts rhythm). The form Plan of Care Order did not indicate Patient 9’s pacemaker and VP shunt were care planned, there were no goals or interventions to monitor the functions, placement, and/or status.   During a concurrent interview and record review on 8/28/2025 at 12:10 p.m., with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated that Patient 9’s pacemaker and VP shunt were not care planned. The DPCS stated that it was important to care plan Patient 9’s VP shunt to assess Patient 9’s neurological status, vital signs, and skin.   2. During a record review of Patient 10’s medical record form titled “Personal Information” undated, indicated a start of care date of 1/29/2025 with the terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries with plaque buildup) without angina pectoris (pain).  During a record review of Patient 10’s medical record form titled “RN (registered Nurse) Initial Assessment” dated 1/29/2025, indicated Patient 10’s co morbidities included hypertension (HTN - high blood pressure), chronic kidney disease stage 3 (CKD - kidneys not working properly), and had a pacemaker (an implanted electronic devise under the skin that helps regulate the hearts rhythm). During a record review of Patient 10’s medical record form titled “Plan of Care Order” dated 7/24/2025, indicated Patient 10’s co morbidities included hypertension, chronic kidney disease stage 3, and had a pacemaker. The form Plan of Care Order did not indicate Patient 10’s pacemaker, HTN, and CKD stage 3 were care planned; there were no goals or interventions to monitor the functions, placement, and/or status. During a record review of Patient 10’s medical record form titled “Medication Profile” dated from 7/28/2025 to 9/25/2025, indicated Patient 10 was prescribed daily Lasix (medication to remove excess fluid from the body) and Losartan-Potassium (medication to lower blood pressure).  During a concurrent interview and record review on 8/28/2025 at 12 p.m. with the Administrator/Director of Patient Care Services (DPCS) of Patient 10’s Electronic Medical record (EMR) and physical medical record, the DPCS stated the HA was supposed to care plan Patient 10’s comorbidities to be able to take care of the “whole patient”. The DPCS stated Patient 10’s HTN needed to be care planned to monitor his blood pressure. The DPCS stated high blood pressure can lead to a stroke and low blood pressure can mean Patient 10 is dehydrated. The DPCS stated Patient 10’s CKD needed to be care planned to monitor for possible kidney failure. The DPCS stated Patient 10’s pacemaker needed to be care planned to assess any heart rate irregularities, chest pain, and swelling around the implantation area.   3.  During a record review of Patient 11’s medical record form titled “Personal Information” undated, indicated a start of care date of 3/30/2024 with the terminal diagnosis of Alzheimer's Disease (gradual memory loss).   During a record review of Patient 11’s medical record form titled “Plan of Care Order” dated 1/17/2025, indicated Patient 11’s co morbidities included HTN. The form Plan of Care Order did not indicate Patient 11’s HTN was care planned; there were no goals or interventions to monitor.  During a concurrent interview and record review on 8/28/2025 at 2 p.m., with the DPCS of Patient 11’s EMR and physical medical record, the DPCS stated Patient 11’s HTN needed to be care planned to observe for sign and symptoms of high blood pressure which can cause headaches, and paralysis.  During an interview on 8/28/2025 at 12 p.m., with the DPCS stated patient's care plan is a document that gives instructions/indications on how to take care of the patient. The DPCS stated that patients care plans are to be updated every time there is an issue. The DPCS stated that patients care plans indicate patients problems, interventions, monitoring assessments, teaching instructions, resolutions, and goals.   During a record review of the agency’s form titled “The Plan of Care” revised 10/2019, indicated “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments…This plan will focus on identified problems, goals, and interventions.”

