Every finding on record at First Health Hospice LLC

It is required that each patient’s individualized written plan of care Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) clinical records reviewed it was revealed that the agency did not ensure that the plans of care documented all interventions for the care of the patients. THIS IS A CONTINUED PRIOR REQUIRED ACTION CLINICAL RECORD 2: The hospice election of benefit form was dated 03/27/2025 with a primary diagnosis of COPD (Chronic Obstructive Pulmonary Disease). The initial comprehensive assessment documented the patient had a Pluerx Drain and written orders to drain 2 times a week by a nurse or caregiver. The drainage has been 500 cc to 600 cc every two days with no signs of infection. There were no interventions documented on the initial plan of care or the updated plans of care that included the Pluerx drain including the weekly dressing change, nor instruction on safety ie checking clamps, dressing, and infection signs and symptoms. Additionally, the social worker assessed the patient on 03/28/2025 and planned to visit 2 times a month. The assessment documented that the son was providing care and would likely need increased support when the patient transitioned. There were no documented interventions or problems for the social worker who documented with an interdisciplinary update that the plan of care would be followed. CLINICAL RECORD 3: The hospice election of benefit form was dated 03/28/2025 with a primary diagnosis of hypertensive heart disease. The initial plan of care and updated plan of care did not document interventions for heart disease. The initial comprehensive assessment documented edema and that the patient had a history of falls. The updated comprehensive assessment dated 03/31/2025 and 04/04/2025 documented that the family was concerned with weakness and that the edema continued but no interventions were documented for heart disease including edema, or additionally for fall risk as of review 04/09/2025. CLINICAL RECORD 6: The hospice election of benefit form was dated 03/28/2025 with a primary diagnosis of muscular dystrophy. The plan of care documented interventions for dysphagia, nutrition, and spiritual support. The interventions for nutrition included sitting up during feeding, oral care, and providing nutrition supplements but lacked detail for the PEG (Percutaneous endoscopic gastroscopy) tube through which feedings were administered 4 times a day, ie flushing, any dressing, what to do if it falls out. During an interview with the administrator on 04/10/2025, she stated that the process improvement project for plans of care was in progress and continuing. This is a Continued Required Action

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 1 of 1 (100%) clinical record of a patient who had died, it was revealed that the agency did not ensure that documentation of the frequency of planned mailings and phone calls for bereavement were documented. THIS IS A CONTINUING PRIOR REQUIRED ACTION CLINICAL RECORD 1: The bereavement plan of care was documented on 03/11/2025 with a risk level of low. The plan documented to assess the family and then the plan documented: "Provide written grief educational materials. Instruct family members on the grief process and what to expect during this phase. Promote family activities and togetherness. Support the family's grief reactions. Assess the family's grief response." There was no specific plan for phone calls and when grief material would be sent to cover the next 13 months. The bereavement coordinator documented a call with the son on 03/11/2025, with a plan to follow the plan of care; however, the plan was non-specific regarding the type and frequency of care to be provided. During an interview with the administrator on 04/10/2025, she stated that the education for bereavement and the process improvement plan had been initiated but were still being worked on. This is a Continued Required Action

