Every finding on record at Atwell Home Health Services Inc.

Based on record review and interview the agency failed to ensure that 1 of 1 ( alternate administrator) volunteer provided administrative or direct patient care services within a 12-month period from 12-1-24 to 11-31-25.The failure to ensure volunteer services were utilized at the hospice can potentially cause a reduced quality of care for patients and  financial instability at the agency. --- During entrance conference on 12-2-25 at 9:29 am the Administrator stated the Alternate Administrator was the Volunteer Coordinator.Record review of agency active employee list revealed the Alternate Administrator was listed as the sole volunteer for the agency.Record review of volunteer surveyor tool completed by the alternate administrator on 12-3-25 revealed in the past 12 months the agency volunteer did not perform any patient care or administrative services for the agency.During an interview on 12-5-25 at 10:41 am the alternate administrator/ volunteer coordinator/volunteer stated she was given the role of volunteer coordinator and is the only volunteer for the agency. The alternate administrator/volunteer coordinator then stated it was never explained to her what the role of volunteer coordinator entailed. The alternate administrator then stated that she was told that the agency had to focus on whether or not the patient needed a volunteer. The alternate administrator further stated that the agency patient had refused a volunteer. The alternate administrator stated she was not aware that as a volunteer she could do administrative tasks to fulfill the volunteer duties. Record review of agency policy titled " Volunteer services" dated 01-31-15 revealed " The Volunteer Coordinator will: Monthly tracking and documenting volunteer services…documentation of volunteer services will include Volunteer role (administrative, direct patient care) …work time spent.”

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure the individualized plan of care included the scope and frequency of services necessary to meet patient and family needs. Clinical Record 1: The patient was admitted to home health services on 04/08/2023 with a diagnosis of cerebral vascular accident. The plan of care dated 04/07/2023 through 07/07/2023 contained no documented evidence of frequency of visits for the Skilled Nurse, Medical Social Worker, and Chaplain. During an interview on 10/16/2023, the Director of Nursing confirmed the plan of care did not include frequencies for all disciplines that were providing care to the patient.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties including orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 6 (17%) personnel records reviewed, the agency did not ensure staff were oriented to the hospice philosophy. Agency policy HR.6 Employee Orientation stated in part, "The agency will orient each employee at respective job responsibilities and agency policies and procedures prior to performing job duties. Upon hire a general orientation which includes but not limited to mission, hospice philosophy and goals." Personnel Record 5: Registered Nurse, Director of Nursing, Administrator dated of hire 03/21/2022. The personnel file contained no documented evidence that the nurse was oriented to hospice philosophy upon hire, as of the date of review on 10/16/2023. During an interview on 10/16/23, the Director of Nursing confirmed that the initial orientation was not completed and orientation to hospice philosophy was not provided.

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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 5 (40%) personnel records reviewed, the agency did not ensure competency skills were assessed of all personnel providing care. Agency policy HR 6 stated in part, "The hospice will assess the skills and competence of all personnel furnishing care. This assessment will occur upon hire and annually and may include written, verbal or demonstration and on site for hospice." Agency policy HR 8 stated in part, "The HHA [home health aide] competency evaluation must be performed by an RN [Registered Nurse]. The completed competency evaluation will be kept in the employee personnel file and will be updated at least every 12 months." Personnel Record 1: Registered Nurse, Director of Nursing, Administrator date of hire 03/21/2022. The personnel file contained no documented evidence that an initial competency assessment was completed upon hire and annually, as of the date of review on 10/16/2023. Personnel Record 3: Certified Nurse Assistant date hire 05/11/2022. The personnel file contained no documented evidence that an initial competency assessment was completed upon hire and annually, as of the date of review on 10/16/2023. During an interview on 10/16/2023, the Director of Nursing confirmed that the initial competencies and annual competencies were not completed per the agency's policies.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed, the agency did not ensure that recertification of terminal illness was completed no later than 2 calendar days after the first day of each benefit period, and no more than 15 days before the next benefit period begins. Clinical Record 2: The patient was admitted to home health services on 05/17/2023 with a diagnosis of heart failure. The recertification of terminal illness dated 08/18/2023 did not include a physician signature. Clinical Record 1: The patient was admitted to home health services on 04/08/2023 with a diagnosis of cerebral vascular accident. Clinical record reviewed revealed the recertification of terminal illness did not include a physician signature. Clinical Record 3: The patient was admitted to home health services on 05/17/2023 with a diagnosis of heart failure. Clinical record reviewed revealed the recertification of terminal illness did not include a physician signature. Clinical Record 4: The patient was admitted to home health services on 06/12/2023 with a diagnosis of dementia. Clinical record reviewed revealed the recertification of terminal illness did not include a physician signature. Clinical Record 5: The patient was admitted to home health services on 05/31/2023 with a diagnosis of congestive heart failure. Clinical record reviewed revealed the recertification of terminal illness did not include a physician signature. During an interview on 10/16/2023, the Director of Nursing confirmed that the recertifications were not signed and therefore not completed.