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised for two of fourteen sampled patients (Patient 1 and Patient 3) plan of care (POC- an individualized care planned).  This failure resulted in patients not accurately evaluated leading to the identified needs are not adressed, reviewed, and updated. --- 1. During a record review of Patient 1’s medical record titled, Patient Information, indicated a start of care date of 8/9/2025 with a terminal diagnosis of Lare B-cell lymphoma (a type of cancer).  During an interview on 8/27/2025, at 12:36 p.m., the Administrator/Director of Patient Care Services (DPCS), stated Patient 1 did not have a spiritual assessment because Patient 1 was a nun, lived in a convent, and had a lot of spiritual support. The DPCS stated the spiritual support was not documented and should have because the staff needed to be aware of what the spiritual needs were and that the HA was monitoring those needs.  During a record review of Patient 1’s record titled, IDG meeting, dated 8/9/2025 and 8/20/2025, indicated the SC was in the meeting. However, there was no SC input documented to indicate participation in the discussion of the plan of care for Patient 1.   2. During a record review of Patient 3’s medical record titled, Patient Information, indicated a start of care date of 7/21/2025, with a terminal diagnosis of Alzheimer’s disease (progressive memory loss).  During an interview a on 8/27/2025, at 2:03 p.m., the DPCS stated the reason why the spiritual assessment was not done was because Patient 3 had refused spiritual care services because her spiritual needs were being met by Patient 3’s priest.  The DPCS stated she had documented in the medical record a brief note about her spiritual needs, but the note was not a comprehensive spiritual assessment. During a record review of Patient 3’s record titled, IDG meeting, dated 7/21/2025, 8/6/2025, and 8/20/2025, indicated the SC was in the meeting. However, there was no SC input documented to indicate participation in the discussion of the plan of care for Patient 3. Continued review of the record also indicated there was no input documented for the doctor.  During an interview on 8/28/2025, at 12:29 p.m., the DPCS stated the Medical Director (MD 1) attended the IDG meetings. The DPCS stated no MD 1 input was documented in the IDG meetings, as the doctor just listens. The DPCS stated documentation of the input of all IDG members was important because the HA is dealing with the entire patient’s condition: mentally, physically, and spiritually.  During a record review of the agency’s form titled “The Plan of Care” revised 10/2019, indicated “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments… The plan of care will be reviewed and revised as frequently as deemed necessary, but no less often that every 15 days, by the interdisciplinary group, with input from the attending physician…”.

Based on interview and record review the Hospice Agency (HA) failed to provide or confirm two of their contracted staff had infection control education and training before providing care to one of fourteen sample patients (Patient 12). This failure had the potential to result in not knowing if staff understood how infection spreads and applying measures to prevent infection. --- During a record review of Patient 12’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/21/2025 and an end of care date of 7/10/2025 with a terminal diagnosis of malignant neoplasm of vertebral column (spine cancer).  During a concurrent interview and record review on 8/27/2025 at 11:37 a.m., with the Medical Record/Quality Assurance (MR) of Patient 12’s electronic medical record (EMR) indicated there were written notes scanned into Patient 12’s medical record. MR was requested to provide copies of those notes dated from 7/6/2025 to 7/10/2025. MR stated the notes were written by two contracted staff members  namely License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3). Both contracted staffs provided continuous care for Patient 12.During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/6/2025 from 4 p.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document was in Word document (program that allows users to create, edit, format,and print documents) and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/6/2025 from 9 p.m. to 7/7/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/7/2025 from 9 a.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document was in Word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/7/2025 from 9 p.m. to 7/8/2025 11 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/8/2025 from 9 p.m. to 7/9/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/9/2025 from 9 p.m. to 7/10/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/10/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/28/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a concurrent interview and record review on 8/28/2025 at 11:30 a.m. with the Administrator/Director of Patient Care Services (DPCS) of LVN3’s employee file, the DPCS stated LVN3’s employee file did not contain documentation that LVN3 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN3’s employee file did not contain documentation that LVN3 was educated/trained/evaluated on infection control or LVN3’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN3 in 2023 for an hour when she (DPCS) met him (LVN3), but did not document his (LVN3) training. The DPCS stated she (DPCS) has full responsibility for all the HAs patient care. The DPCS stated there should be records documenting LVN3’s skills and competencies to ensure he (LVN3) is eligible to continue their work.  During a concurrent interview and record review on 8/28/2025 at 11:45 a.m. with the DPCS of LVN2’s employee file, the DPCS stated LVN2’s employee file did not contain documentation that LVN2 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN2’s employee file did not contain documentation that LVN2 was educated/trained/evaluated on infection control or LVN2’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN2 over the phone after LVN2 provided care to Patient 12 but did not document her (LVN2) training. The DPCS stated she (DPCS) ensures LVN2 provides proper patient care by having LVN2 call her (DPCS) every two hours.  During a record review of the HA’s form titled “Written Agreement for Contracted Services” revised 10/2019, indicated “Hospice will maintain responsibility for the services provided under arrangement to ensure that they are provided in accordance with hospice standards…The organization will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care through performance improvement program and/or corporate compliance program. As part of the organization’s annual evaluation process, the Executive Director/Administrator with the assistance of other hospice personnel, will monitor, evaluate, and audit the contracted services to ensure that they are being provided according to the contract, Medicare Conditions of Participation…”  During a record review of the HA’s form titled “Personal Development” revised 10/2019, indicated “Employees and volunteers who have direct patient contact shall be provided or have provisions made for at least a quarterly in-service education program. An attendance record of all in-service/hospice personnel development program offered will be maintained by the Executive Director/Administrator… (HA) requires that each hospice personnel complete a minimum of the following programs each year… Standard precautions and infection control.”

