Every finding on record at Athena Rhode Island Hospice LLC

Based on clinical record review and staff interview, the hospice agency failed to allow patients to voice grievances regarding treatment of care that was furnished in 2025. --- Findings are as follows:Record review failed to reveal evidence of a grievance log for 2025.During a surveyor interview on 4/9/2026 at approximately 11:00 AM with the Regional Executive Director, he was unable to provide evidence of a grievance log for 2025.

Based on clinical record review and staff interview, the hospice agency failed to provide infection control education for 3 of 7 staff members reviewed, Staff B, E, and F. --- Findings are as follows:1. Record review revealed that Executive Director, Staff B, was hired on 3/31/2026.Further review failed to reveal evidence that infection control education had been provided.2. Record review revealed that Registered Nurse, Staff E, was hired on 3/19/2025.Further review failed to reveal evidence that infection control education had been provided.3. Record review revealed that Social Worker, Staff F, was hired on 10/15/2025.Further review failed to reveal evidence that infection control education had been provided.During a surveyor interview on 4/8/2026 at approximately 11:00 AM with the Clinical Director via Zoom, he was unable to provide evidence that infection control education had been provided to Staff B, E, and F, as required.

Based on clinical record review and staff interview, the hospice agency failed to have a hospice aide successfully complete a competency evaluation program for 1 of 2 hospice aides reviewed, Staff G. --- Findings are as follows:Record review revealed that Staff G was hired on 9/3/2025.Record review failed to reveal evidence that Staff G completed a competency evaluation that addresses the following topics:-Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other hospice staff-Reading and recording temperature, pulse, and respiration-Bed bath-Sponge, tub, and shower bath-Hair shampooing in sink, tub, and bed-Nail and skin care-Oral hygiene-Toileting and elimination-Safe transfer techniques and ambulation-Normal range of motion and positioningDuring a surveyor interview on 4/8/2026 at approximately 11:30 AM with the Clinical Director via Zoom, he was unable to provide evidence that Staff G completed a competency evaluation, as required.

Based on clinical record review and staff interview, the hospice agency failed to ensure that each hospice aide receives at least 12 hours of in-service training during each 12-month period for 2 of 2 hospice aides reviewed for 2025, Staff D and G. --- Findings are as follows:Review of an agency policy titled, “Personnel Management” dated 8/7/2021, states in part, “…Home health/hospice aides will attend 12 hours of in-service education annually…”1. Record review revealed that Staff D was hired on 4/9/2024.Further review failed to reveal evidence that 12 hours of education were provided to Staff D in 2025.2. Record review revealed that Staff G was hired on 9/3/2025.Further review failed to reveal evidence that 12 hours of education were provided to Staff G in 2025.During a surveyor interview on 4/8/2026 at approximately 11:00 AM with the Clinical Director via Zoom, he was unable to provide evidence that 12 hours of in-service education were provided to Staff D and G in 2025, as required.

Based on surveyor observation, clinical record review, and staff interviews, the hospice agency failed to ensure patients were treated with respect during nurse assessment visits. This was identified in 2 of 2 observed Registered Nurse (RN) visits, affecting Patient ID #s 1 and 2. --- Findings are as follows:Review of an agency policy titled, “PATIENT BILL OF RIGHTS,” dated 8/7/2021, states in part, “…1. Exercise of rights and respect to property and person…to have his or her property an [SIC] person treated with respect…”a. Record review revealed that Patient ID #1 was admitted to the hospice agency with a diagnosis including, but not limited to, Alzheimer’s disease. Additionally, his/her mental status is documented as confused.During a surveyor observation on 4/6/2026 at approximately 12:40 PM, Registered Nurse (RN), Staff H, was visiting Patient ID #1, who resides in a Skilled Nursing Facility (SNF). The patient was observed seated in the hallway with other residents, visitors, and staff present. Staff H assessed Patient ID #1 including, obtaining his/her vital signs, listening to his/her lungs and abdomen, and was assessing his/her skin while in the hallway. b. Record review revealed that Patient ID #2 was admitted to the hospice agency with a diagnosis including, but not limited to, severe protein calorie malnutrition (a condition caused by insufficient intake of both protein and calories, leading to profound muscle wasting, organ dysfunction, and increased risk of death). Additionally, his/her mental status is documented as confused.During a surveyor observation on 4/6/2026 at approximately 1:15 PM, of Staff H, was visiting Patient ID #2, who resides in a SNF. The patient was observed seated in the common room with several other residents. Staff H proceeded to assess Patient ID #2 including, obtaining his/her vital signs, listening to his/her lungs and abdomen, and was assessing his/her skin by lifting up his/her shirt in the common area. During a surveyor interview on 4/6/2026 at 1:50 PM with Staff H, she revealed that she often assesses patients in common areas and does not return them to their rooms.  During a surveyor interview on 4/8/2026 at approximately 11:25 AM with the Clinical Director via Zoom, he revealed that staff should not be assessing patients in a common area and would expect that staff would bring a patient into to his/her room or a private area to be assessed.

