Every finding on record at Aquarius Hospice

Based on record review, observation, and staff interviews, it was determined that the hospice failed to maintain personnel records. This deficient practice has the potential that hospice staff are not qualified to provide services to patients, and the patient caregivers posing a risk for negative patient outcomes. --- Findings include:A review of Aquarius Hospice Policy 4.13.1, titled "Personnel Records", revealed:"...POLICY Personnel files will be established and maintained for all staff. All information will be considered confidential and will be made available to authorized management personnel only. PURPOSE To maintain personnel files on current and former employees...PROCEDURE... 4. Personnel records are confidential and will be released only to authorized management for review. Release of personnel information on current and terminated employees without written authorization from the employee will be limited to verification of date of hire, date of termination and job title... 5. Only designated Administrator, Director of Human Resources staff and Managers may access personnel files. 6.  Personnel files will be stored in metal file cabinets in designated Human Resources office. 7. Employees may review their personnel records only in the presence of Administrative staff...."A review of Aquarius Hospice Policy 6.1.1, titled "Information Management Plan", revealed:"... Policy The information management plan serves patients and family members, physicians and their office staff, hospitals, Hospice staff...PROCEDURE...1. Hospice has specific needs related to information management, including availability, timeliness and accuracy. Both within Hospice and externally, mechanisms are continually assessed to ensure optimization... 7. Security and confidentiality of information: Type of Information... Level of Security...Access... Hospice personnel information...High...Director Administrator Individual Hospice Staff...20... administrative information are maintained onsite at Hospice...."A review of Aquarius Hospice Policy 6.5.1, titled "Information Confidentiality, Security, and Data Integrity", revealed:"... 7. Hospice will monitor staff compliance with confidentiality, privacy and security...."A review of Aquarius Hospice Policy 7.1.1, titled "Governing Body", revealed:"... POLICY The Governing Body assumes full legal authority and responsibility fir the management of Hospice...RESPONSIBILITIES...13. Additional activities to the Governing Body include: Decision making...Human resources management...Overall management and operations...."A review of Aquarius Hospice Policy 7.2.1, titled "Leaders and Governing Body Orientation", revealed:"... PROCEDURE... Confidentiality practices and signing a confidentiality agreement(ACHC only)...."A review of Aquarius Policy 7.33.1, titled "Compliance Program", revealed:"...POLICY Managers and staff recognize that Hospice faces a variety of short- and long-term operational and business issues that require attention on a daily basis. Such issues include: Dealing with staff... PROCEDURE... 3. Hospice recognizes that losses may result from four exposures (or sources of loss): Statutory and regulatory exposures: penalties, fines sanctions and/or other governmental penalties that could impose on Hospice for knowingly or unknowingly failing to comply with federal/state/local applicable rules and regulations... rules and regulations typically prohibit and/or mandate certain activities, methods of operation or address issues as billing, information, reporting and licensing... 8. The Compliance Program is designed:...To avoid and detect misbehavior that might occur within the system...COMPLIANCE OFFICER(CO) 1. The Governing Body has designated the Administrator as the Compliance Officer(CO). The CO assumes responsibility for the design, implementation, and daily oversight of the Compliance Program... 3. The CO will oversee and participate in defined compliance audits to gain knowledge about: Existing standards and procedures...Day-to-day operations...Most important applicable legal duties...Staff orientation, education and training programs...4. Hospice employees will report improper practices directly to the CO through the Confidential Disclosure Program. The CO will investigate all such reports, interview appropriate employees to ensure practices are evaluated, ensure consistency in the application of policies and procedures and implement appropriate corrective actions...INFORMATION ACCURACY AND TRUTHFULNESS POLICY...2. Hospice requires each employee to engage in employment process in good faith...7. Each employee has the responsibility to notify the CO, in a timely manner, of any violations or suspected violations of standards for ethics, legal conduct, falsification of information or violations of federal and state laws and regulations...CONFIDENTIALITY DISCLOSURE PROGRAM...3. Improper practices may include (but are not limited to):...Noncompliance with applicable federal and state laws and regulations (e.g., Medicare, Medicaid, state licensure laws)...Violations of standards of ethics or legal conduct...."A review of Aquarius Hospice Policy 7.24.1, titled "Code of Ethics", revealed:"... PURPOSE To define the ethical principles and written guidelines for ethical conduct of Hospice and its employees...Guidelines are related to:... Staff rights...."A review of the document titled" Employee List" revealed 41 employees. Three(3) are the names of the surveyors.Upon observation by the compliance officer, Employee #1 and Employee #2 walked in Employee #1's office, where the locked black cabinet is kept that is used to house personnel files. The compliance officer went through the list provided. Employee #1 and Employee #2  went through all personnel files to ensure that all personnel files were present and accounted for. Employee #1 and #2 went through all files while the compliance observed all stacks of employee files, including current and personnel no longer with the hospice. There were a total of three(3) employee files that could not be accounted. Neither Employee #1 nor #2 could verify where those personnel files were.A review of the submitted plan of corrections revealed a document titled, "STAFF LIST", the name of Employee #4, was not present on the list. Employee #1, presented a manufactured "personnel file" for Employee #4, which contained prefilled signature lines with Employee #4's name, with the wet signature missing on all documents. Employee #1, confirmed he/she printed the forms off and the documents contained in the manufactured personnel file are what "...should be in the personnel file [name readacted] took... unsure of when it went missing...."In an interview conducted on April 30th, 2025, Employee #1 stated, "...the missing personnel file was taken by the employee when the administration was at lunch or sometime I am not sure of...." Employee #1 confirmed that it is the policy to keep personnel files locked in the black cabinet that was observed to be unlocked at the time of the interview. He/she confirmed that three(3) missing personnel files could not be located anywhere in the office. He/she stated Employee #4 was deactivated in the EMR system on April 24, 2025. It was confirmed that anyone with administrative access can manually change the date at anytime and backdate a deactivation of access. Upon review of Patient #1's medical record, Employee #4 made an entry into the medical record on April 24, 2025.A request was made to interview the human resources manager on April 30, 2025. Per Employee #1, he/she was on vacation.In an interview conducted on April 30, 2025, with Employee #2, he/she confirmed the absence of the three(3) personnel files, and they could not be located anywhere in the office.In an interview conducted on April 30, 2025, with Employee #3, he/she stated that the unknown employee(#4) had also been making changes to the administrative forms and in the HR drive. In an additional interview with Employee #3, after he/she had been redirected by Employee #2, Employee #3 stated the unidentified person had only been making changes to administrative forms.