Based on interview and record review the Hospice Agency (HA) failed to provide two of their contracted staffs (LVN 2 & LVN 3) orientation on their agency’s philosophy before providing care to one of fourteen sample patients (Patient 12). This failure had the potential to result in staff does not know the HAs framework, purpose and values to be able to provide their patients consistently. --- During a record review of Patient 12’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/21/2025 and an end of care date of 7/10/2025 with a terminal diagnosis of malignant neoplasm of vertebral column (spine cancer).  During a concurrent interview and record review on 8/27/2025 at 11:37 a.m. with the Medical Record/Quality Assurance (MR) of Patient 12’s electronic medical record (EMR), the EMR indicated there were written notes scanned into Patient 12’s medical record. MR was requested to provide copies of those notes dated from 7/6/2025 to 7/10/2025. MR stated the notes were written by two contracted staff members who provided continuous care for Patient 12, License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3). During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/6/2025 from 4 p.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document was in Word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/6/2025 from 9 p.m. to 7/7/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/7/2025 from 9 a.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document was in Word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/7/2025 from 9 p.m. to 7/8/2025 11 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/8/2025 from 9 p.m. to 7/9/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/9/2025 from 9 p.m. to 7/10/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/10/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/28/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a concurrent interview and record review on 8/28/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (DPCS) of LVN3’s employee file, the DPCS stated LVN3’s employee file did not contain documentation that LVN3 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN3’s employee file did not contain documentation that LVN3 was educated/trained/evaluated on infection control or LVN3’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN3 in 2023 for an hour when she (DPCS) met him (LVN3), but did not document his (LVN3) training. The DPCS stated she (DPCS) has full responsibility for all the HAs patient care. The DPCS stated there should be records documenting LVN3’s skills and competencies to ensure he (LVN3) is eligible to continue their work.  During a concurrent interview and record review on 8/28/2025 at 11:45 a.m., with the DPCS of LVN2’s employee file stated LVN2’s employee file did not contain documentation that LVN2 was oriented to the HA or the HAs philosophy. The DPCS also stated LVN2’s employee file did not contain documentation that LVN2 was educated/trained/evaluated on infection control or LVN2’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN2 over the phone after LVN2 provided care to Patient 12, but did not document her (LVN2) training. The DPCS stated she (DPCS) ensures LVN2 provides proper patient care by having LVN2 call her (DPCS) every two hours.   During a record review of the HA’s form titled “Written Agreement for Contracted Services” revised 10/2019, indicated “Hospice will maintain responsibility for the services provided under arrangement to ensure that they are provided in accordance with hospice standards…The organization will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care through performance improvement program and/or corporate compliance program. As part of the organization’s annual evaluation process, the Executive Director/Administrator with the assistance of other hospice personnel, will monitor, evaluate, and audit the contracted services to ensure that they are being provided according to the contract, Medicare Conditions of Participation…”  During a record review of the HA’s form titled “Personal Development” revised 10/2019, indicated “Employees and volunteers who have direct patient contact shall be provided or have provisions made for at least a quarterly in-service education program. An attendance record of all in-service/hospice personnel development program offered will be maintained by the Executive Director/Administrator… (HA) requires that each hospice personnel complete a minimum of the following programs each year… corporate compliance and standards of conduct.”