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interviews with the Director of Clinical Services/Administrator, which revealed that the governing body failed to ensure the agency implemented the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failed to ensure emergency preparedness plan was reviewed and updated every two years [HSEP.2.D/E4]; Failed to ensure emergency preparedness policies and procedures were reviewed and updated at least every two years [HSEP.3.D/E13]; Failed to ensure the development of an emergency plan for the patient during a natural or man-made disaster as part of a comprehensive assessment [HSEP.3.D/E16]; Failed to ensure emergency preparedness communication plan was reviewed and updated at least every two years [HSEP.4.D/E29]; Failed to ensure the emergency preparedness training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and that the communication plan and was reviewed and updated at least every two years [HSEP.5.D/E36]; and Failed to ensure the emergency preparedness plan was tested annually [HSEP.6.I/E39]. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness plan revealed that the agency did not ensure the emergency plan was reviewed and updated at least every two years. The agency presented a comprehensive emergency plan that met the requirements however the last update and review of the plan was dated 2021. On 02/27/2025 the Administrator/Director of Clinical Services confirmed the plan had not been reviewed or updated as she had been in the field working as a nurse. A review of the emergency plan revealed that the agency does have a comprehensive emergency plan that meets the requirements however the plan has not been reviewed or updated since 2021. In an interview with the Administrator/Director of Clinical Services on 02/27/2025, the administrator stated that the plan had not been reviewed or updated as she had been in the field working as a nurse.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness policy and procedures revealed that they had not been reviewed and updated since 2021. In an interview with the Administrator/Director of Clinical Services, she stated that the policies and procedures had not been reviewed or updated since she arrived in 2023 and agreed there was no evidence of a review since 2021. A review of the emergency preparedness policy and procedures revealed that they had not been reviewed and updated since 2021. In an interview with the Administrator/Director of Clinical Services, she stated that the policies and procedures had not been reviewed or updated since she arrived in 2023 and agreed there was no evidence of a review since 2021.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical record reviews revealed that the agency did not ensure a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 1: The patient was admitted on 08/07/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 2: The patient was admitted on 05/04/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 3: The patient was admitted on 11/11/2023. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 4: The patient was admitted on 12/10/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 5: The patient was admitted on 11/11/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 6: The patient was admitted on 02/06/2025. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 7: The patient was admitted on 11/12/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 8: The patient was admitted on 12/26/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 9: The patient was admitted on 11/05/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 10: The patient was admitted on 10/31/2023. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 11: The patient was admitted on 08/23/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 12: The patient was admitted on 08/05/2024. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 13: The patient was admitted on 11/22/2025. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. CLINICAL RECORD 14: The patient was admitted on 01/25/2025. There was no evidence of a plan for the hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment or a documented discussion of the plan provided to the patient/family and maintained by the hospice. In an interview on 02/26/2025 the Administrator/Director of Clinical Services stated that they have not been completing them as they were informed by the prior administrator that this was not required.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness plan revealed the communication plan been not reviewed and updated since 2021. In an interview with the Administrator/Director of Clinical Services, she stated that the emergency plan (to include the communication plan) had not been reviewed or updated since she arrived in 2023 and agreed there was no evidence of a review since 2021. xxxaaa

It is required that the hospice maintains an emergency preparedness (EP) 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. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness plan revealed that the agency did not ensure that a review and rehearsal of the hospice's EP training program was reviewed and updated at least every two (2) years. The last documented review of the EP plan was dated 2021. In an interview with the Administrator/Director of Clinical Services (DCS) on 01/27/2025, the Administrator stated that they had not performed a periodic review the plan as they were seeing patients in the field. A review of the emergency preparedness plan revealed no evidence that a review and rehearsal of the hospice's EP plan with hospice employees, including carrying out the procedures necessary to protect patients and others was performed. In an interview with the Administrator/Director of Clinical Services (DCS) on 01/27/2025, the administrator stated that they had not performed a periodic review and rehearsal of the plan as the administrator was seeing patients in the field.

