Every finding on record at Coastal Hospice Inc

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. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%), personnel records reviewed revealed the agency did not ensure to provide counseling services in an organized program for bereavement services delivered by or under the supervision of a qualified professional. DOCUMENT 1: The agency's policy and procedure 9-023, titled “Bereavement Services,” dated 05/2022, stated in part, "Services will be provided by personnel who have received training and have experience in dealing with grief." PERSONNEL RECORD 6: The bereavement coordinator was hired on 10/01/2024. The employee signed a job description on 10/01/2024, acknowledging education and/or experience in grief and loss counseling. During the review of the personnel record on 02/26/2026, it was revealed that the personnel record did not include documented evidence of the bereavement coordinator's experience or education in grief or loss counseling. An interview was conducted on 02/26/2026 with the Alternative Administrator/Director of Nursing (PERSONNEL RECORD 11), who confirmed that the employee was hired without experience in grief or loss counseling.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need and the hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 6 (67%) clinical records with aide services ordered revealed that the agency did not ensure supervision of the aide's care plan at least every 14 days. DOCUMENT 2: The agency's policy and procedure titled “Hospice Aide Supervisory Visits,” dated May 2022, stated in part, "The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days." CLINICAL RECORD 6: The patient elected the hospice benefit on 01/20/2026 with a diagnosis of Protein-calorie malnutrition. The hospice aide plan of care was ordered by the IDG on 01/20/2026. The patient was seen by the aide on 01/28/2026, 02/05/2026, 02/10/2026, 02/17/2026, and 02/24/2026. After reviewing the clinical record, it was revealed that the clinical record did not have documented evidence that an aide supervisory visit was conducted as of 02/26/2026 (28 days outstanding). CLINICAL RECORD 7: The patient elected the hospice benefit on 12/11/2025 with a diagnosis of end-stage heart failure. The hospice aide plan of care was ordered by the IDG on 12/10/2025. The patient was seen by the aide on 12/10/2025, 12/18/2056, 12/23/2025, 12/30/2025, 01/07/2026, 01/14/2026, 01/21/2026, 01/28/2026, 02/03/2026, 02/10/2026, 02/18/2026, and 02/25/2026. After reviewing the clinical record, it was revealed that the clinical record did not have documented evidence that an aide supervisory visit was conducted as of 02/26/2026 (77 days outstanding). CLINICAL RECORD 8: The patient elected the hospice benefit on 01/10/2026 with a diagnosis of severe protein-calorie malnutrition. The hospice aide plan of care was ordered by the IDG on 01/12/2026. The patient was seen by the aide on 01/14/2026, 01/21/2026, and 01/28/2026. After reviewing the clinical record, it was revealed that the clinical record did not have documented evidence that an aide's supervisory visit was conducted. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/04/2025 with a diagnosis of moderate protein-calorie malnutrition. The hospice aide plan of care was ordered by the IDG on 12/05/2025. The patient was seen by the aide on 12/11/2025, 12/23/2025, 12/29/2025, 01/06/2026, and 01/13/2026. After reviewing the clinical record, it was revealed that a Registered Nurse (RN) supervisory visit was conducted on 01/21/2026 (40 days after the first aide visit). An interview was conducted with the Alternate Administrator/Director of Nursing (Personnel Record 11) on 02/26/2026. It was confirmed that the record did not have documented evidence that a supervisory visit was conducted every 14 days as per agency policy.

It is required that a registered nurse make an annual on-site visit to the location where a patient is receiving care to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel records reviewed revealed that the agency did not ensure an annual on-site visit to the location where a patient receives care annually. DOCUMENT 2: The agency's policy 1-037 titled “Hospice Aide Supervisory Visits”, dated 05/2022, stated in part “that the overall performance of the aide will be evaluated at least annually for competency by the Case Manager, making an on-site visit.” PERSONNEL RECORD 2: The hospice aide was hired on 11/05/2013. In a review of the personnel record, it was revealed that the record did not have documented evidence that an on-site visit was performed by an RN for the year 2025. An interview was conducted with the Alternate Administrator/Director of Nursing (Personnel Record 11) on 02/26/2026. He confirmed that there is no documented evidence to support an on-site assessment of the aide by the RN case manager in 2025.

It is required that the hospice medical director or physician designee review the clinical information for each patient being evaluated for admission and provide written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the medical director or physician designee reviewed the clinical information for each patient being evaluated for hospice and provided a written certification of terminal illness DOCUMENT 5: The agency's policy 1-007 titled “Certification of Terminal Illness,” dated May 2022, stated in part, "At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness." CLINICAL RECORD 13: The patient elected the hospice benefit on 09/25/2025 with a diagnosis of NSTEMI myocardial infarction. The patient revoked the hospice benefit on 10/17/2025. The clinical record did not include a documented certification of terminal illness. An interview was conducted on 02/26/2026, with the Alternate Administrator/Director of Nursing (Personnel Record 11). The finding was reviewed, and he confirmed that the initial written certification was not found in the clinical record.