Based on interview and record review the Hospice Agency (HA) failed to provide two of their contracted staffs orientation before providing care to one of fourteen sample patients (Patient 12). This failure had the potential to result in staffs lack of knowledge and training of the hospice policies, procedures, goals, staff's specific responsibilities, roles and duties. --- During a record review of Patient 12’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/21/2025 and an end of care date of 7/10/2025 with a terminal diagnosis of malignant neoplasm of vertebral column (spine cancer).  During a concurrent interview and record review on 8/27/2025 at 11:37 a.m. with the Medical Record/Quality Assurance (MR) of Patient 12’s electronic medical record (EMR), the EMR indicated there were written notes scanned into Patient 12’s medical record. MR was requested to provide copies of those notes dated from 7/6/2025 to 7/10/2025. MR stated the notes were written by two contracted staff members who provided continuous care for Patient 12, License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3). During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/6/2025 from 4 p.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document is a word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/6/2025 from 9 p.m. to 7/7/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/7/2025 from 9 a.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document is a word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/7/2025 from 9 p.m. to 7/8/2025 11 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/8/2025 from 9 p.m. to 7/9/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/9/2025 from 9 p.m. to 7/10/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/10/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/28/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a concurrent interview and record review on 8/28/2025 at 11:30 a.m. with the Administrator/Director of Patient Care Services (DPCS) of LVN3’s employee file, the DPCS stated LVN3’s employee file did not contain documentation that LVN3 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN3’s employee file did not contain documentation that LVN3 was educated/trained/evaluated on infection control or LVN3’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN3 in 2023 for an hour when she (DPCS) met him (LVN3), but did not document his (LVN3) training. The DPCS stated she (DPCS) has full responsibility for all the HAs patient care. The DPCS stated there should be records documenting LVN3’s skills and competencies to ensure he (LVN3) is eligible to continue their work.  During a concurrent interview and record review on 8/28/2025 at 11:45 a.m. with the DPCS of LVN2’s employee file, the DPCS stated LVN2’s employee file did not contain documentation that LVN2 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN2’s employee file did not contain documentation that LVN2 was educated/trained/evaluated on infection control or LVN2’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN2 over the phone after LVN2 provided care to Patient 12, but did not document her (LVN2) training. The DPCS stated she (DPCS) ensures LVN2 provides proper patient care by having LVN2 call her (DPCS) every two hours.   During a record review of the HA’s form titled “Written Agreement for Contracted Services” revised 10/2019, indicated “Hospice will maintain responsibility for the services provided under arrangement to ensure that they are provided in accordance with hospice standards…The organization will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care through performance improvement program and/or corporate compliance program. As part of the organization’s annual evaluation process, the Executive Director/Administrator with the assistance of other hospice personnel, will monitor, evaluate, and audit the contracted services to ensure that they are being provided according to the contract, Medicare Conditions of Participation…”  During a record review of the HA’s form titled “Personal Development” revised 10/2019, indicated “Employees and volunteers who have direct patient contact shall be provided or have provisions made for at least a quarterly in-service education program. An attendance record of all in-service/hospice personnel development program offered will be maintained by the Executive Director/Administrator… (HA) requires that each hospice personnel complete a minimum of the following programs each year… corporate compliance and standards of conduct.”

