Every finding on record at Covenant Home Services

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 it was revealed that the agency did not ensure bereavement services were provided per a bereavement plan of care that included the types of bereavement services offered and the frequency of services. CLINICAL RECORD 12: The hospice benefit was elected on 10/13/2025, and the date of death was 12/08/2025. The clinical record review lacked documented evidence of a bereavement plan of care that specified the types of bereavement services offered and their frequency. Bereavement documentation included the following post-death activities: condolence call 12/09/2025, condolences card mailed 12/10/2025, phone call 01/28/2026, call 02/09/2026, bereavement letter mailed 02/25/2026, and call 03/16/2026. Activities were being completed, however, there was no documented evidence of a bereavement plan of care. CLINICAL RECORD 11: The hospice benefit was elected on 08/30/2025, and the date of death was 09/17/2025. The clinical record review lacked documented evidence of a bereavement plan of care that specified the types of bereavement services offered and their frequency. Bereavement documentation included the following post-death activities: initial call to discuss bereavement services on 09/18/2025, condolence care mailed 09/19/2025, phone call on 11/07/2025, letter mailed 11/14/2025, call 01/13/2026, letter mailed 01/29/2026. Activities were being completed, however, there was no documented evidence of a bereavement plan of care. During an interview with the Administrator (Personnel Record 6) on 03/26/2026 she stated she and the volunteer coordinator have discussed the bereavement plan of care and have figured out how to input the plan of care into the electronic medical record so that this will no longer be an issue in the future.

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; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed of patients who elected hospice aide services it was revealed that the agency did not ensure hospice aides were supervised by a registered nurse who made 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. CLINICAL RECORD 2: In the benefit period dated 12/06/2025 to 02/03/2026, the nurse documented on-site supervisory visits for the hospice aides on 12/09/2025, 12/15/2025, 12/22/2025, 01/01/2026, 01/06/2026, 01/13/2026, and 02/04/2026 (22 days). CLINICAL RECORD 3: In the benefit period dated 01/08/2026 to 03/08/2026, the nurse documented on-site supervisory visits for the hospice aides on 01/13/2026, 01/20/2026, 01/27/2026, 02/03/2026, 02/10/2026, 02/17/2026, and then 03/10/2026 (21 days). CLINICAL RECORD 10: In the benefit period dated 08/22/2025 to 10/20/202, the nurse documented on-site supervisory visits for the hospice aides on 08/22/2025, 09/02/2025, and 10/28/2025 (56 days). CLINICAL RECORD 12: In the benefit period dated10/13/2025 to 12/08/2025, the nurse documented on-site supervisory visits for the hospice aides on 10/24/2025, and 11/05/2025. No other aide supervisory visits were documented. The date of death was 12/08/2025 (33 days). During an interview with the Administrator (Personnel Record 6) and hospice clinical supervisor (Personnel Record 5) on 03/25/2026 they stated they did not know how the aide supervisory visits were not documented but they will continue to educate the clinical staff on importance of an aide supervisory visit being completed weekly so as not to miss the fourteen day requirement.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview that revealed the agency did not ensure volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The document review of the volunteer hours lacked evidence that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This was evidenced by the volunteer percentage for the last 12 months as follows: March 2025 -February 2026 was 0.86%. During an interview with the volunteer coordinator (Personnel Record 6) on 03/24/2026 she stated that she has recently taken over the roll and is aware that the hours were not meeting the requirement but they are working on increasing the volunteer percentage, they have had improvement the last couple of months but still have some work to do. The document review of the volunteer hours lacked evidence that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This was evidenced by the volunteer percentage for the last 12 months as follows: March 2025 0.38%, April 2025 0.54, May 2025 0.56%, June 2025 0.59%, July 2025 1.08, August 2025 0.81, September 2025 0.47, October and Novemeber 2025 0%, December 2025 0.66%, January 2026 2.27%, and February 2026 2.99%, this is an average of 0.86% for the last 12 months.