Based on clinical record review and staff interview, the hospice agency failed to have the Medical Director or Physician designee review the clinical information for each hospice patient and provide a written Certification of Terminal Illness (CTI) for 1 of 1 patient reviewed without a CTI, Patient ID #9. --- Findings are as follows:Review of the agency policy titled, “CERTIFCATION OF TERMINAL ILLNESS,” last revised November 2021 states in part, “…At the time of admission to hospice, the hospice Medical Director or the patient’s attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement…If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care…”Record review revealed Patient ID #9's start of care date for hospice services began on 11/12/2025.Review of a document titled, “Statement of Consent and Election” revealed, Patient ID #9 elected to receive hospice benefits beginning on 11/12/2025.Record review failed to reveal evidence of verbal certification documented in the clinical record or that a CTI was obtained and authorized by the Medical Director or Physician designee as of 4/9/2026, until it was brought to the agency’s attention by the surveyor.During a surveyor interview on 4/9/2026 at approximately 10:15 AM with the Executive Director, she was unable to provide evidence that a CTI or appropriate documentation was completed within the timeframe outlined in the facility policy for Patient ID #9.

Based on clinical record review and staff interview, the hospice agency failed to ensure continuity of communication of the hospice patients' care for patients that reside in a Skilled Nursing Facility (SNF) for 2 of 2 Registered Nurse (RN) visits observed, affecting Patient ID #s 1 and 2. --- Findings are as follows:During a surveyor interview on 4/6/2026 at 12:55 PM with RN, Staff H, she revealed that upon admission, the hospice agency will create a hospice binder for each patient to be left at the SNF. She indicated that the hospice staff should be updating the hospice binder with documentation including, but not limited to, the interdisciplinary team review document, hospice care plan/physician order form, and the patient’s certification/recertification document. She indicated the hospice binder is utilized as the tool of communication between the hospice agency and the SNF staff.a. Record review revealed that Patient ID #1 was admitted to the hospice agency with a diagnosis including, but not limited to, Alzheimer’s disease. Additionally, his/her mental status is documented as confused, and s/he resides in a SNF.Record review failed to reveal evidence of documentation in the patient’s hospice binder to ensure continuity of communication and easy access to pertinent information, including Patient ID #1’s interdisciplinary team review, hospice care plan/physician orders, and the patient’s certification/recertification document for the SNF staff.b. Record review revealed that Patient ID #2 was admitted to the hospice agency with a diagnosis including, but not limited to, severe protein calorie malnutrition (a condition caused by insufficient intake of both protein and calories, leading to profound muscle wasting, organ dysfunction, and increased risk of death). Additionally, his/her mental status is documented as confused, and s/he resides in a SNF.Record review failed to reveal documentation in the patient’s hospice binder to ensure continuity of communication and easy access to ongoing information, including Patient ID #2’s interdisciplinary team review, hospice care plan/physician orders, and the patient’s certification/recertification document for the SNF staff.During surveyor observations and simultaneous interviews on 4/6/2026 at approximately 1:00 PM and 1:30 PM with Staff H, she reviewed Patient ID #1 and 2’s hospice binders in the presence of the surveyors. She was unable to locate Patient ID #1 and 2’s interdisciplinary team review, hospice care plan/physician orders, or the patient’s certification/recertification document for the SNF. Additionally, she indicated that both hospice binders were missing the appropriate documentation required for the coordination of Patient ID #s 1 and 2's care.Durning a surveyor interview on 4/8/2026 at 11:22 AM with the Clinical Director via Zoom, he revealed that it is his expectation that the patient’s hospice binders are complete and up to date for each patient receiving hospice services in a SNF.