Based on interview and record review the Hospice Agency (HA) failed to ensure two of their contracted staffs competencies and skills were assessed before providing care to one of fourteen sample patients (Patient 12).  This failure had the potential to result in staff not having the right skills and capabilities to be able to take care of Patient 12. --- During a record review of Patient 12’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/21/2025 and an end of care date of 7/10/2025 with a terminal diagnosis of malignant neoplasm of vertebral column (spine cancer).  During a concurrent interview and record review on 8/27/2025 at 11:37 a.m., with the Medical Record/Quality Assurance (MR) of Patient 12’s electronic medical record (EMR), the EMR indicated there were written notes scanned into Patient 12’s medical record. MR was requested to provide copies of those notes dated from 7/6/2025 to 7/10/2025. MR stated the notes were written by two contracted staff members who provided continuous care for Patient 12, License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3). During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/6/2025 from 4 p.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document is a word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/6/2025 from 9 p.m. to 7/7/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/7/2025 from 9 a.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document is a word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/7/2025 from 9 p.m. to 7/8/2025 11 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/8/2025 from 9 p.m. to 7/9/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/9/2025 from 9 p.m. to 7/10/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/10/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a record review of HA’s contract with a staffing agency (SA) dated and signed on 4/28/2023 by the Administrator/Director of Patient Care Services (DPCS) and the SA representative, indicated the client duties and responsibilities included to provide appropriate information and training. The SA contract also indicated the HA was the client.   During a concurrent interview and record review on 8/28/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (DPCS) of LVN3’s employee file, the DPCS stated LVN3’s employee file did not contain documentation that LVN3 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN3’s employee file did not contain documentation that LVN3 was educated/trained/evaluated on infection control or LVN3’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN3 in 2023 for an hour when she (DPCS) met him (LVN3), but did not document his (LVN3) training. The DPCS stated she (DPCS) has full responsibility for all the HAs patient care. The DPCS stated there should be records documenting LVN3’s skills and competencies to ensure he (LVN3) is eligible to continue their work.  During a concurrent interview and record review on 8/28/2025 at 11:45 a.m., with the DPCS of LVN2’s employee file, the DPCS stated LVN2’s employee file did not contain documentation that LVN2 was oriented to the HA or the HAs philosophy. The DPCS also stated that LVN2’s employee file did not contain documentation that LVN2 was educated/trained/evaluated on infection control or LVN2’s skills and competencies. The DPCS stated she (DPCS) verbally oriented and instructed LVN2 over the phone after LVN2 provided care to Patient 12, but did not document her (LVN2) training. The DPCS stated she (DPCS) ensures LVN2 provides proper patient care by having LVN2 call her (DPCS) every two hours.   During a record review of the HA’s form titled “Written Agreement for Contracted Services” revised 10/2019, indicated “Hospice will maintain responsibility for the services provided under arrangement to ensure that they are provided in accordance with hospice standards…The organization will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care through performance improvement program and/or corporate compliance program. As part of the organization’s annual evaluation process, the Executive Director/Administrator with the assistance of other hospice personnel, will monitor, evaluate, and audit the contracted services to ensure that they are being provided according to the contract, Medicare Conditions of Participation…”  During a record review of the HA’s form titled “Personal Development” revised 10/2019, indicated “Employees and volunteers who have direct patient contact shall be provided or have provisions made for at least a quarterly in-service education program. An attendance record of all in-service/hospice personnel development program offered will be maintained by the Executive Director/Administrator...”

Based on interview, observation, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- 1. The HA failed to ensure any amendment, corrections or late entries within an electronic clinical record must clearly identify the original content, the modified content, date, and authorship of each record modification for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10). (Refer to L679).  2. The HA failed to ensure one of fourteen sample patients (Patient 12) continuous care notes were safeguarded. This failure had the potential to result in patients’ personal information being leaked or accessed by an unauthorized person. (Refer to L680).  The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview, observation, and record review the Hospice Agency (HA) failed to ensure any amendment, correction or late entries within an electronic clinical record must clearly identify the original content, the modified content, date, and authorship of each record modification for six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in inaccurate patient information or assessment will be entered in the patients’ clinical record that could affect the patient’s quality of care and well-being. --- During an interview on 8/27/2025, at 1:30 p.m., the Administrator/Director of Patient Care Services (DPCS), stated the agency documented patient care notes on the HAs Electronic Medical Record (EMR) system and on physical paper.   