It is required that the hospice medical director or physician-designee provide 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 2 of 7 (29%) clinical records reviewed, where recertification is required revealed that the agency did not ensure recertification was completed no later than two calendar days after the first day of each benefit period. CLINICAL RECORD 1: The patient elected hospice benefit on 09/23/2025 with a diagnosis of protein-calorie malnutrition. The clinical record does not include a documented recertification of terminal illness for the benefit period 12/22/2025 – 03/21/2026. CLINICAL RECORD 5: The patient elected hospice benefit on 09/03/2025 with a diagnosis of cerebral vascular dementia. The clinical record does not include a documented recertification of terminal illness for the benefit period 12/02/2025 – 03/01/2026. An interview was conducted on 02/26/2026, with the Alternate Administrator/Director of Nursing (Personnel Record 11). The findings were reviewed, and he confirmed that the written recertification of terminal illness was not found in the clinical record.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical records reviewed, where the patient was revoked from hospice care, it was revealed that the agency did not ensure a discharge summary was sent to the attending physician. DOCUMENT 4: The agency's policy 1-024 titled "Revocation of Hospice Benefit," dated May 2022, stated, in part, "A discharge summary will be sent to the attending physician." CLINICAL RECORD 13: The patient elected the hospice benefit on 09/25/2025 with a terminal diagnosis of NSTEMI myocardial infarction. The patient revoked the hospice benefit on 10/17/2025. There was no documented evidence in the clinical record that a discharge summary was sent to the attending physician. An interview was conducted on 02/26/2026, with the Alternate Administrator/Director of Nursing (Personnel Record 11). The finding was reviewed, and he confirmed that a discharge summary was not sent to the attending physician.

It is required that the hospice obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 15 (7%) personnel records reviewed revealed that the agency did not ensure a criminal background check was obtained for a contracted employee prior to direct patient contact or access to records. DOCUMENT 6: The agency's policy 1-005, titled Selection/Hiring of Personnel, dated May 2022, stated in part, "A criminal background check will be obtained for positions." PERSONNEL 14: The medical director was hired on 11/01/2023. A review of the personnel record revealed that the contracted employee signed a contract on 11/01/2023. The personnel record showed that a criminal background check was not conducted at the time of hire and as of 02/26/2026. An interview with the Human Resources Designee was conducted on 02/26/2026, and confirmed that no criminal background check was conducted for the contracted employee. The agency has requested a criminal background check during the site visit. An Interview was conducted with the Alternative Administrator/Director of Nursing (Personnel Record 11) on 02/26/2026, during which the findings were reviewed, and he confirmed that the contracted employee has had direct patient contact and access to patient records.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the initial psychosocial assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 3/14/2023. The initial psychosocial assessment was completed by the social worker on 3/21/2023, day 7. There was no documented reason for the delay. Clinical Record 3: The patient elected the hospice benefit on 3/28/2023. The initial psychosocial was completed by the social worker on 4/3/2023, day 6. There was no documented reason for the delay. The hospice Clinical Director was interviewed on 4/20/2023 and agreed, there was no documented evidence the initial psychosocial assessments were completed within five days of the election of hospice care.

It is required that each patient’s individualized written plan of care reflects patient and family goals, includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the plan of care reflected patient and family goals with outcomes that were defined and measurable. Clinical Record 3: The patient elected the hospice benefit on 3/28/2023 with a primary diagnosis of moderate protein calorie malnutrition. The plan of care for 3/28/2023-4/19/2023 was reviewed. Problem: nutrition. Goal: Patients nutritional intake will be to patient’s desire while on hospice. There was no documented evidence of the patient’s desired level for nutrition. Clinical Record 11: The patient elected the hospice benefit on 3/2/2023. The plan of care for 3/2/2023-3/11/2023 (date of death) was reviewed. The Registered Nurse assessment on 3/2/2023 documented 3+ BLE (bilateral extremity) edema. Problem: Edema. Goal: Patient’s edema will be managed to a desired level while on hospice. There was no documented evidence of the patient’s desired level for edema. The hospice Clinical Director was interviewed on 4/20/2023 and agreed, there was no documented evidence the plans of care included goals that were defined and measurable.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 1 of 3 (33%) home visit observations revealed the hospice did not ensure adherence to the agency’s infection control policies and procedures for hand hygiene. Document 2: Agency Policy, “Hand Hygiene, Policy No. 7-009,” stated in part, “Hand washing with soap and water. Wash hands for at least 20 seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off the faucet.” Home Visit 3: During observation of home visit 3 with the hospice aide on 4/19/2023, the hospice aide was observed turning on the faucet, washing her hands then turned the faucet off with her hands. The hospice aide then proceeded to provide cares to the patient. The hospice aide was not observed turning off the faucet with a paper towel. The hospice Clinical Director was interviewed on 4/20/2023 and agreed, the hospice aide did not follow the agency’s hand hygiene policy.