Based on interview, review of policy and procedure and review of facility documents, the Department has determined the Administrator failed to ensure that each hazard identified as a high risk in the facility risk assessment was addressed in the facility emergency plan. Failure to address high-risk scenarios can result in the facility being unprepared for emergency events, resulting in injury or death of patients and staff. --- Facility policy titled, "...Emergency Operations Plan and Policies...." reviewed 6/1/2024 revealed: "...The plan...includes strategies for addressing emergency events identified by the risk assessment...." "...Aquarius Hazard Vulnerability Analysis...." undated document revealed: "...Type of Emergency...Thunderstorm...Electrical Utility Failure...Hazardous Material Internal Exposure...Hazardous Material External Exposure...Bomb Threat...Hostage Situation...Workplace Violence...Explosion...Biological Terrorism...Nuclear Terrorism...Trauma...Medical or Infectious Mass Casualty...Multiple Staff Illness...Flood: Internal...Flood: External...Fire: Internal...Fire: External...Building Damage....Human Impact...High...." "...Aquarius Hospice Emergency Preparedness Plan...." most recently updated 12/15/2023 revealed no content or plans related to the hazards identified on the HVA (hazard vulnerability analysis). An interview was conducted with Employee #1 on July 10, 2024. Employee #1 confirmed that interventions relevant to Aquarius Hospice staff and patients related to the hazards identified on the HVA were not included on the current Emergency Preparedness Plan.

Based on interview, review of policy and procedure, review of patient medical records and review of facility documents, the Department has determined the Administrator failed to ensure that the hospice had procedures or systems in place to inform incident command or the AHJ (authority having jurisdiction) about patients in need of evacuation from residencies and any issues that they may have related to disability, psychiatric conditions or other impairment that may hinder evacuation efforts. Failure to develop a procedure or system to inform authorities of the needs of vulnerable patients requiring evacuation can hinder the efforts of authorities to assist patients requiring evacuation, resulting in injury to patients or death. Findings include: --- Facility policy titled, "...Emergency Operations Plan and Policies...." reviewed June 1, 2024 revealed: "...Mitigation activities...will be undertaken. Such activities include...Individual plans for each patient must be included as part of the comprehensive patient assessment...At the time of admission, each patient's acuity or priority level is determined....." A review of patient medical records revealed that the "...Emergency Disaster Plan/Evacuation Plan-Patient...." assessment was blank in 16 out of 16 patients reviewed. In a subsequent interview with Employee #1 conducted on 7/10/2024, Employee #1 confirmed the Emergency Disaster Plans were supposed to be completed at the time of admission with the patient.

Based on interview, review of facility records and review of facility policies and procedures, the Department has determined the Administrator failed to ensure that Emergency Preparedness training was provided at least every 2 (two) years that demonstrated staff knowledge of emergency preparedness procedures by including documentation of the specific training completed as well as the method used for demonstrating knowledge for the facility Emergency Preparedness program. Failure to adequately ensure and to document staff knowledge of a facility's emergency preparedness program can result in staff being unprepared in the event of emergencies, leading to staff and patient harm, as well as liability to the facility. Findings include: --- Facility policy, "...Emergency Operations Training Program reviewed June 1, 2024 revealed: "...Hospice will do the following...Provide emergency preparedness training at least biennially...Ideally, biennially training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies that occurred in the last year and during the biennial review of the Hospices emergency program....Maintain documentation of the training...Demonstrate staff knowledge of emergency procedures....." Aquarius Hospice "...Emergency Preparedness Training Disaster/Emergency Preparedness Summary...." dated December 15, 2023 consisted of a one-page document with a staff signature page attached. The document summarized the content of a staff meeting in which emergency preparedness was discussed. The document indicated no discussion or incorporation of real-life emergencies or of exercises conducted over the previous year. The document failed to demonstrate the staff's knowledge of emergency procedures. In an interview conducted with Employee #1 on July 10, 2024, Employee #1 verified that the one-page Emergency Preparedness Training Disaster/Emergency Preparedness Summary was the only training material that could be provided. Curriculum for Emergency Preparedness training for staff was requested but could not be provided. Employee #1 stated that training was provided through discussion and no further documentation could be provided.

Based on interview, review of facility policies and procedures and review of facility documents, the Department has determined the facility failed to conduct exercises to test the facility's emergency preparedness plan annually. Failure to test the facility's emergency preparedness plan can result in a facility not being prepared in the event of an actual emergency event, resulting in preventable harm or fatality to patients or staff. Findings include: --- Facility policy titled, "...Testing Program for Emergency Operations Plan (EOP)...." approved June 1, 2024 revealed: "...Hospice will conduct exercises to test the EOP at least biennially. Hospice will do the following...Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise...Conduct an additional exercise that may include, but is not limited to...A second full-scale exercise that is community-based or individual, facility-based...A tabletop exercise that includes a group discussion led by a facilitator...Exercises must sufficiently stress Hospices plan to identify weaknesses...Exercises must activate and test...Patient acuity assignment and tracking procedures to validate the ability to...identify and locate high risk patients...Key care processes consistent with planned response activities: management of medications, medical equipment and supplies, instructions for self-evacuation, medical record documentation and coordination of information with alternative care site. Analyze Hospices response to and maintain documentation of all drills, tabletop exercises and emergency events...." A review of Aquarius Hospice Emergency Preparedness training and testing records revealed no documentation of any full-scale exercises, no documentation of tabletop drills, and no documentation of any critiques following activation of the facility EOP following a real-life emergency. A request was made for documentation of exercises testing the EOP but they could not be provided. In an interview conducted with Employee #1 on July 10, 2024, Employee #1 stated he believed the fire drills completed by the staff in the office would be sufficient testing of the EOP. Employee #1 confirmed no full-scale or tabletop exercises had been completed testing the Emergency Operations Plan in accordance with facility policies and procedures.