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. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 8 (25%) personnel records reviewed revealed the agency did not ensure to assess the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary. The agency Policy titled "Hospice Human Resources" Policy No. H: 3-001.1 CHAP Hospice Manual/Revised April 2018 stated in part, "Clinical competencies will be assessed during the orientation process and annually thereafter for professional and paraprofessional personnel providing direct patient care." PERSONNEL RECORD 5: The registered nurse (RN) Nursing Supervisor was hired on 11/03/2023. The personnel record review lacked documented evidence of an annual competency as required by agency policy . The RN Nursing supervisor provided patient care as needed. There was no documented evidence of a nursing competency for 2024 or 2025. PERSONNEL RECORD 6: The Volunteer Coordinator was hired on 08/01/2016. The Volunteer Coordinator performed volunteer assessments. The personnel record review lacked documented evidence of an annual competency as required by agency policy for 2023 2024, and 2025. During an interview with the Administrator (Personnel Record 6) on 04/24/2026 she stated that she did not know why the annual competency was not completed but they would review and revise their process and educate staff of the requirement.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the nurse performed a complete assessment related to changes in the patient's physical condition. Clinical Record 2: Election of hospice benefit 2/16/23. A nursing clinical note dated 2/20/23 documented, "POA reports patient was confused today, now baseline. POA requests U/A C/S (urinalysis with culture and sensitivity). (Physician's name) ordered. Facility will carry out the test." A nursing clinical note dated 2/23/23 documented, “UA (urinalysis) shows UTI (urinary tract infection), culture still pending. Staff educated on bladder schedule, increase fluid intake." A nursing clinical note dated 2/27/23 documented “Confusion improved after taking Fosfomycin today." A review of the patient's medication list revealed an entry on 2/27/23 for “Fosfomycin Trom 3gm daily one time for UTI (urinary tract infection)." The nursing comprehensive assessments dated 2/20/23, 2/23/23, and 2/27/23 did not indicate the nurse had assessed the patient's urinary system or patterns of urinary elimination related to the patient having a urinary tract infection. During an interview on 5/4/23, the Administrator confirmed the finding.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments and includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) records reviewed, the agency did not ensure the written plan of care was individualized to include planned interventions and patient and family goals related to problems identified by the Registered Nurse in the initial and updated comprehensive assessments. Clinical Record 1: Election of hospice benefit 8/18/22. The nursing clinical note dated 2/6/23 documented, "Bilateral lower extremities (LE) edematous, Right LE 2+ edema, left LE 1+ edema." The current medication list dated 5/2/23 included, "Xarelto 20mg tablet by mouth 1 tab daily and Colace 100mg 1 cap po (by mouth) BID." The plan of care dated 4/15/23 to 6/13/23 did not include individualized patient/family goals or interventions specific to bleeding precautions, constipation, or edema. Clinical Record 2: Election of hospice benefit 2/16/23. The nursing initial assessment dated 2/16/23 documented, “Is pain an active problem for the patient: Yes, and location: generalized pain, frequency: intermittent, medication had adverse/side effect: constipation." Nursing clinical note dated 2/20/23 documented, “Pain controlled with Fentanyl patch. Start on Senna-s BID (twice a day) for constipation.” The current medication list dated 5/2/23, included routine scheduled medications: Fentanyl transdermal patch, Oxycodone 15mg, and Colace 100 mg. The plan of Care dated 2/16/23 to 5/16/23, did not include individualized patient/family goals related to pain or constipation. Clinical Record 3: Election of hospice benefit 11/21/22. Nursing clinical note dated 2/16/23 documented, “She was a little constipated two days ago and took a suppository. Pt (patient) takes Senna and Miralax daily”. The current medication list dated 5/2/23 included, “Miralax powder 17gm/scoop, 17gm daily po (by mouth) scheduled, and Senna plus tablet 8.6-50mg daily po (by mouth)." The plan of care dated 2/19/23 to 5/19/23 did not include individualized patient/family goals or interventions specific to constipation. Clinical Record 6: Election of hospice benefit 4/16/23. A supplemental physician order dated 4/20/23 documented, "Senna-S tablet 8.6-50mg 2 tabs daily po (by mouth) for constipation." The plan of care dated 4/16/23 to 7/14/23 did not include individualized patient/family goals or interventions specific to constipation. During an interview on 5/5/23, the Administrator confirmed the findings and stated, "We know what we need to document in the plan of care, but we didn't do it."