It is required that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with CMS §418.24. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) records reviewed revealed the hospice did not ensure that the initial comprehensive assessment was completed within 5 calendar days after the election of hospice care. Clinical Record 1: The record was reviewed and identified the patient elected hospice care on 8/29/22. The initial comprehensive assessment was not completed by the Chaplain within 5 days of the election of hospice care. There was no evidence that the chaplain completed an assessment or that the patient refused the assessment. Clinical Record 2: The record was reviewed and identified the patient elected hospice care on 9/13/22. The initial comprehensive assessment was not completed by the Chaplain within 5 days of the election of hospice care. There was no evidence that the chaplain completed an assessment or that the patient refused the assessment. Clinical Record 7: The record was reviewed and identified the patient elected hospice care on 9/23/22. The initial comprehensive assessment was not completed by the Chaplain within 5 days of the election of hospice care. There was no evidence that the chaplain completed an assessment or that the patient refused the assessment. Clinical Record 8: The record was reviewed and identified the patient elected hospice care on 9/14/22. The initial comprehensive assessment was not completed by the Chaplain within 5 days of the election of hospice care. There was no evidence that the chaplain completed an assessment or that the patient refused the assessment. Clinical Record 9: The record was reviewed and identified the patient elected hospice care on 8/29/22. The initial comprehensive assessment was not completed by the Chaplain within 5 days of the election of hospice care. There was no evidence that the chaplain completed an assessment or that the patient refused the assessment. During an interview and a joint review of the record on 11/17/22, the Director of Nursing confirmed that the assessment was not documented and there was no documentation of why the assessment was not completed.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and observations. 3 of 11 (27%) records reviewed revealed the agency did not ensure that the registered nurse (RN) provided care in accordance with the plan of care. Clinical Record 7: was reviewed and identified the patient elected hospice care on 9/23/22. The plan of care dated 9/23/22, ordered Skilled Nursing (SN) services "one to two times weekly." Review of the completed SN visit notes revealed missed visits for the weeks ending: 10/8/22;10/22/22; and 11/5/22. The record did not include documentation of the reasons the visits were not provided or communication with the physician. Clinical Record 8: was reviewed and identified the patient elected hospice care on 9/14/22. The plan of care dated 9/14/22 ordered SN services "one to two times weekly." Review of the completed SN visit notes revealed missed visits for the week ending 10/29/22. The record did not include documentation of the reasons the visits were not provided or communication with the physician. Clinical Record 9: was reviewed and identified the patient elected hospice care on 8/29/22. The plan of care dated 8/29/22 ordered SN services "one to two times weekly." Review of the completed SN visit notes revealed missed visits for the weeks ending 10/29/22 and 11/12/22. The record did not include documentation of the reasons the visits were not provided or communication with the physician. During an interview and a joint review of the record on 10/17/22, the Director of Nursing confirmed that there were missed Skilled Nursing visits and that the agency did not have documentation of missed visits or reasons the visits were not provided.