Based on interview, review of facility policies and procedures and review of medical records, the Department has determined the hospice failed to ensure that copy of advanced directives for patients are in obtained and maintained in patient records. 16/16 patients acknowledged that have have advanced directives and have provide a copy to the hospice agency on the signed Hospital Election and consent form. Upon review of the medical records of 16 (sixteen) out of 16 (sixteen) patients, advance directives were not uploaded. Failure to not obtain patient advance directives can result in a patient's needs not being adequately addressed by the hospice, leading to poor patient outcomes. Findings include: --- Findings include: Record review and staff interview revealed; "...Patient Admission Criteria...." revealed "...During the initial assessment, the RN will:... Explain and provide a copy of the Patients Bill of Rights/Responsibilities and advance directives. If patient has an advance directive, a copy will be obtained or the patients wishes will be documented. Patient #1 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #2 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #3 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #4 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #5 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #6 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #7 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #8 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #9 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #10 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #11 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #12 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #13 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #14 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #15 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. Patient #16 Hospice Election and Informed consent marked as. "I have executed an advance directive and provided a copy to the hospice agency. Advance directive not found in patient chart. In interview with Employee #1 confirmed that staff have misidentified "DNR (Do Not Resuscitate)" forms with advanced directives.

Based on interview, review of facility policies and procedures and review of medical records, the Department has determined the Administrator failed to ensure that patients were able to receive effective pain management and symptom control for 3 out of 16 patients reviewed, Patient #3, #4, #15. Failure to ensure that pain and other symptoms related to terminal illness are controlled lead to unnecessary suffering for patients and substandard outcomes. Findings include: --- Patient #3 Start of Care: September 15, 2023 End of Care: December 13, 2023 "...LVN Visit Note...." dated 9/20/2023 revealed: "...Last week he complained of nausea and vomiting for two days and was not feeling well. I asked him to go to the nearest Urgent Care or to the nearest ER but he refused...." Patient #4 Start of Care: March 25, 2024 "...Visit note LVN (licensed vocational nurse)...." dated 4/17/2024 revealed: "...c/o (complaint of) pain to bilat knees and back. Rates 5 of 10....r/t the importance of taking pain meds prn for pain...." "...Visit note LVN...." dated 5/1/2024 revealed: "...c/o pain to dorsal left eye and lower back. Nurse teaching done r/t pain control meds. Patient also encouraged to go to hospital for left eye dorsal pain. Patient refused...." "...Visit note LVN...." dated 5/8/2024 revealed: "...c/o pain to dorsal left eye pressure and lower back...Nurse suggested that patient to er (emergency room). Patient refused...Patient encouraged to take pain meds prn for pain...." "...Visit note LVN...." dated 5/22/2024 revealed: "...Patient conts (continues) to c/o pain in left dorsal eye. Patient refuses to go to hospital or urgent care....." "...Aquarius Hospice Physician Orders..." for Patient #4 revealed no medications and no history of any medications prescribed to Patient #4 for the purpose of pain management. The only medication prescribed that could be identified was: "...Aspirin...81mg...2 tabs by mouth...inflammation...." Patient #15 Start of Care: December 12, 2023 End of Care: April 16, 2024 "...Communication Log...." dated 2/28/2024 at 12:47 AM revealed: "...Received a call from a caregiver over upping the pain medication dosage...since...in alot more pain now. The caregiver claimed he talked to an RN about the situation. Ann is communicating with the carehome about the situation...." "...Communication Log...." dated 2/28/2024 at 11:57AM revealed "...Spoke with PCG Dan and instructed to give tylenol 650 mg instead of just 325mg. MD aware and order changed .... "Honor Health Emergency Department Note....dated 3/31/2024 at 2307 revealed"... Chief Complaint:... PT presents via EMS from group home. Per EMS, daughter called because she feels like pt is not receiving enough pain medication. Pt is on hospice. hx of dementia...." "Honor Health Emergency Department Note....dated 3/31/2024 at 2307 assessment note revealed"...Social determinants of health considered that impacted clinical care: lack of access to timely care from specialty service...." Honor Health Emergency Department Note....dated 3/31/2024 at 2307 Medications Prescribed this visit revealed"... HYDROcodone-acetaminophen 5-325 mg per tablet, Take 1 tablet by mouth every 6 hours as needed for pain up to 15 days.... Review of patient medication records revealed pain medication ordered at time of ER visit was not continued upon return to group home.

Based on interview, review of facility policies and procedures and review of patient medical records, the Department has determined the Administrator failed to ensure that all members of the IDG (interdisciplinary group) were involved in the completion of the comprehensive assessment for 16 (sixteen) out of 16 (sixteen) patients reviewed. Failure to involve all members of the IDG in the completion of the comprehensive assessment can result in a patient's comprehensive needs not being adequately assessed and fully addressed by the hospice, leading to poor patient outcomes. Findings include: --- A facility policy was requested but not provided. 16 patient comprehensive assessments were reviewed. A qualified MSW was not involved in the completion of the comprehensive assessment for any of the reviewed patients. A qualified Spiritual Counselor was not involved in the completion of the comprehensive assessment for any of the reviewed patients. In an interview conducted on July 12, 2024, Employee #1 confirmed that comprehensive assessments should be completed according to facility policies and procedures.

