Every finding on record at Family First Hospice Care LLC

It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed revealed the agency did not ensure the patient or his representative received written notice of his rights and responsibilities in advance of providing care. CLINICAL RECORD 1: A review of the clinical record on 04/03/2026 revealed that the election of benefits signed was on 03/19/2026 by the legal representative, but the start of care/election of benefits date was left blank. The patient was not admitted until 03/26/2026, and there was no documentation provided that explained the patient or legal representative was notified of the election of the hospice benefit date. An interview and joint clinical record review were conducted with the Director of Clinical Services on 04/03/2026, during which time she stated, "The paperwork had been signed on 03/19/2026, the family was undecided about hospice, and the start of care date was left blank. They later called back and decided to be admitted, and the consents had not been completed again."

It is required that 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 and interview. In 1 of 4 (25%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 3: A physician's order and nursing assessment dated 02/12/2026 noted the patient had a Foley catheter. The hospice aide plan of care dated 01/22/2026 included the following tasks: "Assist with diapers/briefs; bedpan/urinal; incontinent of bladder/bowel; bedbath; assist to dress; comb/brush hair; shampoo/style hair; inspect skin; shave; perineal care; bathe feet; turn and position; inspect mouth; assist with brushing teeth; record recent BM (bowel movements); gentle range of motion; linen change-weekly." All tasks were to be completed every visit unless otherwise specified, with an aide frequency of 5x per week. The Foley was not noted on the hospice aide care plan, and the aide was not given specific instructions for the care of the Foley. An interview and joint clinical record review were conducted with the Director of Clinical Services on 04/03/2026, during which time she stated: "The patient had a Foley placed on 02/12/2026 and still had the Foley in place; however, it had mistakenly not been added to the aide care plan."

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; The frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. 3 of 3 (100%) clinical records reviewed of patients who were discharged due to death revealed that the hospice did not ensure that the needs of the bereaved were identified in a bereavement plan of care. Agency policy, "Bereavement Services", policy No. 2-010.1, stated in part, "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 12: The patient elected the hospice benefit on 09/02/2025 and was discharged due to death on 12/16/2025. The record included bereaved individual(s), however, there was no documented evidence of a bereavement plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/21/2025 and was discharged due to death on 03/02/2025. The record included bereaved individual(s) and regular bereavement mailings, however, there was no documented evidence of a bereavement plan of care. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/11/2025 and was discharged due to death on 06/18/2025. The record included bereaved individual(s) and regular bereavement mailings, however, there was no documented evidence of a bereavement plan of care. During a joint record review and interview on 02/26/2026, the Bereavement Coordinator agreed there was no documented evidence of bereavement plans of care in the 3 cited records. Additionally, the Bereavement Coordinator stated, "The last Bereavement Coordinator and I shared the role, then she left and I realize I didn't pick up where she left off. I have not done any bereavement plans of care. I didn't know we needed one." During an interview on 02/26/2026, the Administrator stated, "He may not have received enough education. We need to educate the Bereavement Coordinator on what the expectations are on the policy."

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. AND The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 2 (100%) personnel records reviewed of hospice aides revealed that the hospice did not ensure that a Registered Nurse (RN) evaluated the aide's competency by observing the required skills before the hospice aide began providing independent care to patients. Agency policy, "PC.H35 Hospice Aide Qualifications," stated in part, "An individual may furnish hospice aide services on behalf of a hospice only after that individual has successfully completed a competency evaluation program. Hospice Aide skills and competencies are assessed prior to delivery of services and updated at least every 12 months. The following must be evaluated by observing an aide's performance of the task with a patient: Bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning." PERSONNEL RECORD 7: This Hospice Aide was hired on 02/18/2025. The Hospice Aide competency evaluation forms dated 02/18/2025 and 02/18/2026 revealed that all skills were evaluated verbally (without observation). The signature pages stated, "Items that are not observed cannot be performed independently until an RN is able to observe the aide performing the tasks. If an aide is not competent in 2 or more areas, the aide cannot perform patient visits independently." There was no documented evidence that a RN evaluated the hospice aide's competency by observing the required skills (Bed bath, sponge, tub, and shower bath, hair shampoo [sink, tub, and bed], nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning) before the hospice aide began providing hospice aide services. PERSONNEL RECORD 8: This Hospice Aide was hired on 12/01/2023. The Hospice Aide competency evaluation forms dated 12/01/2023, 12/01/2024, and 12/01/2025 revealed that all skills were evaluated verbally (without observation). The signature page stated, "Items that are not observed cannot be performed independently until an RN is able to observe the aide performing the tasks. If an aide is not competent in 2 or more areas, the aide cannot perform patient visits independently." There was no documented evidence that a RN evaluated the hospice aide's competency by observing the required skills (Bed bath, sponge, tub, and shower bath, hair shampoo [sink, tub, and bed], nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning) before the hospice aide began providing hospice aide services. During a joint record review and interview on 02/26/2026, the Director of Patient Care Services agreed there was no documented evidence that the hospice completed a competency evaluation by observing the required skills before the aides began providing hospice aide services to patients independently. Additionally, the Director of Patient Care Services stated, "I signed off on these and we had a verbal discussion. I did not observe them completing the skills. I did not realize it was required."