During a concurrent observation and interview of the Physician’s Certification of Terminal Illness records for Patients 1, 2, and 3, on 8/27/2025, at 1:33 p.m., with the DPCS, the following observation of the document were noted: the record was typed, the signatures were both typed and included a written signature. The DPCS stated the document was a template, and not part of the EMR. The template was in the Medical Records/Quality Assurance (MR) computer. The DPCS stated she and the MR typed the information, based on what the Medical Director (MD 1) told them. The document would then be printed, taken to MD 1, then MD 1 would review and sign it. Continued review of the records indicated MD 1 had attested/confirmed that he had composed the narrative.   During an interview on 8/27/2025, at 1:38 p.m., the DPCS stated the nursing visit notes were in the EMR, but the continuous care notes were typed. The DPCS stated for the continuous care notes, the nurses would type the notes on their own personal computer. The DPCS stated she did not know what computer software the nurses used to type their notes.   During an interview on 8/27/2025, at 1:00 p.m., the DPCS was asked how she tracked any changes made to the medical records that were not part of the EMR, but were typed using a template or other software, not included in the HA’s EMR. The DPCS stated the medical record was not printed until it was accurate, and no changes were made to the records. The DPCS stated the HA did not have a process in place to monitor changes made in the medical records that were not part of the EMR. The DPCS also stated the HA did not have a policy or procedure in place to indicate what is documented on the EMR, and what is not.   1.  During a record review of Patient 2’s document titled Patient Information, indicated a start of care 3/24/2025 with a terminal diagnosis of senile degeneration of the brain (brain and body functions do not work properly).  During a concurrent interview and record review on 8/28/2025, at 1:14 p.m., the MR reviewed Patient 2’s record titled, Task Details (a document that records the date, time, and name of person who made changes to the medical record), dated 7/26/2025. The record indicated the MR had added and changed (revision) nursing notes to the nursing visit document, dated 7/26/2025. These included entering vital signs and notes about the body assessment. When asked why the MR had entered and revised nursing notes, the MR stated that she had noticed the documentation was really late and was trying to help. The MR stated she called the nurse who visited the patient and asked her what she wanted the MR to document. The MR stated once she documented, the nurse reviewed the information and signed the document. When asked if it was okay for other people to document for the nurse, the MR stated other people could not document for nurses because the information was confidential.  2. During a record review of Patient 1’s medical record titled, Patient Information, indicated a start of care date of 8/9/2025 with a terminal diagnosis of Lare B-cell lymphoma (a type of cancer).  During a record review of Patient 1’s Task Details report, dated 8/12/2025, indicated the MR made revisions to the skilled nursing visit note of 8/12/2025, on 8/27/2025. During a review of Patient 1’s Task Details report, dated 8/19/2025, indicated the MR made revisions to the skilled nursing visit note of 8/19/2025, on 8/27/2025.  3. During a record review of Patient 3’s medical record titled, Patient Information, indicated a start of care date of 7/21/2025, with a terminal diagnosis of Alzheimer’s disease (progressive memory loss). During a record review of Patient 3’s Task Details report, dated 8/12/2025, indicated the MR made revisions to the skilled nursing visit note of 8/15/2025, on 8/15/2025. During a record review of Patient 3’s Task Details report, dated 8/19/2025, indicated the MR made revisions to the skilled nursing visit note of 8/19/2025, on 8/27/2025.  4. During a record review of Patient 8’s medical record form titled “Personal Information” undated, indicated a start of care date of 9/25/2024 with the terminal diagnosis of Alzheimer's Disease (progressive memory loss). During a record review of Patient 8’s medical record form titled “Physician’s Certification of Terminal Illness” dated from 7/22/2025 to 9/19/2025, indicated it was typed and had MD1 and the DPCS’s written signature. The form also indicated MD1’s signature specified he (MD1) attested/confirmed that he had composed the narrative.  5.  During a record review of Patient 9’s medical record form titled “Personal Information” undated, indicated a start of care date of 6/6/2025 with the terminal diagnosis of senile degeneration of brain (gradual loss of cognitive function).  During a record review of Patient 9’s medical record form titled “Physician’s Certification of Terminal Illness” dated from 6/6/2025 to 9/3/2025, indicated it was typed and had MD1 and the DPCS’s written signature. The form also indicated MD1’s signature specified he (MD1) attested/confirmed that he had composed the narrative.  6. During a record review of Patient 10’s medical record form titled “Personal Information” undated, indicated a start of care date of 1/29/2025 with the terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart arteries with plaque buildup) without angina pectoris (pain).  During a record review of Patient 10’s medical record form titled “Physician’s Certification of Terminal Illness” dated from 7/28/2025 to 9/25/2025, indicated it was typed and had MD1, MD2, and the DPCS’s written signature. The form also indicated MD1’s signature specified he (MD1) attested/confirmed that he had composed the narrative.  A record review of the HA’s document titled, Entries Into the Clinical Record, dated 10/2019, indicated, “Policy Hospice personnel providing direct patient care and supervisory have authority to make entries into the clinical record...14. Amendments, correction or late entries within an electronic health record must: A. Distinctly identify any amendment, correction or late entry B. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification.”

