Every finding on record at Crater Community Hospice

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 10 of 10 (100%) personnel records reviewed revealed the agency did not ensure that Emergency Preparedness training was provided to and documented for all staff per the agency's policy. POLICY: The agency's "Emergency Preparedness Plan (EPP): Training and Testing" policy (undated) stated in part, "B. All new staff will be trained on the EPP in orientation. C. Volunteers must be trained in the EPP. D. Emergency Preparedness training will be conducted annually. E. Documentation of the training on the EPP and annual emergency preparedness training will be maintained by the Director of Compliance and Quality Care." PERSONNEL RECORD 1: A review of the Administrator's personnel record (DOH 08/03/2020) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 2: A review of the Director of Compliance's personnel record (DOH 01/07/2019) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 3: A review of the Director of Clinical Services' personnel record (DOH 01/07/2019) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 4: A review of the Registered Nurse's personnel record (DOH 04/11/2022) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2023- 2024 and none year to date 2025. PERSONNEL RECORD 5: A review of the Hospice Aide's personnel record (DOH 10/28/2014) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 6: A review of the Social Worker's personnel record (DOH 05/14/2007) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 7: A review of the Spiritual Counselor's personnel record (DOH 05/24/2021) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 8: A review of the Medical Director's personnel record (DOH 10/14/2021) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 9: A review of the Volunteer Coordinator's personnel record (DOH 02/07/2011) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2022- 2024 and none year to date 2025. PERSONNEL RECORD 10: A review of the Volunteer's personnel record (DOH 05/16/2023) revealed that there was no documented annual training on the agency's Emergency Preparedness Plan per the agency's policy. There was no documented evidence of training for 2024 and none year to date 2025. The Director of Compliance (Personnel Record 2) was interviewed on 09/25/2025 and stated, "I don't have any sign-in sheets or documented attendance for all employees on the Emergency plan. We have gone over it at staff meetings, but it's not well documented."

It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal. This standard was not met as evidenced by document review and interview. In 18 of 19 (95%) clinical records reviewed revealed the agency did not ensure that patients were provided with contact information for CHAP for the purpose of voicing grievances. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 01/22/2025. The signed and dated (01/22/2025 by the Power of Attorney) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 04/10/2025. The signed and dated (04/10/2025 by the Power of Attorney) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 06/05/2025. The signed and dated (06/05/2025 by the Power of Attorney) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 07/17/2025. The signed and dated (07/17/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 08/20/2025. The signed and dated (08/20/2025 by the patient's spouse) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 7: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 04/13/2025. The signed and dated (04/13/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 07/30/2025. The signed and dated (07/30/2025 by the patient's daughter) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 9: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 03/25/2025. The signed and dated (03/25/2025 by the patient's daughter) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 10: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 07/31/2025. The signed and dated (07/31/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 11: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 08/09/2025. The signed and dated (08/09/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 12: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 08/26/2025. The signed and dated (08/26/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 13: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 02/28/2025. The signed and dated (02/28/2025 by the patient's son) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 04/16/2025. The signed and dated (04/16/2025 by the patient's son) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 15: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 01/16/2025. The signed and dated (01/16/2025 by the patient's Power of Attorney) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 16: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 08/05/2025. The signed and dated (08/05/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 17: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 06/25/2025. The signed and dated (06/25/2025 by the patient's spouse) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 02/20/2025. The signed and dated (02/20/2025 by the patient's Power of Attorney) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact name, address, phone number, or email for CHAP. CLINICAL RECORD 19: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 03/10/2025. The signed and dated (03/10/2025 by the patient) "Informed Consent" stated in part, "16-I understand I have a right to a timely process of review and resolution if any complaints regarding hospice services without fear of reprisal. These complaints should be made to the (Agency name and CEO name) at (phone number), or in writing, to the complaint unit of (the Department of Health-address and phone number). I understand I may also contact the State Ombudsman at (phone number), or in writing at the (State)Area on Aging - address." The section of the consent regarding complaints did not include the contact's name, address, phone number, or email for CHAP. The Director of Compliance (Personnel Record 2) was interviewed on 09/23/2025 and stated, "We didn't realize that CHAP contact information needed to be included in the booklet (for complaints)."

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by interview and clinical record review. In 1 of 1 (100%) discharged patient records where Medicare was the primary payor, the agency did not ensure that the Notice of Medicare Non-Coverage was provided to the patient as outlined in the "Notice Instructions for the Notice of Medicare Non-Coverage (NOMNC)" instructions (form CMS-10123). CLINICAL RECORD 15: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 01/16/2025. Medicare was the payor source for the hospice admission. The patient was recertified two (2) times. The patient was discharged from hospice care on 08/20/2025 because the patient no longer qualified for the hospice benefit. A documented and signed Notice of Medicare Non-Coverage (NOMNC) was present in the record dated 08/19/2025. The agency did not ensure that the NOMNC was provided to the patient at least two calendar days before Medicare-covered services ended. During the interview with the Compliance Director (Personnel Record 2), it was stated, "Many of the family members want the forms emailed to them and we don't always get them back timely." A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 01/11/2024. Medicare was the payor source for the hospice admission. The patient was recertified four (4) times. The Interdisciplinary Team (IDT) documented in the IDT team meeting note dated 10/17/24 that the patient had stabilized and that hospice services were no longer required. The patient was discharged from hospice care on 10/28/2024. A documented and signed Notice of Medicare Non-Coverage (NOMNC) was present in the record dated 10/28/2024. The agency did not ensure that the NOMNC was provided to the patient at least two calendar days before Medicare-covered services ended.