Based on interview, review of facility policy and procedure and interview, the Department has determined the Administrator failed to ensure that the hospice Interdisciplinary Group or IDG included a social worker, marriage and family therapist, or a mental health counselor as well as a pastoral counselor for 15 (fifteen) out of 16 (sixteen) patients reviewed, Patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, & 16. Failure to ensure the IDG includes a social worker or other mental health counselor as well as a pastoral counselor within the IDG can result in a patient's psychosocial and spiritual needs being neglected, resulting in poor outcomes for the patient. Findings include: --- Patient #1 Start of Care: December 17, 2023 End of Care: April 16, 2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14. Patient #2 Start of Care: November 8, 2023 End of Care: January 23, 2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14. Patient #3 Start of Care: March 25, 2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14. Patient #5 Start of Care: 10/20/2021 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14. Patient #6 Start of Care: 06/06/2024 A review of the IDG notes revealed participation signature from Employee #14. Patient #7 Start of Care: 09/15/2023 End of Care: 12/13/2023 A review of the IDG notes revealed participation signatures from Employee#2 and Employee #14. Patient #8 Start of Care: 06/20/2023 A review of the IDG notes revealed participation signatures from Employee#2 and Employee #14. Patient #9 Start of Care: 07/07/2023 A review of the IDG notes revealed participation signatures from Employee#2 and Employee #14. Patient #10 Start of Care: 05/05/2023 Patient #11 Start of care: 07/14/2023 A review of the IDG notes revealed participation signatures from Employee#2 and Employee #14. Patient #12 Start of Care: 04/01/2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14 Patient #13 Start of Care: 03/21/2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14 Patient #14 Start of Care: 12/20/2022 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14 Patient #15 Start of Care:12/17/2023 End of Care: 4/16/2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14 Patient #16 Start of Care: 11/18/2023 End of Care: 01/23/2024 A review of the IDG notes revealed participation signatures from Employee #2 and Employee #14

Based on interview, review of facility policy and procedure and review of facility documents, the Department has determined the Administrator failed to track quality indicators including adverse events as defined in hospice policy. Failure to track adverse events and demonstrate ability to improve performance can result in substandard patient care due to lack of awareness of adverse trends affecting the care of patients. Findings include: --- Facility policy titled, "...Adverse Event Policy...." reviewed June 1, 2024 revealed: "...Hospice will investigate any incident or injury in which home medical equipment,prosthetics, orthotics or supplies (DMEPOS) provided by Hospice may have contributed to the injury or incident, staff administered medication errors, falls with patient injury requiring medical intervention and drug diversion of Hospice-provided medications. Any action or inaction by Hospice that caused harm to a Hospice patient will also be investigated....When adverse event monitoring reveals a problem area, Hospice will implement changes designed to decrease occurrence of the adverse event. Hospice will assure that the new process is implemented hospice-wide...." Facility policy titled, "...Quarterly Record Review Process...." reviewed June 1, 2024 revealed: "...Hospice will collect data quarterly on quality indicators...." "...Client Adverse Event/Incident/Occurrence Log...." revealed: "...July 2022...No incident or occurrence...July 2023...No incident or occurrence...." "...Incident Report...1/1/2023 to 12/31/2023...." revealed: "...6...Minor injury...8...Minor injury...12...Minor injury...15...Minor injury...17...Minor injury...18...Minor injury...21...Hospitalization required...23...Minor injury...24...Minor injury...." The Hospitalization Required injury was logged on 4/4/2023. In an interview conducted with Employee #1 on July 11, 2024, Employee #1 confirmed that adverse events data had not been collected in accordance with facility policies and procedures.

Based on interview, review of facility policies and procedures and facility documents, the Department has determined the Administrator failed to collect and evaluate data related to the provision of physician services, nursing services, medical social services, counseling services, clinical records, infection control, pharmaceutical services, durable medical equipment (DME), patient rights, administrative services, contract services, volunteers, hospice aides, adverse events or other measures. Failure to regularly monitor and evaluate quality metrics can result in a failure to identify adverse trends that negatively impact patient care. Findings include: --- Facility policy titled, "...Quality Assessment and Performance Improvement (QAPI) Plan...." approved June 1, 2024 revealed: "...Sources of information from which data may be collected include (but arenot limited to)...Home visits...Patient medical records...Patient/caregiver interviews...Staff interviews...Contracted services...Incident reports...Medication profiles...On-call logs...Supervisory visit observation...Peer review...Patient perception of care surveys...Recommendations from federal, state and accreditation surveys and other regulatory agencies...Comprehensive assessment...Hospice will consider data collection about the following activities:..Staff opinions and needs...Staff perceptions of risks to individuals and suggestions for improving patient safety...Staff willingness to report unanticipated adverse events...Conditions in the patient and organization environment...Hospice will collect patient outcome measures.Hospice will also collect data about...Equipment used in providing care...Quarterly clinical record review...Infection surveillance, identification, prevention, control and investigation of infectious and communicable diseases... Annual aggregation data re: PPD's...Priorities identified by leaders...Incident reporting...Review of Emergency Operations Plan, if implemented or through an exercise (two times per year)....Policies and Procedures Manual for Aquarius Hospice and Palliative Care 10.1.7...Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey....Annual program evaluation....Medication errors....Adverse drug reactions...Internal and external complaints, including patient complaints/grievances...Effectiveness of pain management...Risk management activities and outcomes...Patient falls requiring medical interventions or witnessed by staff...Drug diversions of Hospice-provided medications (pharmaceutical services)...Physician services...Nursing services...Medical social services...Counseling services...Patient rights...Administrative services...Contract services...Volunteers....Hospice Aides...Durable medical equipment....." A review of Aquarius Hospice Performance Improvement Monitoring Logs revealed: "...Performance Improvement Monitoring...." was most recently completed December 27, 2020. This appeared to be a patient medical record audit. No patient data was entered that would allow for the medical records audited to be identified or the number of records audited to be quantified. "...Agency Performance Evaluation...." was most recently completed December 20, 2023. The document revealed: "...Activity...Management...Acceptable Findings...Almost Up to Date...Unacceptable Findings...None...Recommendation...Develop a system...Intake....Acceptable Findings...Almost Up to Date...Unacceptable Findings...None...Recommendation...Always Triple Check...Field Staff...Acceptable Findings...Almost Up to Date...Unacceptable Findings...None...Recommendation...More Communication...QA....Acceptable Findings...Almost Up to Date...Unacceptable Findings...None...Recommendation...Completion...." "...Agency Annual Evaluation Tool...." was most recently completed December 20, 2023. The document revealed: "...There are statistics which identify # of reasons for discharge...All reasons are identified in our EMR...All needs of the patient are being reviewed accordingly...All patients needs are being indicated on all aspects...All patients are being assessed and documented...." "...Employee Infection Control Log...." was completed July 2023 and revealed: "...There were no employee reported [sic]...." "...Complaint Log...." completed July 2023 revealed: "...No complaints...." Patient infections log completed July 2023 revealed: "...No infections reported...." "...On-Call Log"..." completed July 2023 revealed: "...pls see on-call log--no emergencies...." "...Hospice Aide/MSW Log...." was completed but undated. "...Employee Inservice Log...." completed 2023 revealed: "....pls see inservice binder...." In an interview conducted with Employee #1 on July 10, 2024, Employee #1 confirmed that QAPI metrics should be collected and evaluated according to facility policies and procedures.