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) records reviewed, the agency did not ensure the plan of care was revised with updated goals and progress towards the expected outcomes when the patient's condition or level of care changed. Clinical Record 2: Election of hospice benefit 2/16/23. A nursing clinical note dated 2/23/23 documented, “UA (urinalysis) shows UTI (urinary tract infection), culture still pending. Staff educated on bladder schedule, increase fluid intake." A review of the patient's medication list revealed an entry dated 2/27/23 for “Fosfomycin Trom 3gm daily one time for UTI (urinary tract infection)." The plan of care was not revised to include updated goals for the patient's urinary tract infection. The interdisciplinary group (IDG) meeting notes and plan of care review dated 3/15/23 documented, “Infection in last two weeks: No.” There was no documentation of urinary issues or infection. Clinical Record 5: Election of hospice benefit 11/4/22. A nursing clinical note dated 12/28/22 documented, “Patient has left foot, left bunion open wound measuring 1.0cm x 1.0cm x 0.1cm with surrounding erythema 3.0cm x 3.5cm. Patient started on Augmentin 875mg -125mg 1 tab po (by mouth) bid x 10 days for left big toe bunion wound infection. Wound care and dressing changed per order." The plan of care was not revised to include updated goals for the patient's wound or infection. The interdisciplinary group (IDG) meeting notes and plan of care review that dated 1/4/23 documented the following: “Skin breakdown/wound: No; and Infection in last two weeks: No." Clinical Record 17: Election of hospice benefit 2/2/23. A physician's order dated 2/16/23 documented, “Respite level of care for 5 consecutive days. Respite care start date 2/16/23 to provide short term relief for overwhelmed primary caregiver." The plan of care was not updated to include goals or interventions related to the patient's respite stay in a facility, or the caregiver's needs related to being overwhelmed. During an interview on 5/5/23, the Administrator confirmed the findings and stated, "We talk about the patient's changes in the IDG (interdisciplinary group) meetings, but we aren't getting those things documented in the plan of care."

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, document review, and interview. In 2 of 3 (67%) clinical records reviewed, in which bereavement services were provided, the agency did not follow its policy and procedure for completion of a bereavement risk assessment after the death of a patient, and did not ensure the clinical record included a bereavement plan of care. Agency policy stated in part: “Within 3-5 weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief ... A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: a bereavement plan of care.” Clinical Record 15: Election of hospice benefit 2/21/22. Patient date of death 8/16/22. The record did not contain evidence of a bereavement plan of care. Clinical Record 16: Election of hospice benefit 5/6/22. Date of death 7/15/22. The bereavement coordinator documented a clinical note on 7/18/22 that stated, “Called daughter to offer condolences.” There was no documented assessment of the caregiver’s symptoms related to grief and bereavement needs per the agency's policy. In addition, there was no bereavement plan of care. During an interview on 5/3/23, the Bereavement Coordinator confirmed the finding and stated, "We document all of the bereavement activity, including the phone calls and mailings, in the clinical notes section of the chart." The Bereavement Coordinator stated "no," when asked if the agency included a plan of care as part of the bereavement services documentation.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 4 of 18 (22%) records reviewed, in which aide services were provided, the agency did not ensure the aide plan of care included specific instructions relevant to the care and condition of the patient. Clinical Record 5: Election of hospice benefit 11/4/22. A review of the aide plan of care dated 11/4/22, effective through the date of the site visit, documented the patient's diet as "regular," and included the task "assist with feeding (if visit done during meal time) two times per week." It was documented that the hospice aide completed the tasks on 4/19/23, 4/24/23, and 4/26/23. A skilled nurse clinical note dated 4/17/23, documented the patient had swallowing issues, including "pureed diet and pocketing food." The aide plan of care was not revised to include