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. POLICY: The agency's policy "Bereavement Services" (Policy Number PFC.B30, dated 10/13/2022) stated in part, "6. The hospice nurse or social worker may perform the initial bereavement assessment on admission." CLINICAL RECORD 16: A review of the clinical record revealed that the Registered Nurse (RN) completed the initial nursing assessment on 08/25/2025. The RN's note included documentation that stated, "Bereavement Risk Assessment: Risk assessment completed: No. Reason Bereavement Risk Assessment not completed: Other: to be completed." There were no orders on the plan of care (POC) for Social Work services, as the patient declined. There was no documented initial bereavement risk assessment in the clinical record. CLINICAL RECORD 17: A review of the clinical record revealed that the Registered Nurse (RN) completed the initial nursing assessment on 06/25/2025. The RN's note included documentation that stated, "Bereavement Risk Assessment: Risk assessment completed: No. Reason Bereavement Risk Assessment not completed: Other: TO BE COMPLETED BY SOCIAL WORKER." There were no orders on the plan of care (POC) for Social Work services, as the patient declined. There was no documented initial bereavement risk assessment in the clinical record. The Bereavement Coordinator (BC) (Personnel Record 7) reviewed the records and was interviewed on 09/24/2025. The BC confirmed that the initial bereavement assessments were not completed as part of the comprehensive assessments.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visit observation visits revealed the agency did not ensure that clinical staff disinfected equipment per the agency's policy. POLICY: The agency's "Infection Control - Standard and Transmission based precautions" policy (Policy CES.I55 - dated 04/22/2025) stated in part, "Procedures: 1. All Hospice staff are required to use standard precautions in the care of all hospice patients, regardless of diagnosis or presumed infection status. Standard precautions include but are not limited to: e. Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Centers for Disease Control and Prevention (CDC) standards. HOME VISIT 4: A home observation visit was conducted on 09/23/2025 with the Social Worker (SW). During the visit, the SW handed the computer tablet to the patient's daughter for her to sign. The patient's daughter held the tablet and signed her name with her finger on the screen. The SW retrieved the tablet from the daughter, closed the tablet's cover, and concluded the home visit. The SW did not disinfect the tablet or the screen after it was handled by the patient's daughter. The SW did not follow the agency's policy on cleaning and disinfecting contaminated surfaces. The Compliance Director (Personnel Record 2) was interviewed on 09/23/2025 and stated, "The tablet should be disinfected each time after patient or family contact."

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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. 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 3 of 3 (100%) discharge records reviewed revealed the agency did not ensure that the bereavement plan of care included the types of bereavement services to be offered and the frequency of service delivery. POLICY: The agency's policy "Bereavement Care Planning" (Policy Number PFC.B10, dated 09/07/2022) stated in part, "5. The bereavement plan of care reflects the assessed need of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery." POLICY: The agency's policy "Bereavement - Files" (Policy Number PFC.B15, dated 11/22/2022) stated in part, "2. The bereavement file contains a. The bereavement risk assessment(s) and care plans(s) for the person(s) for whom the hospice will provide bereavement services; and b. Bereavement notes documenting all services to and contact with the bereaved person(s)." CLINICAL RECORD 17: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 06/25/2025. There was no initial bereavement assessment documented during the initial comprehensive assessment dated 06/25/2025. The patient died on 08/13/2025. A bereavement plan of care did not address the needs of the bereaved and did not specify the type of bereavement services to be offered and the frequency of delivery, as per the agency's policy. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 02/20/2025. An initial bereavement assessment was documented during the comprehensive assessment dated 02/20/2025. The risk assessment was documented as having a "low risk" rating. The patient died on 04/03/2025. A bereavement plan of care did not address the needs of the bereaved and did not specify the type of bereavement services to be offered and the frequency of delivery, as per the agency's policy. CLINICAL RECORD 19: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 03/10/2025. An initial bereavement assessment was documented during the comprehensive assessment dated 03/10/2025. The risk assessment was documented as having a "low risk" rating. The patient died on 07/12/2025. A bereavement plan of care did not address the needs of the bereaved and did not specify the type of bereavement services to be offered and the frequency of delivery, as per the agency's policy. The Bereavement Coordinator (Personnel Record 7) was interviewed on 09/24/2025 and stated, "We don't have a specific bereavement care plan for each of the bereaved."