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years or when a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) year or the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event., conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted or a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness plan (EP) revealed the plan did not include participation in a full-scale exercise or functional exercise, an additional exercise every two years, a mock drill, a table-top exercise, or a documented activation of the emergency plan since 2021. The Administrator/Director of Clinical Services was interviewed on 02/27/2025, and confirmed that this requirement was not met, citing a lack of time due to working as a field nurse. A review of the emergency preparedness plan (EP) revealed the plan did not include participation in a full-scale exercise or functional exercise, an additional exercise every two years, a mock drill, or a table-top exercise since 2021. In an interview with the Administrator/Director of Clinical Services (DCS) on 02/27/2025, the administrator confirmed that this requirement was not met citing a lack of time due to working as a field nurse.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that the interdisciplinary group completed an initial assessment no later than five calendar days after the election of the hospice care. CLINICAL RECORD 4: The patient was admitted to hospice services on 12/10/2024. The initial Plan of Care (POC) (effective 12/10/2024) included an order for a psychosocial assessment. The initial psychosocial assessment was completed on 01/16/2025 (37 days). There was no entry in the clinical record explaining the reason why the assessment was not completed within the required timeframe. CLINICAL RECORD 9: The patient was admitted to hospice services on 11/05/2024. The initial Plan of Care (POC) (effective 11/05/2024) included an order for a psychosocial assessment. The initial psychosocial assessment was completed on 02/07/2025 (94 days). There was no entry in the clinical record explaining the reason why the assessment was not completed within the required timeframe. The Administrator/Director of Clinical Services (DCS) was interviewed on 02/26/2025 and stated without a note in the chart she was unable to explain why the assessments were not completed timely.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical record reviewed, it was revealed that the agency did not ensure that the drug profile was updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. Agency Policy, Medication List and Monitoring (09/01/2024), read in part, "The hospice Registered Nurse will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all hospice staff involved in the patient's care, including the pharmacist. A medication/drug profile will be maintained on all patients. Changes in the medication/drug profile will be documented in the medical record either on the medication profile or on a verbal order POC (plan of care) and communicated to the patient and/or caregiver. The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate.” CLINICAL RECORD 1/Home Visit 1: A home visit was conducted on 02/26/2025 to observe the Social Worker (Personnel Record 1). The patient's medication profile included Aripiprazole 2mg take 2 tablets daily, the patient reported they took one 2mg tablet daily effective 08/22/2024. The patient was also taking acetaminophen 650 mg every six hours as needed (effective 08/22/2024), Ibuprofen 400mg every six hours as needed (effective 08/22/2024), and DuoNeb via nebulizer three times daily as needed (effective 08/22/2024). These were not included in the hospice medication profile or medication review process. In an interview on 02/27/2025, the Director of Clinical Services stated that the nurses are probably not asking about medication changes when they see the patient.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that each patient's individualized plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/07/2024 with a diagnosis of senile degeneration of the brain. The comprehensive assessment dated 01/26/2025 indicated the patient was at risk for falls as evidenced by a fall risk assessment score of 13 (scores greater than 10 indicate high risk). The plan of care dated 02/03/2025 to 04/03/2025 did not include fall interventions. In an interview on 02/27/2025 the Director of Clinical Services stated fall risk interventions should have been added to the plan of care and she was unsure why the problem had not been added. CLINICAL RECORD 2: The patient was admitted on 05/04/2024 with a suprapubic catheter. The patient has a history of urinary tract infections, and the suprapubic catheter required the removal and new catheter insertion. The Plan of Care (POC) for the episode 12/30/2024 to 02/27/2025 did not include interventions or goals for the patient's suprapubic catheter. In an interview on 02/27/2025 the Director of Clinical Services stated that the catheter should be on the plan of care.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by document review and interview. A review of the Quality Assurance and Performance Improvement (QAPI) program revealed that the agency lacked documentation to demonstrate measurable improvement among indicators related to improved palliative outcomes. Information on incidents, infections, and adverse events was tracked quarterly; there was no documented evidence the information was analyzed, or that actions were taken to improve performance. The agency did not have documented evidence of QAPI activities/meetings for the first, second or third quarter of 2024. The fourth quarter meeting minutes included a performance improvement plan to meet the requirement. In an interview on 02/27/2025, the Administrator/Director of Clinical Services stated that they hired an outside source who assisted with the QAPI for the fourth quarter. A review of the Quality Assurance and Performance Improvement(QAPI) program and minutes revealed that the agency lacked evidence of documentation to demonstrate compliance and was unable to demonstrate measurable improvement among indicators related to improved palliative outcomes and hospice services for the first, second, and third quarters of 2024. The fourth quarter meeting minutes included a performance improvement plan to meet the requirement. In an interview with the Administrator/Director of Clinical Services on 02/27/2025, the Administrator stated that they hired an outside source who assisted with the QAPI for the fourth quarter.