Based on interview and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 12) continuous care notes were safeguarded against unauthorized use. This failure had the potential to result in patients’ personal information being leaked or accessed by an unauthorized person. --- During an interview on 8/27/2025 at 1 p.m., with the Administrator/Director of Patient Care Services (DPCS) stated the HA did not have a policy or procedure in place to indicate what documents are documented on the Electronic Medical Record (EMR), and what is not.   During an interview on 8/27/2025 at 1:38 p.m., with the DPCS stated the nursing visit notes were in the EMR, but the continuous care ( is an intense, short term level of care provided when a terminally ill patients experience acute symptoms that can't be managed by their primary caregiver) notes were typed. The DPCS stated for the continuous care notes, the nurses would type the notes on their own personal computer. The DPCS stated she did not know what computer software the nurses used to type the continuous care notes. When asked how the DPCS ensured the patient information in the nurses’ personal computer was secured, the DPCS stated: What I tell them is to type the notes, print them, then delete their notes from the computer. I respect them, if they tell me they deleted them, I believe them. They are nurses, they have their own license. They are responsible for PHI (protected information). I don’t know if the nurses computer has anti-virus, anti-hacking software installed. I don’t know if their computer requires a password to open it. Yes, the nurses will email the notes to our business email. I don’t know if the email server is protected against hacking.  1. During a record review of Patient 12’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/21/2025 and an end of care date of 7/10/2025 with a terminal diagnosis of malignant neoplasm of vertebral column (spine cancer).  During a concurrent interview and record review on 8/27/2025 at 11:37 a.m., with the Medical Record/Quality Assurance (MR) of Patient 12’s electronic medical record (EMR), the EMR indicated there were written notes scanned into Patient 12’s medical record. MR was requested to provide copies of those notes dated from 7/6/2025 to 7/10/2025. MR stated the notes were written by two contracted staff members who provided continuous care for Patient 12, License Vocational Nurse 2 (LVN2) and License Vocational Nurse 3 (LVN3). During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/6/2025 from 4 p.m., to 9 p.m., indicated LVN2 wrote and signed the document. The document was in word document Word document (program that allows users to create, edit, format,and print documents) and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/6/2025 from 9 p.m., to 7/7/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Continuous Care Documentation” dated 7/7/2025 from 9 a.m. to 9 p.m., indicated LVN2 wrote and signed the document. The document was in Word document and was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/7/2025 from 9 p.m. to 7/8/2025 11 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/8/2025 from 9 p.m. to 7/9/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a record review of Patient 12’s medical record form titled “Documentation” dated from 7/9/2025 from 9 p.m. to 7/10/2025 9 a.m., indicated LVN3 hand wrote and signed the document. The document was scanned into Patient 12’s EMR.  During a concurrent interview and record review on 8/28/2025 at 11:30 a.m., with the Administrator/Director of Patient Care Services (DPCS) of LVN2 and LVN3’s employee files, the DPCS stated LVN2 and LVN3’s employee files did not contain documentation that they (LVN2 and LVN3) were oriented to the HA or the HAs philosophy. The DPCS stated she (DPCS) has full responsibility for all the HAs patient care.  During a concurrent interview and record review on 8/27/2025 at 1:43 p.m., with the DPCS of Patient 12’s EMR and physical medical record, the DPCS stated LVN2 and LVN3 type their notes on their personal computers. The DPCS stated that she (DPCS) instructed LVN2 and LVN3 to delete Patient 12’s continuous care notes after they print the notes. The DPCS stated she (DPCS) did not know if LVN2 or LVN3 deleted the notes, because she (DPCS) was not there. The DPCS stated that she respected LVN2 and LVN3 when both informed her that the notes had been deleted because she believed them (LVN2 and LVN3).  During a record review of the agency’s form titled “Computer Access to Information” revised 10/2019, indicated “Information accessible via remote terminals will be filtered through these passwords and security checks, creating an audit trail to identify individual users when necessary.”