Based on review of facility policies and procedures, review of facility documentation and interview, the Department has determined the Administrator failed to ensure that the Hospice identified opportunities for improvement, developed and implemented changes designed to reduce adverse events or other identified problem areas. Failure to develop and implement changes designed to improve identified problem areas can result in program stagnation and poor care outcomes for patients. Findings include: --- Facility policy titled, "...Quality Assessment and Performance Improvement (QAPI) Plan...." approved June 1, 2024 revealed: "...For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified...For each established process to be improved, the performance expectation will be determined. The frequency of data collection and analysis will be specified for each process...Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them...The QAPI program will be evaluated annually by the Governing Body as a part of the annual program evaluation...." A review of QAPI meeting minutes and documentation revealed no performance improvement projects for 2022, 2023 or 2024. A review of Governing Body minutes revealed no discussion of QAPI program outcomes or performance improvement projects for 2022, 2023 or 2024. In an interview conducted with Employee #1 on July 10, 2024, Employee #1 confirmed that no further documentation regarding QAPI performance improvement projects could be provided.

Based on interview, review of facility documentation and review of facility policies and procedures, the Department has determined the Governing Body failed to ensure the QAPI (Quality Assessment and Performance Improvement) program addressed priorities for improved quality of care and patient safety and that the QAPI program's improvement actions were evaluated for effectiveness. Failure to ensure QAPI programs are addressing established priorities and are effectively evaluated can result in patient care deficits not being addressed. Findings include: --- Facility policy titled, "...Quality Assessment and Performance Improvement (QAPI) Plan...." approved June 1, 2024 revealed: "...The QAPI program will be evaluated annually by the Governing Body as a part of the annual program evaluation...." "...Aquarius Hospice Governing Body Meeting Minutes of Meeting...." dated June 1, 2024 revealed no content related to QAPI metrics, performance improvement plans or QAPI program evaluation. In an interview conducted with Employee #1 on July 10, 2024, Employee #1 confirmed that no further documentation could be provided regarding Governing Body minutes documentation.