Based on record review and staff interview, it has been determined that the agency failed to provide medical social services by a qualified social worker for 3 of 3 patients reviewed, Patient ID #s 1, 2, and 3. --- Findings are as follows: Record review of the agency provided job description for the social worker revealed in part... ";Essential Job Functions/Responsibilities...Assesses the psychosocial status of patients and families/caregivers related to the patients terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group...carries out social evaluations, including family dynamics, caregiver abilities, communication patterns, high-risks for suicide, neglect or abuse and plans intervention based on evaluation findings. Counsel patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties...Participation in ongoing case management with the hospice interdisciplinary team..." Record review of the personnel record for Social Worker, Staff A, revealed a hire date of 11/27/2023. It further revealed that Staff A left the agency on 8/9/2024. 1)Record review of Patient ID #1s Hospice Plan of Care with a certification period of 8/18/2024 through 10/16/2024, revealed an order for a social worker 1 time per month for 3 months with 3 as needed visits for psychosocial support. Further record review of Patient ID #1s Hospice Plan of Care with a certification period of 10/17/2024 through 12/15/2024 revealed an order for a social worker 1 time per month for 3 months. Additional record review of Patient ID #1s Hospice Plan of Care with a certification period of 12/16/2024 through 2/13/2025 revealed an order for a social worker 1 time per month for 3 months. Additional record review revealed that the patients last social worker visit was dated 7/1/2024. There failed to be documentation of any other Social Worker visits in the medical record. 2) Record review for Patient ID #2, revealed a Hospice Plan of Care with a certification period of 11/8/2024 through 2/5/2025. Record review failed to reveal evidence of an initial psychosocial assessment completed by the social worker. 3) Record review for Patient ID #3, revealed a Hospice Plan of Care with a certification period of 12/9/2024 through 2/6/2025. Record review failed to reveal evidence of an initial psychosocial assessment completed by the social worker. During surveyor interviews on 1/17/2025 at approximately 9:00 AM and 12:45 PM with the Executive Director, she acknowledged that the agency has not had a Social Worker since Staff A left the agency on 8/9/2024. Further, she acknowledged that the last time that Patient ID #1 was seen by a social worker was on 7/1/2024. Additionally, she acknowledged that Patient ID #s 2 and 3 failed to have an initial assessment/evaluation completed by a Social Worker. She revealed that the initial evaluation would then be used to determine the number and frequency of Social Work visits needed for the patient.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: 1. Development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment; 2. The documented discussion of the plan provided to the patient/family, and maintained by the hospice; 3. Follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency; 6. The minimum information provided to facilitate patient evacuation and transportation including: If the patient is mobile or not; If the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and, Any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.); This standard was not met as evidenced by clinical record review and interview. 8 of 8 (100%) patient files reviewed revealed that individual emergency plans were not documented/discussed. Clinical Record #74681 was reviewed and identified that the patient elected the hospice benefit on 3/17/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #80973 was reviewed and identified that the patient elected the hospice benefit on 3/4/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #15629 was reviewed and identified that the patient elected the hospice benefit on 3/7/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #51017 was reviewed and identified that the patient elected the hospice benefit on 4/12/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #60500 was reviewed and identified that the patient elected the hospice benefit on 4/12/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #41692 was reviewed and identified that the patient elected the hospice benefit on 3/17/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #18872 was reviewed and identified that the patient elected the hospice benefit on 3/21/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". Clinical Record #50185 was reviewed and identified that the patient elected the hospice benefit on 3/4/2022. There was no individual emergency plan identified for the patient. The emergency plan completed on admission stated "No Evacuation". In an interview with the Administrator on 5/18/2022 she agreed that the individual emergency plan created for patients in facilities was not sufficient and that they would update them to indicate more specific plans that included following the facility protocols.