swallowing issues or pureed diet. Clinical Record 6: Election of hospice benefit 4/16/23. The aide visit notes dated 4/24/23 and 4/26/23 documented, "Hoyer lift with two people," as a completed task. The aide plan of care dated 4/16/23, effective through the date of the site visit, did not include instructions to utilize a Hoyer Lift. During a joint visit on 4/3/23, to the facility where the patient resided, the facility nurse confirmed the patient is to be transferred utilizing a Hoyer lift. Clinical Record 8: Election of hospice benefit 1/5/23. The physician's orders/plan of care dated 1/5/23 to 4/4/23, and 4/5/23 to 7/3/23, included orders and interventions for wound care to the patient's coccyx including, "Cleanse wound with wound cleanser, pat dry with gauze, apply Alginate Calcium Dressing and Island dressing, with border daily until healed." The aide plan of care dated 1/5/23, and revised on 2/27/23 and 3/27/23, did not include the coccyx wound or the wound dressing. Clinical Record 17: Election of hospice benefit 2/2/23. The plan of care dated 2/17/23 documented, “Cleanse wound to coccyx with wound cleanser, pat dry with gauze, apply Alginate dressing, cover with foam border dressing daily until heals." The plan of care dated 3/23/23 documented, “Left buttock wound cleanse with wound cleanser, pat with gauze, apply Silver Sulfadiazine to wound bed, and cover with foam dressing daily until heals." The skilled nursing assessments completed between 2/17/23 and 4/14/23, indicated the ongoing presence of the wounds until the patient’s death on 4/14/23. The aide plan of care dated 2/9/23, effective until the patient's death on 4/14/23, did not include the wounds or the wound dressings. During an interview on 5/5/23, the Administrator confirmed the findings, and agreed the aide care plans did not include all instructions pertinent to the care of the patient.

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 5 of 18 (28%) records reviewed, in which hospice aide services were provided, the agency did not ensure the hospice aide communicated with a registered nurse when there were changes in the patient's condition or when services were not provided according to the written aide plan of care. Clinical Record 2: Election of hospice benefit 2/16/23. The aide plan of care dated 2/16/23 - 4/19/23, required the aide to perform a complete bed bath two times per week. On 3/13/23 and 3/15/23, the aide visit notes documented that a shower was completed instead of a bed bath. There was no documentation of notification to a registered nurse (RN). Clinical Record 4: Election of hospice benefit 3/13/23. The aide plan of care dated 3/13/23, effective through the date of the site visit, required the aide to complete the following: shower and hair care/shampoo two times a week. During the week of 3/26/23, the aide visit notes documented the following: completed shower and shampoo on 4/1/23; shower refused, patient allowed to wash upon toilet on 3/28/23. There was no documentation that a RN was notified of the refusal of services. In addition, the aide visit note dated 3/28/23 documented, “Skin breakdown noted: redness. Location: peri-area. CM (case manager) aware.” There was no evidence that the aide notified the RN. The skin assessment in the nursing clinical notes, dated 3/27/23 and 3/30/23 documented, “No skin issues noted, no redness." Clinical Record 6: Election of hospice benefit 4/16/23. The aide visit note dated 4/26/23 documented, “Skin breakdown noted: redness. Location: bottom, CM (case manager) aware”. The aide visit note dated 4/24/23 documented, “Skin breakdown noted: redness. Location: peri-area, CM (case manager) aware." The aide visit note dated 4/18/23 documented, “Skin breakdown noted: redness. Location: buttocks. CM (case manager) aware." There was no evidence that the aide contacted the RN to report the skin breakdown. The skin assessments in the nursing clinical notes dated 4/17/23, 4/21/23, 4/24/23, and 4/27/23, documented "skin integrity intact, thin and fragile." Clinical Record 8: Election of hospice benefit 1/5/23. The aide plan of care dated 1/5/23 - 2/25/23, required the aide to complete a shower two times per week. During the week of 2/12/23, the aide visit notes documented the following: completed a shower on 2/17/23; the shower was refused, complete bed bath was given on 2/14/23. During the week of 2/19/23, the aide visit notes dated 2/23/23 and 2/24/23 documented the shower was refused and a complete bed bath given. There was no evidence the aide reported the change in services to a RN. Clinical Record 17: Election of hospice benefit 2/2/23. The aide plan of care dated 2/9/23, effective until the patient's death on 2/14/23, required the aide to complete a bed bath two times per week. The aide visit notes documented the following: “Pt (patient) refused due to daughter there” on 2/9/23; and bed bath refused on 2/14/23. There was no evidence the aide reported the refusal of services to a RN. During an interview on 5/4/23, the Administrator confirmed the findings, and agreed the aide did not document communication with a registered nurse, when needed.