Based on interview, review of policies and procedures it was determined the facility failed to ensure an active infection control program was in place that includes monitoring staff for infections control practices as well as tracking, investigation, and follow up of communicable diseases and active infections for patients and employees. Inadequate infection control programs have the potential to lead to increased rates and severity of infections, increase the likelihood of multidrug-resistant bacteria, and increases the risk of outbreaks that have the potential to disseminate to the community. Severe infections have the potential to lead to sepsis as well as unnecessary patient suffering and substandard outcomes. --- Findings include: Review of facility policy, ";Infection Control Surveillance System: Prioritized risks Defined" revealed, ";Patient infections to be reported while patient is on service.... wound infections that develop 30 days or greater after admission which require an antibiotic or identified by lab test or MD that may or may not require an antibiotic...and all infections that are identified as infections to be reported at admission... Written reporting of infections will occur through documentation on the applicable log (patient or employee). At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form...." Employee #1 was asked to provide a copy of the infection control surveillance log for patients and staff. Employee #1 presented an EMR report print out. Information on infections not documented per policy on Infection Control Logs. Several patients listed on EMR print out could not be identified as having an infection instead had medication allergies list in lieu of infections. In addition, patient record review revealed patients #3,5,8,12,15, and 16 identified as having qualifying infections not represented on EMR print out. During an interview with employee #1, they acknowledged the print EMR report presented as infection control log is not accurate. Completed Patients and Employees Forms infection control forms per policy were requested. Not provided. Requested the completed Infection Control Quarterly Data Aggregation and Analysis form. Not provided. Review of facility policy entitled, "Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan" revealed, ";...For employees or patient care volunteers who have not had a documented negative PPD test during the preceding 12 months, the baseline PPD testing will include the two-step method...PPD negative employees and patient care volunteers will undergo repeat PPD testing at regular intervals (but at least annually)...." During interview with Employee #1, they stated, ";All employees and volunteers have TB skin tests upon hire and annually." Employee record review revealed: Employee #1 Hire date: 6/01/2015 No evidence PPD testing completed upon hire in file. TB screen assessment completed on date of hire. No evidence of annual TB testing from 2016 to 2024. Employee #2 Hire date: 10/15/2021 PPD testing administered/read upon hire invalid. Test results read prior to 48 hours. No evidence of annual PPD testing in file. TB screen assessment completed 2/15/2024. No evidence of annual TB testing for 2022 or 2023. Employee #3 Hire date: 4/20/22 Evidence TB screen assessment only completed upon hire. No evidence PPD testing completed upon hire. Employee #4 Hire date: 6/19/2023 Evidence TB screen assessment completed upon hire. No evidence PPD testing completed upon hire. Annual TB testing completed on 3/25/24 invalid. Test results read prior to 48 hours. Employee #5 Hire date: 3/01/2021 No evidence PPD testing completed upon hire in 2021 in file. Annual PPD testing completed 3/1/24 invalid - no administer/read result time documented for test. No evidence of annual PPD testing for 2022 or 2023. Employee #6 Hire date: 3/08/2023 No evidence of annual TB testing. Employee #7 Hire date: 2/20/2023 Evidence TB screen assessment completed upon hire. No evidence PPD testing completed upon hire. Annual TB testing completed on 3/25/24 invalid. Test results read prior to 48 hours. Employee #8 Hire date: 1/11/2023 No evidence PPD testing completed upon hire in file. TB screen assessment completed on date of hire. Employee #9 Hire date: 3/01/2021 No evidence PPD testing completed upon hire in file. TB screen assessment completed on date of hire. No evidence of annual PPD testing for 2022 or 2023. Employee #10 Hire date: 3/11/2021 No evidence PPD testing completed upon hire in file. TB screen assessment completed on date of hire. No evidence of annual PPD testing for 2022 or 2023. Employee #11 Hire date: 11/08/2016 No evidence PPD testing completed upon hire in file. No evidence of annual PPD testing in file. No evidence of annual PPD testing for 2017 through 2021, and 2023, 2024. Employee #12 Hire date: 7/01/2021 No evidence PPD testing completed upon hire in file. TB screen assessment completed on date of hire. No evidence annual TB testing in file for 2022 through 2024. Employee #13 Hire date: 9/12/2016 No evidence PPD testing completed upon hire in file. No evidence annual TB testing in file for 2016- through 2021 and 2023, 2024. Review of facility policy, ";Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan" revealed, ";...The Director will perform annual and ongoing risk assessment to determine the need, type and frequency of testing/assessment for direct care personnel..." Review of infection control binder revealed document outlining procedures for completing an annual TB Risk assessment. ";...An Annual risk assessment will be performed to determine the risk of TB transmission....The initial assessment will be based on the following three factors: 1) Local TB profile (obtained from the Public Health Department), 2) Number of TB patients by area, 3) Health care worker PPD..." In Interview with employee #1 0n 7/11/2024, the most recent completed Annual TB risk assessment was requested and not received. On 7/12/2024 employee #1 presented a copy of the Tuberculosis Exposure Checklist 2023 stating, ";This is the annual TB Risk Assessment." The document did not address the three factors as outlined in the aforementioned procedural document in the ";Infection Control" binder presented on 7/09/2024. Review of facility policy, ";Inservice Education" revealed, Certain inservice programs are determined by Hospice to be mandatory initially and annually for all staff. These include, but are not limited to: ... TB risk program...." Inservice Education binder presented on 7/9/2024 did not reflect topic TB risk or infection control education. Requested evidence of annual training on these topics 7/10/2024 and 7/11/2024. Not provided. Review of facility policy, ";Exposure Control Plan: OSHA Regulations" revealed, ";...Nursing Bag Technique, Upon entering the home, place the bag on a clean surface...Remove all items that will be needed for the visit. Place items on one of the paper towels..." During Home visit with patient #6, it was observed that Employee #14 failed to follow policy failing to put vital equipment on paper towel. Review of facility policy, ";Hand Hygiene and Compliance Program" revealed, ";...Hospice has implemented an aggressive program to address hand hygiene and decrease rates of infections... Staff compliance with hand hygiene will be monitored annually (see Hand Hygiene Monthly Monitoring tool)...Hospice has established a hand hygiene compliance goal of 90% or greater. Staff compliance with hand hygiene will be monitored monthly to determine compliance rate (see Hand Hygiene Monthly Monitoring tool)...Monthly compliance data will be shared with staff...." Completed hand hygiene monitoring tool for the last 12 months along with evidence the compliance data had been shared with the staff monthly was requested and not provided. Employee #1 stated during interview, ";I admit, we have not been doing hand hygiene audits." Review of facility policy, ";Hand Hygiene and Compliance Program" revealed, ";...Hospice has implemented an aggressive program to address hand hygiene and decrease rates of infections... Orientation and annual staff training will include hand hygiene...." Annual Inservice Education binder presented on 7/9/2024 did not reflect topic on Hand Hygiene/ Infection Control. Requested evidence of annual training on this topic 7/10/2024 and 7/11/2024. Not provided. Review of facility policy, ";Influenza Vaccination Program" revealed, "... Hospice acknowledges that patient care staff, contract staff and LIPs can acquire and transmit influenza from patients or transmit influenza to patients and other staff. Vaccination remains the single most preventive measure. 2. The goals of the Hospice Vaccination Program are to: Decrease losses in staff productivity and absenteeism, Improve patient outcomes by decreasing transmission of influenza. Meet the nationwide target goal of staff vaccination of 90% by 2020. Hospice will incrementally improve its vaccination rate by 2 percent annually to achieve targeted long-term goal of 100 percent. Measure and improve vaccination rates for patient care staff, contract staff and LIPs. Hospice will collect and review at least annually the reasons given by patient care staff, contract staff and LIPs for declining the vaccination. Patient care staff, contract staff and LIPs are not required to sign a declination form. Vaccination rate data will be provided at least annually to key stakeholders, e.g., leaders, mangers and Hospice staff...." During review of Infection control binder documentation Influenza vaccination rates for staff not found. During employee #1 interview, requested evidence of staff flu vaccination rates and evidence influenza vaccination rate data provided annually to key stakeholders, e.g., leaders, mangers and Hospice staff. Employee #1 stated , ";Flu vaccines are only documented in staff files".

Based on record review and staff interviews qualified bereavement counseling services are not available to patient's family or other vested individuals after the death of a patient. This deficient practice can result in family members or other individuals experiencing unresolved, complicated grief increasing the risk for suicide. --- Findings Include: Review of facility policy, "...Bereavement Services...." revealed "...Hospice provides an organized Bereavement Program supervised by a qualified bereavement counselor who has documented evidence of education or experience in dealing with grief or loss counseling. The services are available to assist the patient and family in minimizing stress and problems that arise from the terminal illness, related conditions and the dying process. Bereavement services shall be available a minimum of five (5) days a week and for up to one year following the death of the patient...Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patients death..". Review of personnel records revealed that Employee #5 had signed job description as bereavement counselor. Per job, description employee #5 does not meet the qualifications. Employee #1, stated, "I was not aware (employee #5) was not qualified."