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 and interview. In 2 of 2 (100%) discharge records reviewed revealed the agency did not ensure that the discharge summary was sent to the patient's community primary care provider following discharge or revocation of services. CLINICAL RECORD 15: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice service on 01/16/2025. The patient was recertified twice and was discharged on 08/20/2025 because the patient no longer met hospice criteria. A discharge summary was present in the clinical record, but there was no documentation that it was sent to the patient's attending physician. CLINICAL RECORD 16: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice service on 08/05/2025. The patient revoked the hospice benefit on and was discharged on 08/16/2025. A discharge summary was present in the clinical record, but there was no documentation that it was sent to the patient's attending physician. The Director of Compliance (Personnel Record 2) reviewed the records and validated that the Discharge Summaries were not sent to the patients' attending physicians. The Director of Compliance (Personnel Record 2) stated, "There would be documentation if the summaries were sent. There is no documentation in these records."

It is required that the 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 418.24. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 12 (8%) records reviewed revealed the agency did not ensure that the interdisciplinary group (IDG) completed an initial comprehensive assessment no later than 5 calendar days after the election of hospice care. Clinical Record 4: The patient elected hospice on 12/8/21. Review of the initial comprehensive assessments completed by the registered nurse and the social worker revealed there was no evidence that an assessment of the patient's spiritual needs was completed. There was no evidence that an initial comprehensive assessment of the patient's spiritual needs was completed by the interdisciplinary group (IDG) within 5 days of the start of care. During an interview conducted on 12/8/22, the quality manager (staff 6) confirmed that the IDG did not complete an initial comprehensive assessment that included the patient's spiritual needs within 5 days of the election of hospice care.

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 a review of document reviews, interviews and observations. 1 of 3 (33%) home visits revealed the agency did not ensure that the staff use standard precautions such as hand hygiene. The agency policy #CES.155 "Infection Control-Standard Precautions", (revision 1/15/22), stated in relevant parts "Handwashing... Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments." Home Visit 1: A home visit was conducted on 12/7/22 with a Registered Nurse (RN)(Staff 5). The RN doffed gloves after performing a hands on assessment of the patient and proceeded to work with the patients' medications and document on their electronic medical record tablet without washing hands as per the policy. During an interview conducted on 12/7/22, the quality manger (staff 6) confirmed that staff 5 did not follow standard precautions and the established policy for hand hygiene.

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 a review of clinical records and interviews. In 5 of 8 (62%) records reviewed for patients requiring recertification it was revealed that the agency did not ensure that the medical director or physician-designee completed the recertification no later than two (2) calendar days after the first day of each benefit period. Clinical Record 3: The patient elected hospice care on 12/11/21. Review of the recertification of terminal illness for benefit period number 6 (BP#6), dated 9/7/22 through 11/5/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 9/29/22, 22 days after the start of the benefit period. There was no evidence that a verbal recertification had been obtained within 2 days of the start of the benefit period (BP#6). Clinical Record 4: The patient elected hospice care on 12/8/21. Review of rectification of terminal illness for benefit period number 4 (BP#4), dated 8/5/22 through 10/3/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was signed by the medical director on 9/30/22, 56 days after the start of the benefit period. In addition, a review of the recertification of terminal illness for benefit period number 5, (BP #5) dated 10/4/22 through 12/2/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 10/23/22, 19 days after the start of the benefit period. There was no evidence that a verbal recertification had been obtained for these benefit periods (BP#4 and BP#6). Clinical Record 5: The patient elected hospice care on 4/15/22. Review of the recertification of terminal illness for benefit period number 4 (BP #4), dated 10/12/22 through 12/10/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 11/7/22, 26 days after the start of the benefit period. There was no evidence that a verbal recertification had been obtained for this benefit period (BP#4). Clinical Record 7: The patient elected hospice care on 1/23/2019. Review of the recertification of terminal illness for benefit period number 22 (BP #22), dated 9/4/22 through 11/2/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 9/29/22, 25 days after the start of the benefit period. There was no evidence that a verbal recertification had been obtained for this benefit period (BP #22). Clinical Record 9: The patient elected hospice care on 4/30/2021. Review of the recertification of terminal illness for benefit period number 8 (BP #8), dated 8/23/22 through 10/21/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 9/9/22, 17 days after the start of the benefit period. In addition, the recertification of terminal illness for benefit period number 9 (BP #9), dated 10/22/22 through 12/20/22, did not include evidence that the recertification document was completed within 2 days of the start of the benefit period. It was completed with the signature of the medical director on 11/2/22, 11 days after the start of the benefit period. There was no evidence that a verbal recertification had been obtained for these benefit periods (BP#8 and BP#9). During an interview conducted on 12/9/22, the Quality Manager confirmed that the medical director or designee had not completed the recertification of terminal illness, or a verbal recertification obtained for clinical record 3, clinical record 4, clinical record 5, clinical record 7 and clinical record 9, within 2 days after the start of the benefit periods identified in the findings.