It is required that the hospice must provide an assessment of the patient's and family's spiritual needs. Provide spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service, and in a manner consistent with patient and family beliefs and desires. Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of its ability. Advise the patient and family of this service. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) records reviewed revealed that the agency did not document the patient's acceptance or refusal of spiritual counseling services. Clinical Record 1: Record was reviewed and identified that the patient elected hospice care on 8/29/22. The plan of care dated 8/29/22 ordered, "Chaplain to evaluate", but there was no documentation of an evaluation or if the patient refused spiritual counseling services. Clinical Record 2: Record was reviewed and identified that the patient elected hospice care on 8/24/22. The plan of care dated 8/24/22 ordered, "Chaplain to evaluate", but there was no documentation of an evaluation or if the patient refused spiritual counseling services. Clinical Record 7: Record was reviewed and identified that the patient elected hospice care on 8/29/22. The plan of care dated 8/29/22 ordered, "Chaplain to evaluate", but there was no documentation of an evaluation or if the patient refused spiritual counseling services. Clinical Record 8: Record was reviewed and identified that the patient elected hospice care on 9/23/22. The plan of care dated 9/23/22 ordered, "Chaplain to evaluate", but there was no documentation of an evaluation or if the patient refused spiritual counseling services. Clinical Record 9: Record was reviewed and identified that the patient elected hospice care on 9/23/22. The plan of care dated 9/23/22 ordered, "Chaplain to evaluate", but there was no documentation of an evaluation or if the patient refused spiritual counseling services. During an interview and a joint review of the clinical record on 11/17/22, the Director of Nursing confirmed that there was no documentation of patient refusal of spiritual services.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 3 (67%) clinical records reviewed of patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide provided services according to the plan of care. Clinical Record 4: was reviewed and identified the patient elected hospice care on 5/11/22. The plan of care dated 5/11/22 ordered aide services "three times weekly." Review of completed aide visits revealed missing visits for the weeks ending: 9/10/22; 9/16/22; 10/8/22; and 11/11/22. The record lacked documentation of why the visits were not provided as ordered and that the Registered Nurse RN or Physician was notified. Clinical Record 5: was reviewed and identified the patient elected hospice care on 5/11/22. The plan of care dated 5/11/22 ordered aide services "three times weekly." Review of completed aide visits revealed missing visits for the weeks ending: 9/10/22; 9/16/22; 10/8/22; and 11/11/22. The record lacked documentation of why the visits were not provided as ordered and that the RN or Physician was notified. During an interview and a joint review of the record on 11/17/22, the Director of Nursing confirmed that there were missed aide visits and that the agency did not have documentation of a missed visit or why the visit was not provided.

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. The record may be maintained electronically or on paper. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) clinical record reviewed of a transferred patient revealed that the agency did not document a discharge summary. Clinical Record 11: was reviewed and identified the patient elected hospice care on 3/9/22 and transferred to another agency on 3/28/22. There was no evidence that a discharge summary was documented. During an interview and a joint review of the record on 11/17.22, the Director of Nurses confirmed that there was no evidence that the discharge summary was documented.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) clinical record reviewed of a patient transferred to a facility revealed the agency did not ensure that the discharge summary was forwarded to the receiving facility. Clinical Record 11: was reviewed and identified the patient elected hospice care on 3/9/22. The patient was transferred to another hospice on 3/28/22. There was no evidence that a discharge summary was forwarded to the receiving agency. During an interview and a joint review of the record on 11/17/2022, the Director of Nurses confirmed that there was no evidence that the discharge summary was forwarded to the receiving agency.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals, and if the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and interviews. 7 of 11 (64%) revealed that the agency did not ensure the Interdisciplinary Group (IDG) determined the ability of the patient and/or family to safely administer drugs and/or biologicals to the patient in their home. . Clinical Record 1: Record was reviewed and identified the patient elected hospice care on 8/29/22. The plan of care dated 8/29/22 or the IDG dated 8/31/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 2: Record was reviewed and identified the patient elected hospice care on 9/13/22. The plan of care dated 9/13/22 or the IDG dated 9/28/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 3: Record was reviewed and identified the patient elected hospice care on 8/24/22. The plan of care dated 8/24/22 or the IDG dated 8/31/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 6: Record was reviewed and identified the patient elected hospice care on 8/25/22. The plan of care dated 8/25/22 or the IDG dated 8/31/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 7: Record was reviewed and identified the patient elected hospice on 9/23/22. The plan of care dated 9/23/22 or the IDG dated 9/24/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 8: Record was reviewed and identified the patient elected hospice care on 9/14/22. The plan of care dated 9/14/22 or the IDG dated 9/28/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 9: Record was reviewed and identified the patient elected hospice care on 8/29/22. The plan of care dated 8/29/22 or the IDG dated 8/31/22 did not document the ability of the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. During an interview and a joint review of the clinical record on11/17/22, the Director of Nurses confirmed that there was no documentation in the patients plan of care or IDGs stating the patients/family ability to administer drugs and/or biologicals safely in their home.

It is required that organization policy and procedure define a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19. This standard was not met as evidenced by document review and interview. The agency did ensure a process was defined stating the precautions intended to mitigate the transmission and spread of COVID-19. Review of the agency's infection control and COVID-19 policies revealed that the agency did not define their process for ensuring the implementation of precautions intended to mitigate the transmission and spread of COVID-19 for individuals who were not fully vaccinated for COVID-19. During an interview and a joint review of the policies on 11/17/22, the Director of Nurses confirmed that the agency did not have a policy stating the process for ensuring precautions to prevent the transmission and spread of COVId-19 for exempt vaccinated staff. ies