Based on facility policies and procedures, interview and review of facility documents, the Department has determined the Administrator failed to ensure that direct-care volunteer services were provided to patients by volunteer staff. Failure to adequately document volunteer activity as provided by volunteers can result in patients not receiving volunteer services. Findings include: --- Findings include: "...Aquarius Hospice Volunteer 5% Cost Savings Match Information Sheet...." dated 12/23/2023 revealed: "...Volunteer Patient Care and Administrative Volunteer Hours...36 hours office...Volunteer...participated in Administrative hours including...Call patient and try to talk with them...Delivery of supplies...Pickup DME and bring to patient...Deliver some food...Filing...Auditing and copying...Data entry of records...Developing and packaging patient information packets...Fixing up HR files accordingly....." There was no documentation indicating what volunteer provided these services, on what dates these services were provided or to which patients the services were provided. When Compliance Officer requested a copy of a patient information packet, one was not available and a copy had to be made. Personnel files for volunteers were requested and a file was provided for Employee #3. The following job descriptions were found in the personnel file of Employee #3: Community Volunteer in PAC (Professional Advisory Group) signed 2/20/2023 by Employee #3. It should be noted that Aquarius Hospice does not have a Professional Advisory Group. Volunteer Coordinator signed 4/20/2023 Hospice Aide signed April 20, 2022 The personnel file contained a W-4 tax form signed by Employee #4. There was no indication in the cost savings of how the hospice differentiated between Employee #4's paid work as a Hospice Aide and as Volunteer Coordinator versus any work Employee #4 may have provided as a volunteer. In a subsequent interview conducted with Employee #1 on July 10, 2024, Employee #1 was not able to provide additional clarification on how volunteer hours were differentiated from paid hours. Employee #1 stated that volunteer hours were spent completing administrative office tasks only because care facilities continued to refuse access for Aquarius Hospice volunteers due to COVID concerns.

Based on interview, review of facility documents and review of facility policy and procedure, the Department has determined the Administrator failed to ensure that recruitment efforts for the volunteer program have taken place at Aquarius Hospice. Failure to attempt to recruit and retain volunteers can result in a loss of services for patients. Findings include: --- A review of the "...Aquarius Hospice Volunteer Program...." binder contents revealed no documentation of recruitment efforts. A request was made for documentation of recruitment efforts but none could be provided. In an interview conducted with Employee #1 on July 9, 2024, Employee #1 stated there was little need for volunteers at the hospice because the long-term care facilities would not allow volunteers to visit hospice patients due to COVID restrictions.

Based on interview, review of medical records and review of facility policies and procedures, the Department has determined the hospice has failed to ensure the hospice provided care that optimized comfort and dignity of the patient as well as being consistent with patient and family needs and goals, making family and patient needs a priority. Failure to preserve the comfort and dignity of the patient while prioritizing the needs and goals of the patient and their family can result in substandard care for the patient. Findings include: --- Based on interview, review of medical records and review of facility policies and procedures, the Department has determined the hospice has failed to ensure the hospice provided care that optimized comfort and dignity of the patient as well as being consistent with patient and family needs and goals, making family and patient needs a priority. Failure to preserve the comfort and dignity of the patient while prioritizing the needs and goals of the patient and their family can result in substandard care for the patient. Findings include: "...Hospice Patient Bill of Rights and Responsibilities...." reviewed June 1, 2024 revealed: "...Patients have the right to...Receive information about the scope of services that Hospice will provide and any specific limitations of Hospice services.Be informed of rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment...Refuse care or treatment without fear of reprisal or discrimination and in accordance with law and regulation....Receive effective pain management and symptom control for conditions related to terminal illness...." Patient #4 Start of Care: March 25, 2024 "...LVN Visit Note...." dated 4/17/2024 revealed: "...patient states that he had to cancel appointment with his cardio doctor r/t transportation issues...." "...LVN Visit Note...." dated 5/1/2024 revealed: "...patients b/p remains elevated often r/t patients noncompliance with taking meds...remains noncompliant...." "...LVN Visit Note...." dated 5/8/2024 revealed: "...patient hopes to see cardio doctor this week...patient remains noncompliant...." "...LVN Visit Note...." dated 5/22/2024 revealed: "...nurse gave patient a med container...to set up meds...to help with better compliance with meds. Patient forgets to take meds often....No upcoming doctor's appointments at this time...." "...LVN Visit Note...." dated 6/5/2024 revealed: "...patient conts to be noncompliant with meds. Patient states that he just took b/p meds before nurse visit...remains noncompliant...." "...LVN Visit Note...." dated 6/12/2024 revealed: "...patient states that he is still unable to get his new med farxiga [sic]. Patient states that he does not have transportation to get med from pharmacy. Nurse suggested med delivery. Patient to check into this....remains noncompliant...." "...LVN Visit Note...." dated 6/19/2024 revealed: "...patient remains noncompliant with taking meds. Patient states that he forgot to take his meds this AM. re direction [sic] unsuccessful by nurse. Patient was given a med container for his meds. Patient is still noncompliant...Patient has still not picked up his farxiga [sic] medication. Nurse education done to tell patient to call his primary doctor and make aware...remains noncompliant...." "...LVN Visit Note...." dated 7/3/2024 revealed: "...remains noncompliant...patient has still not gotten his meds from er follow up [sic]. Patient conts to make excuses....patient remains noncompliant with meds. Patient conts to tell nurse that he is taking meds as ordered by doctor. Patient states that he is setting up his meds in his med container...Patient conts to eat highly processed foods with high salt content. Dietary teaching done by nurse. Patient remains noncompliant...." In an interview with Patient #4, Patient #4 stated that he has still been unable to get prescribed medications, including Farxiga, Hydralazine and Meclizine. A review of the medications prescribed by the hospice revealed that these medications were not currently being provided but other medications related to heart disease were being prescribed. Patient #4 provided emergency room discharge orders that revealed recommendations for the indicated medications. In an interview with Employee #1 conducted on July 10, 2024, Employee #1 confirmed that Aquarius Hospice does have a contract with a transportation company to provide transportation for patients if needed.

Based on observation, interview and review of facility documentation, the Department has determined the Administrator failed to ensure that hospice services are available on a 24-hour basis. Failure to ensure that hospice services are available on a 24-hour basis can result in patients being unable to access critically needed care. Findings include: --- On July 9, 2024 at 9:00 a.m., Compliance Officers arrived at Aquarius Hospice. The lights were out in the office and nobody responded to the knocks of Compliance Officers. An after-hours phone number was posted on a sign indicating that staff was available 24 hours a day, seven days a week. Compliance Officer called the posted 24/7 phone number for Aquarius Hospice, (602) 466-3686 at 9:02 a.m., and the call went to voicemail. A second attempt was made at 9:06 a.m. This call was terminated by the recipient of the phone call. A third attempt was subsequently made. A message was received stating the caller was busy. No voicemail was offered. A fourth attempt was made at 9:07 a.m. A message was received stating the caller was busy. No voicemail was offered. On the fifth attempt at 9:10 a.m., Employee #1 answered the phone. In a subsequent interview, Employee #1 stated that the phone system is set on a phone tree to ring to three subsequent employees and is then supposed to go to voicemail.