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care; and documented in the patient record, including the time spent. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview which revealed the agency did not ensure the presence of a current, viable volunteer program as follows: 1. No (0) volunteer hours documented for the years 2024, 2025 and to-date 02/26/2026 (HCDT.21.I/L644); 2. No documented evidence of volunteer recruitment and retention efforts from 04/01/2023 through 02/262026 (HSRM.30.I/L645); and 3. No current volunteer training program (HSRM.31.I/L643). The cumulative effect of these deficiencies indicates a lack of effective oversight and implementation of an effective volunteer program and could result in the hospice agency's inability to ensure the provision of quality health care, in a safe environment, in order to meet all patients' needs for the Condition of Participation CFR 418.78 Volunteer Program. The deficient practice demonstrates systemic process failures that have the potential to affect all patients cared for by the hospice agency.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes: The volunteer’s duties and responsibilities; the person to whom they report; the person to contact if they need assistance and instruction; hospice goals, services, and philosophy; confidentiality and protection of the patient’s and family’s rights; family dynamics and psychological issues surrounding terminal illness, death, and bereavement; procedures to be followed in an emergency and/or following the death of a patient; guidance specific to individual responsibilities. Volunteers are supervised by a designated hospice employee. This standard was not met as evidenced by document review and interview. A review of the Volunteer Binder revealed that hospice did not ensure to have a volunteer training program that is consistent with industry standards. The Volunteer Binder did not include any documented evidence of a volunteer training program. During an interview on 02/26/2026, the Volunteer Coordinator agreed there was no volunteer training program. Additionally, the Volunteer Coordinator stated, "I am aware we do not have a volunteer training program. We haven't had a patient want a volunteer, so we don't have a training for volunteers." During an interview on 02/26/2026, the Administrator agreed there was no documented evidence of volunteer training. Additionally, the Administrator stated, "We don't have a volunteer training program, just an outline. I have been looking at the guidelines, and I will be working on this." The Administrator also stated, "We don't have anyone that has completed volunteer training because we don't have a volunteer training program." A review of the Volunteer Binder revealed that hospice did not ensure to have a volunteer training program that is consistent with industry standards.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by document review and interview. A review of the Volunteer Binder and Volunteer Requirement Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care roles. The Volunteer Binder did not include any documented evidence of Volunteer hours for 2024, 2025 or 2026 to-date. The Volunteer Requirement Report for January 1, 2024, through February 26, 2026, revealed that the volunteer hours were at 0. During an interview on 02/26/2026, the Volunteer Coordinator agreed there have been no volunteer hours or volunteers available to see patients. During an interview on 02/26/2026, the Administrator stated, "We haven't had anyone ask for a volunteer." The Administrator also stated, "We could have a staff member go see a patient if requested but we don't have anyone that has completed volunteer training because we don't have a volunteer training program." A review of the Volunteer Binder and Volunteer Requirement Report revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care roles.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. A review of the Volunteer Binder revealed the hospice did not ensure to demonstrate and document viable and ongoing efforts to recruit and retain volunteers. The Volunteer Binder did not include any documented evidence of recruitment and retention efforts for April 1, 2023, through February 26, 2026. During an interview on 02/26/2026, the Volunteer Coordinator agreed there was no documented evidence of volunteer recruitment efforts. Additionally, the Volunteer Coordinator stated, "The program has not been effective. I've been thinking about it, where we can get volunteers, but I haven't done any recruitment efforts." During an interview on 02/26/2026, the Administrator agreed there was no documented evidence of volunteer recruitment efforts. Additionally, the Administrator stated, "Everything we have is in the binder. I spoke to the Volunteer Coordinator and they don't have anything. We didn't realize this was required." A review of the Volunteer Binder revealed the hospice did not ensure to demonstrate and document viable and ongoing efforts to recruit and retain volunteers.

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. 2 of 2 (100%) clinical records reviewed of patients who had a live discharge revealed that the hospice did not ensure that the discharge summary was sent to the patients' attending physicians CLINICAL RECORD 10: The patient elected the hospice benefit on 10/15/2024 and was discharged due to no longer terminally ill on 10/09/2025. A discharge summary was completed on 10/09/2025. There was no documented evidence that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/29/2025 and was discharged due to revocation on 08/27/2025. A discharge summary was completed on 08/27/2025. There was no documented evidence that the discharge summary was sent to the patient's attending physician. During a joint record review and interview on 02/26/2026, the Director of Patient Care Services agreed there was no documented evidence that the discharge summaries were provided to the patients' attending physicians.