Every finding on record at Cfhc No20 Inc

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure documentation of an initial bereavement assessment that included the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. CLINICAL RECORD 1: The patient elected the hospice benefit on 10/02/2025 with a diagnosis of cardiomegaly. The bereavement risk assessment section of the initial spiritual assessment dated 10/06/2025 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/07/2025 with a diagnosis of acute on chronic right heart failure. The bereavement risk assessment section of the initial spiritual assessment dated 11/10/2025 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/07/2026 with a diagnosis of Parkinson’s disease. The bereavement risk assessment section of the initial spiritual assessment dated 01/08/2026 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 10: The patient elected the hospice benefit on 12/31/2025 with a diagnosis of chronic combined systolic and diastolic heart failure. The bereavement risk assessment section of the initial spiritual assessment dated 01/02/2026 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 11/24/2025 with a diagnosis of chronic obstructive pulmonary disease. The bereavement risk assessment section of the initial spiritual assessment dated 11/25/2025 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/26/2025 with a diagnosis of hemiplegia following cerebral infraction. The bereavement risk assessment section of the initial spiritual assessment dated 07/30/2025 was left blank and there was no documented evidence in the clinical record of an initial bereavement assessment. During an interview on 02/27/2026, the Clinical Manager (Personnel Record 5) stated that she does not know why the bereavement risk assessment part of the spiritual initial assessment was blank, but they would be investigation and provide education to staff.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who died on hospice services, the agency did not ensure documentation of a bereavement plan of care that included the types of bereavement services offered and the frequency of services. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/27/2025, and the patient’s death was dated 08/15/2025. Clinical record review revealed documentation of post-death bereavement assessment, mailings, and letters; however, there was no documented evidence in the clinical record of a bereavement plan of care that included the bereavement services to be offered and the frequency of services. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/18/2025, and the patient’s death was dated 03/22/2025. Clinical record review revealed documentation of post-death bereavement assessment, mailings, and letters; however, there was no documented evidence in the clinical record of a bereavement plan of care that included the bereavement services to be offered and the frequency of services. During an interview on 02/27/2026, Bereavement Coordinator (Personnel Record 3) stated that she has it on her computer and she produced a tracking sheet that had bereavement services and when due, but states that she did not know that the bereavement care plan was built into the electronic medical record but that she has found it now and will be sure that everyone has a bereavement care plan from this day forward.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered in the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/23/2024 with a diagnosis of atherosclerotic heart disease without angina pectoris. Clinical record review revealed the hospice aide documented aide visits to the patient on 12/30/2025, 01/02/2026, 01/27/2026, 01/29/2026, 02/03/2026, 02/05/2026, 02/10/2026, 02/12/2026, 02/17/2026, and 02/24/2026. The plans of care updated by the IDG on 12/30/2025, 01/13/2026, 01/28/2026, 02/11/2026, and 02/25/2026 did not include an order for hospice aide frequency of visits. During an interview on 02/27/2026, the Clinical Manager (Personnel Record 5) stated that the plan of care was not updated at recertification and explained that adding the frequency to the new benefit period is an ongoing education needed by the staff. The Clinical Manager stated they will be providing additional education and adding audits to monitor.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes in the patient’s needs to the registered nurse. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/07/2025 with a diagnosis of acute on chronic right heart failure. The hospice aide plan of care dated 11/09/2025 assigned the aide the tasks of clean/file toenails, comb hair, inspect mouth, inspect skin, perineal care, shampoo hair, and shower and the following were documented as completed apply lotion, assist with dressing, bathe/inspect feet, brush teeth/dentures, clean/file fingernails at every visit. On the aide visit note dated 11/26/2025, the aide documented the tasks were not completed, however there was no documentation in the clinical record that the Registered Nurse was notified of the incomplete tasks. During an interview on 02/27/2026, the Clinical Manager (Personnel Record 5) stated that this is education that she will be providing to her hospice aides in the near future. The Clinical Manager stated that they are notifying the registered nurse, but are not adding it to the notes section, but they will in the future.

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 4 of 8 (50%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals that provided care were assessed and documented. Agency policy titled Staff Competency Program, date unknown, required in part, "Initial competency is completed during orientation and before independent patient care (or within defined onboarding timeframes by role). Ongoing competency is completed at least annually for all staff, and more often when indicated." PERSONNEL RECORD 1: Registered Nurse date of hire 08/18/2025. Personnel record review revealed no documented evidence of an initial competency assessment for the registered nurse. The nursing competency form in the personnel record was left blank. PERSONNEL RECORD 6: Licensed Clinical Social Worker/Volunteer Coordinator date of hire 01/27/2025. Personnel record review revealed no documented evidence of an initial competency assessment for the social worker. The social worker competency form in the personnel record was left blank. PERSONNEL RECORD 7: Nurse Practitioner date of hire 11/11/2024. Personnel record review revealed no documented evidence of an initial competency and annual competency for the nurse practitioner. The nurse practitioner competency form in the personnel record was signed and dated 11/20/2024 was not completed and there was no clinical competency assessment found for 2025. PERSONNEL RECORD 9: Volunteer date of hire 04/18/2024. Personnel record review revealed no documented evidence of an initial competency and annual competency for the volunteer. During an interview on 02/27/2026, the Clinical Manager (Personnel Record 5) stated that they share administrative tasks and that the competencies just fell through the cracks; however, she had a conversation with her superiors, and they agreed to hire someone specifically for personnel records.

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 described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient transferred to another hospice, the agency did not ensure the hospice discharge summary was forwarded to the receiving hospice. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/26/2025 and was transferred to another hospice agency on 08/14/2025. There was no documented evidence in the clinical record that the discharge summary dated 08/15/2025 was sent to the receiving hospice. During an interview on 02/27/2026, the Clinical Manager (Personnel Record 5) stated that she remembered sending the discharge summary, plan of care, medication list, and current certification of terminal illness, but does not have documentation that the information was sent to the receiving agency. She also stated that they would be looking at the process and providing education to the staff to ensure the information is sent and documented.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) clinical records reviewed of patients who had a social work assessment, revealed the agency did not ensure the social worker developed an individualized hospice plan of care for each patient that included patient and family goals and interventions based on problems identified in the initial assessment. Clinical Record 2: Date of hospice election was 5/16/2023. The social worker made an initial assessment visit on 5/16/23 and noted a need "to continue to offer psychosocial and end-of-life support to the patient and caregiver/family." There was no documented evidence in the clinical record that the social worker added patient and family goals and interventions to the plan of care to address the problem related to the need for psychosocial and end of life support. Clinical Record 3: Date of hospice election was 5/18/2023. The social worker made an initial assessment visit on 5/19/23 and noted a need "to continue to offer psychosocial and end-of-life support to the patient and caregiver/family." There was no documented evidence in the clinical record that the social worker added patient and family goals and interventions to the plan of care to address the problem related to the need for psychosocial and end of life support. In an interview on 6/13/23, the Director of Nursing agreed there were no goals or interventions on the care plan for problems identified during the social work assessment.