Every finding on record at Anchored by Grace Hospice Care, Inc.

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 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the registered nurse provided coordination of care to ensure continuous care and ensure the implementation of the interdisciplinary plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/16/2024. Documentation revealed the plan of care did not match the order from the wound consultant company. The hospice plan of care dated 06/14/2025 to 08/12/2025 stated the patient had a pressure injury to the left heel, left sacrum, and right medial tibial and was managed by the wound consultants three times a week. The plan of care from the wound consultant stated ""Dressing to sacrum left buttock to be changed 2x daily by caregivers if dressing becomes dislodged or soiled. Dressings to be changed 4 x weekly. Dressing to be changed on Thursdays by [*] Hospice. Dressings to be changed Wednesday and Friday by wound consultant RN with ultrasound wound mist therapy." The wounds were described as pressure injuries on the hospice plan of care but described as a stage 3 to left heel, left sacrum, and right medial tibia on the wound consultant plan of care. During an interview with the administrator (personnel record #4) on 07/02/2025 she stated that the wound consultants were responsible for the wound care and had just not updated the care plan with the new orders.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by interview and observation. In 1 of 3 (33% home visit observations revealed that the agency did not ensure that standard precautions were followed during hand hygiene. Document 1: The agency policy titled Hand Hygiene (IC.15, last reviewed 090124) stated in relevant parts, "With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet." Home Visit 1: During the home visit with the registered nurse (PRR #1) it was observed that the registered nurse used her clean hands to turn off the water and dried her hands with the patient's towel. During an interview with the administrator (personnel record 4) on 07/03/2025, she stated that the nurse was nervous, but they will do additional education on hand washing with all clinical staff.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed of patients who elected spiritual counseling services revealed that the agency did not ensure that the spiritual needs of the patient were addressed in a manner consistent with the patient's and family's beliefs and desires. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/07/2024. During the benefit period from 08/05/2024 to 11/02/2024, there was an order dated 09/04/2024 for a chaplain to visit 1 x monthly and prn for spiritual support and emotional support. There was no evidence of a spiritual care visit during the month of September. There was one missed visit that was documented on 10/10/2024. During an interview with the administrator on 07/03/2025, she stated that she did not know what happened or how the spiritual care visit for September was missed.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 6 of 8 (75%) personnel record review revealed that the agency did not ensure that the hospice assessed the skills and competencies of all individuals providing care. Personnel Record 1: The registered nurse hired on 10/22/2024, lacked evidence of a competency assessment that evaluated the nurse's skills in providing care. The personnel record had a self-study that was signed; however, the form was not filled out. Personnel Record 4: The chaplain hired on 10/01/2023, lacked evidence of a competency assessment that evaluated the chaplain's skills in providing care. The personnel record had a self-study that was signed; however, the form was not filled out. Personnel Record 5: The registered nurse/Director of Nurses hired on 10/01/2023, lacked evidence of a competency assessment that evaluated the nurse's skills in providing care. The personnel record had a self-study that was signed; however, the form was not filled out. Personnel Record 6: The Hospice Medical Director hired on 11/23/2023, lacked evidence of a competency assessment that evaluated the physician's skills in providing care. The personnel record had a self-study that was signed; however, the form was not filled out. Personnel Record 8: The LVN hired on 03/24/2025, lacked evidence of a competency assessment that evaluated the nurse's skills in providing care. The personnel record had a self-study that was signed; however, the form was not filled out. During an interview with the administrator (personnel record #4) on 07/02/2025 she stated that they will be doing some education regarding competencies and how to complete them.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that physician orders were included in the patient's clinical record. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/14/2025. The initial nursing assessment stated that the patient had a G-tube and was using Jevity 240 ml every six hours. The clinical record lacked evidence that physician orders for G tube maintenance and Jevity were included in the patient's clinical record. In an interview with the administrator on 07/02/2025, the administrator confirmed that the plan of care did not address the G-tube, but the clinical staff would be receiving additional education.

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 a review of clinical records and interviews. 3 of 5 (60%) records reviewed of patients who had accepted psychosocial services revealed the agency failed to ensure that the psychosocial assessment component of the initial comprehensive assessment, had been completed within 5 days of the hospice care election statement. Record #1 was reviewed and identified the patient elected hospice care on 5/9/2022. A review of the record revealed there was no evidence that the Medical Social Worker (MSW) completed the psychosocial assessment component of the initial comprehensive assessment within 5 days of the hospice care election statement. Record #0 was reviewed and identified the patient elected hospice care on 5/4/2022. A review of the record revealed the MSW completed the psychosocial assessment component of the initial comprehensive assessment on 6/4/22,31 days outstanding due to a “scheduling conflict” by the MSW. Record #4 was reviewed and identified the patient elected hospice care on 5/5/2022. A review of the record revealed the MSW completed the psychosocial assessment component of the initial comprehensive assessment on 6/4/22, 30 days outstanding due to a “scheduling conflict” by the MSW. In an interview with the Administrator and Alternate Director of Nurses on 8/31/2022, they stated that the psychosocial assessment had not been completed timely by the MSW.