Observed in HR File Review. In 6 of 10 HR files reviewed, the organization failed to train staff on emergency management per policy. During HR file review, the Hospice Nurse Surveyor observed HR#5-HR#10 did not have annual emergency preparedness education documented for 2021, 2022, and 2023 per organizational policy. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 3 of 16 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for RRNHV#1, RRDC#1, and RRDC#2, the hospice nurse surveyor observed the inaccurate or contradictory documentation. For example in RRNHV#1, the wound was documented with a date of 10.28.23 which is 3 weeks ahead of the current survey date. In both RRDC#1 and RRDC#2, the patients were discharged for extended prognosis but the most recent F2f and nursing documentation suggested continued decline and continued hospice appropriateness. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 11 of 16 patient records reviewed, the organization failed to plan the patients care. During record review for RRBR#1, RRHV#1, RRHV#2, RRHV#3, RRDC#1, RRDC#2, RRNHV#1, RRNHV#2, RRNHV#5, RRNHV#6, and RRNHV#7, the Hospice Nurse Surveyor observed the documentation did not include all services, frequencies or measurable outcomes needed to meet the patients needs. For example in RRBR#1 the patient was declining per the nurses notes and this was not added to the POC. In RRHV#1, RRHV#2, RRHV#3, RRDC#1, and RRNHV#7 the patient's all had active wounds and the wound goals and interventions on the POC were resolved. In RRDC#1, RRDC#2, and RRNHV#1 the patients were discharged but the POC did not reflect discharge planning. In RRDC#2, the patient had continued pain but this was resolved on the POC. In RRNHV#2, the patient had anxiety and was placed on continuous care per the nursing notes but this was not reflected on the POC. In RRNHV#5, the patient had a problem listed as knowledge deficit related to infection control with a goal timeframe of 1 cert period but the goal was placed on the POC almost a year earlier with no updates. In RRNHV#6, the patient had a problem of poor oral intake with a goal timeframe of 1 cert period and it was never updated. This was discussed and reviewed with the Administrator. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 16 of 16 patient records reviewed, the organization failed to document involvement of the patient/ CG in the development and implementation of the POC. During record review of all records, the hospice nurse surveyor observed no documentation in the IDG notes or the clinical visit notes that the pt/ CG were informed and included in the POC. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 4 of 16 patient records reviewed, the organization failed to plan the patient's care. During record review for RRBR#1, RRBR#2, RRBR#3, and RRBR#4 the Hospice Nurse Surveyor observed the organization failed to document a bereavement care plan that was specific and individualized. All patients reviewed had a low risk score and the 4 bereavement charts had identical care plans and interventions. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 5 of 16 patient records reviewed, the organization failed to assess its patients. During record review for RRHV#3, RRHV#1, RRNHV#7, and RRNHV#1, the organization failed to complete a spiritual care assessment, as required. Upon record review there was no SC staff involved in the patient episode and there was no documentation that the Spiritual Care Counselor was refused or that the assessment was completed by someone other than the Spiritual Care Counselor. Also in RRNHV#4, the organization failed to complete a risk assessment post death in order to inform the IDT of family needs. This was discussed and reviewed with the Administrator.

Observed in Record Review. The organization failed to document its efforts to recruit and retain volunteers. During tracer activities for Volunteer Services, the Hospice Nurse Surveyor observed the organization had no documentation of recruitment or retention efforts for 4 years. This was discussed and reviewed with the Administrator.

Observed in HR File Review. In 10 of 10 HR files reviewed, the organization failed to document ongoing education and training. During HR file review, the Hospice Nurse Surveyor observed for all HR files no documentation of OSHA required Infection Control and Blood Borne Pathogens training. And per organizational policy there was no documentation of the required annual education related to Environmental Safety or Body Mechanics. The organizational policy states all hospice personnel would complete a minimum of these courses. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, During HV#1 record review from the September 2022 certification to current certification in March 2023, it was noted the POC lacked interventions and goals established by the MSW. Interventions and goals for the Chaplain were not added to the POC until December 2022. Their visit frequencies were 1x/month.

Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN after disinfecting the equipment used during the visit, placed the clean equipment on the barrier used to place the equipment after patient use. The equipment used was BP cuff, stethoscope, pulse oximetry device, and a digital thermometer. This was discussed with the Administrator. Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN did not perform hand hygiene between glove changes during a wound care procedure. This was discussed with the Administrator.