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review and interview. In 2 of 3 (67%) personnel files reviewed, for employees hired on or after 8/20/20, the agency did not ensure the initial orientation included information on hospice philosophy, advanced directives, or the employee's specific job duties. Personnel Record 2: Registered Nurse/Hospice Clinical Manager, date of hire 8/16/21. During a review of the employee's personnel record, there was no documented evidence that the employee had been oriented to the roles and responsibilities of a hospice clinical manager. Nor was there evidence of orientation on hospice philosophy or advanced directives. During an interview on 5/5/23, the Administrator confirmed the finding and stated, that the employee was hired and oriented to be the agency's Home Health Clinical Manager, but was also appointed, at the time of hire, to be the interim Hospice Clinical Manager. The Administrator confirmed the employee is currently in the role of Hospice Clinical Manager and stated, "We did not have her complete the hospice core courses as part of her orientation." Personnel Record 4: Hospice Aide, date of hire 4/11/22. During a review of the employee's personnel record, there was no documented evidence of orientation of hospice philosophy, advanced directives, or the needs and concerns of patients and families coping with a terminal illness. During an interview on 5/5/23, the Administrator confirmed the finding and stated, "She was an employee at a facility within our company, who wanted to come work for hospice. We did not have her complete the hospice core courses as part of her orientation when she transferred to us."

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 15 (7%) records reviewed, in which the patient resided in a nursing facility, revealed the agency did not ensure the plan of care specified which provider was responsible for performing treatment orders for wound care Agency policy, Professional Management of Hospice Plan of Care, stated in part, “The Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. Hospice retains the primary responsibility for development of the Plan of Care.” Clinical Record 8: Election of hospice benefit 1/5/23. Physician’s orders/Plan of care dated 1/5/23 to 4/4/23 included, "Wound care to coccyx per staff RN or hospice RN, cleanse with NS/wound wash, pat dry, apply CA alginate, cover with island border dressing as needed if soiled or dislodged," with a start date of 1/5/23 and end date of 1/20/23. The same plan of care documented a treatment order including: “Frequency of wound care: Coccyx: Cleanse wound with wound cleanser, pat dry with gauze, apply Alginate Calcium Dressing and Island dressing with border daily until healed,” with a start date of 1/20/23 to current. The plan of care did not indicate who was responsible, including which days, to complete the wound care treatments. During an interview on 5/4/23, the Administrator confirmed the finding and stated, "In that facility, the wound care is usually managed by the facility’s wound doctor and we follow their directives.”

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: The most recent hospice plan of care and physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, observation, and interview. 1 of 3 (33%) home visit observations, for patients residing in a facility, revealed the hospice did not ensure a copy of all required documents had been provided to the facility. Agency policy, Staff Coordination, stated in part, “The designated interdisciplinary team member will be responsible for the following: providing the Nursing Facility with the following information: the most recent hospice plan of care specific to each patient; physician certification and recertification of the terminal illness specific to each patient." Home Visit 3: During the observed home visit on 5/3/23, for a patient with a hospice election date of 3/20/23, the facility's patient chart was reviewed. The following required hospice documentation was missing: the current plan of care and the physician certification. During the joint visit on 5/3/23, the Registered Nurse confirmed the missing documentation and stated, "The information is usually emailed to the facility for them to place in the chart. I do not know why it is not here." During an interview on 5/5/23, the Administrator confirmed the finding, and stated they did not have additional evidence to support the documentation had been emailed or sent to the facility.