Based on interview and review of personnel files, the Department has determined the Administrator failed to ensure that the hospice contracted with a self-employed physician or a physician employed by a physician's group or a professional entity when engaging the services of Employees #2 and #10. Failure to ensure that physicians are contracted can result in physicians who are not independent and objective regarding the services of the hospice, potentially resulting in inappropriate care for patients. Findings include: --- Employee #2 Date of Hire: October 15, 2021 A review of the personnel record revealed a job description and a W-4 tax document signed on October 15, 2021. Employee #10 Date of Hire: March 10, 2021 A review of the personnel record revealed a job description and a W-4 tax document signed on March 11, 2021. A request was made for signed contracts for Employee #2 and Employee #10 but they could not be provided. In an interview conducted with Employee #1 on July 9, 2024, Employee #1 confirmed that Employee #2 and Employee #10 were employees of Aquarius Hospice and were not contracted employees but Employee #1 stated the opinion that this was okay because they were working part-time.

Based on interview, review of facility policies and procedures and review of medical records, it has been determined the hospice failed to ensure medical patient records are not altered. Upon review of the medical records of 2 (two) out of 16 (sixteen) patients, dates on initial consents were altered -Hospital Election and Informed Consent, Authorization for Payment and Financial Responsibility, Request for Medical Record Information, Informed Consent for Psychotropic Medications, Statement of Consent, COVID-19 Liability Waiver, Telemedicine Consent Form, Emergency/Disaster/Evacuation Plan- Patient, Patient Notification of Hospice Non-Covered Drugs/Services/Items, Photograph Consent, Patient/Family Handbook, Important Notice to Our Patients, Acknowledgement Form, Do not Resuscitate Form. Altering medical documents can result in a patient's needs not being adequately addressed by the hospice, leading to poor patient outcomes. --- Findings include: Review of facility policy, "...Patient Admission Criteria...." revealed "...During the initial assessment, the RN will:... Explain and provide a copy of the Patients Bill of Rights/Responsibilities and advance directives. If patient has an advance directive, a copy will be obtained or the patients wishes will be documented. Review of facility policy, ".. Professional Standards of Practice....) revealed,"...Hospice and staff will comply with accepted professional standards and principles that apply to the professionals who are furnishing care, e.g., state practice acts. Patient care and services will be provided for each patient according to applicable law and regulation and accepted standards of practice...." Patient #7 Dates on initial consents -Hospital Election and Informed Consent, Authorization for Payment and Financial Responsibility, Request for Medical Record Information, Informed Consent for Psychotropic Medications, Statement of Consent, COVID-19 Liability Waiver, Telemedicine Consent Form, Emergency/Disaster/Evacuation Plan- Patient, Patient Notification of Hospice Non-Covered Drugs/Services/Items, Photograph Consent, Patient/Family Handbook, Important Notice to Our Patients, Acknowledgement Form, Do not Resuscitate Form have been altered. Patient #8 Dates on initial consents -Hospital Election and Informed Consent, Authorization for Payment and Financial Responsibility, Request for Medical Record Information, Informed Consent for Psychotropic Medications, Statement of Consent, COVID-19 Liability Waiver, Telemedicine Consent Form, Emergency/Disaster/Evacuation Plan- Patient, Patient Notification of Hospice Non-Covered Drugs/Services/Items, Photograph Consent, Patient/Family Handbook, Important Notice to Our Patients, Acknowledgement Form, Do not Resuscitate Form have been altered. During interview with employee #1, request was made to review original consents for patients ##3,#5,6,7,8, and 15. Only #3, 7, and 8 of the original files where available to review. Employee #1 stated, (employee #14) must have the other original consents." Employee #1 acknowledged dates on consents for #7 and #8 had been altered. "...Consents from previous admission were used" and the dated altered to match most recent admission. Employee #1 stated, "(Employee 14) needs additional education."

Based on interview, review of personnel records and review of facility policies and procedures, the Department has determined the Administrator failed to ensure that Employee #6 was supervised by a MSW (Master of Social Work) from a school of social work accredited by the CSWE and who has one year of experience in a health care setting. Failure to ensure that qualified personnel provide clinical services can result in substandard care being provided to patients. Findings include: --- A facility policy was requested but was not provided. "...Aquarius Hospice...." job description revealed: "...Social Worker/Social Work Assistant...Qualifications...A hospice social worker must meet at least one of the following options...Have an MSW degree from a school of social work accredited by the Council on Social Work Education (CSWE), and one year of experience in a health care setting...Have a baccalaureate degree in social work (BSW) from a school of social work accredited by the CSWE, and one year of experience in a health care setting and be supervised by a MSW from a school of social work accredited by the CSWE and who has one year of experience in a health care setting. If the BSW is employed by the Hospice before December 2, 2008, he//she is exempted from the MSW supervision requirement...Have a baccalaureate degree in psychology, sociology or other field related to social work, and at least one year of social work experience in a health care setting and be supervised by a MSW from a school of social work accredited by the CSWE and who has one year of experience in a health care setting...Hospice must employ or contract with at least one MSW to serve in the supervisor role as an active advisor, consulting with the BSW on assessing the needs of patients and families, developing and updating the social work portion of the plan of care and delivering care to patients and families...." Personnel file of Employee #6 revealed a diploma from Grand Canyon University conferring the following degree: "...Master of Science Health and Wellness with an emphasis in Community Mental Health Administration...." Resume of Employee #6 revealed: "...Bachelor of Science in Family Studies and Human Development...." An employee list was provided of all employees, both contracted and non-contracted, for Aquarius Hospice. The list revealed that there are no MSWs currently employed or contracted by Aquarius Hospice. In an interview conducted with Employee #1 on July 11, 2024, Employee #1 confirmed that documentation of supervision of Employee #6 by a CSWE accredited MSW could not be provided.