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 and interview. In 2 of 2 (100%) bereavement record reviews revealed that the agency did not ensure a bereavement plan of care that included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 11: The patient expired on 08/23/2024. There was no evidence of a bereavement plan of care. The bereaved received one call from the bereavement coordinator on 12/05/2024. A bereavement assessment was not documented after the patient's death. The record lacked documented evidence that the bereaved had declined bereavement services. CLINICAL RECORD 12: The patient expired on 10/09/2024. There was no evidence of a bereavement plan of care. The bereaved received one call from the bereavement coordinator on 01/20/2025. A bereavement assessment was not documented after the patient's death. The record lacked documented evidence that the bereaved had declined bereavement services. In an interview on 02/26/2025 the Bereavement Coordinator and Director of Clinical Services both stated that the bereavement program needed work and was not running smoothly.

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 and interview. In 1 of 9 (11%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure written patient care instructions were prepared by a registered nurse (RN) who is responsible for the supervision of the hospice aide. CLINICAL RECORD 2: The patient is bedbound with a diagnosis of Multiple Sclerosis and was admitted with a suprapubic catheter. The aide care plan dated 05/04/2024 did not include catheter care. The Director of Clinical Services was interviewed on 02/27/2025 and stated she did not know why the catheter care was not on the aide care plan but should have been.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical record reviews with aide care plans, the agency did not ensure that the hospice aide reported changes in the patient needs to a registered nurse as the changes related to the plan of care. CLINICAL RECORD 2: The aide care plan dated 05/04/2024 included the following relevant tasks: turn and reposition and provide social/emotional support every visit. The aide visit note, dated 02/25/2025, was blank for these tasks. At the bottom of the aide note, was a place for communication with the nurse, and "N/A" was there. Another statement at the bottom of the aide visit note had a place to record any activities not performed and explain why any boxes were unchecked. "N/A" was written. There was no documented evidence the aide reported to the RN that these tasks were not completed. CLINICAL RECORD 4: The current aide care plan effective as of 12/10/2024 included the following relevant tasks: shampooing/styling hair, cleaning fingernails and toenails, and assistance with brushing teeth every visit. Those tasks for the aide visit notes dated 12/13/2024, 01/10/2025, 02/13/2025 were left blank. The aide visit notes dated 12/27/2024 and 02/07/2025 were blank for cleaning fingernails and toenails. At the bottom of the aide note there was a place for communication with the nurse and "N/A" was placed there. Another statement at the bottom of the aide visit note had a place to record any other activities performed and explain why leaving boxes unchecked and "N/A" was placed. There was no documented evidence the aide reported to the RN that these tasks were not completed. CLINICAL RECORD 8: The aide care plan dated 12/26/2024 included shampooing/styling hair, and cleaning fingers and toenails every visit. On the aide visit note, dated 02/13/2025, these tasks were left blank. At the bottom of the aide note, there is a place for communication with the nurse, and "N/A" was placed there. Another statement at the bottom of the aide visit note had a place to record any activities not performed and explain why any boxes were unchecked "N/A" was written. There was no documented evidence the aide reported to the RN that these tasks were not completed. On 02/26/2025 the Director of Clinical Services (DCS) stated in an interview that the only assignments that show up on the aide plan of care are the tasks specifically assigned by the Registered Nurse. The DCS confirmed that boxes next to the specific tasks assigned to the aide should be checked every visit and if the boxes were blank that this indicated the tasks were not completed. The DCS stated there were sections at the bottom of the visit note for the aide to document an explanation of the incomplete tasks and a section to document if the nurse was notified of the incomplete tasks.

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. Cost Savings Report: A review of the annual cost savings report revealed that the cost savings was 1.4% from January 2024 through December 2024. The Volunteer Coordinator stated in an interview, on 02/27/2025, that since she assumed the role in the last quarter of 2024, and she was actively recruiting volunteers. 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.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by personnel record review, document review and interview. In 4 of 6 (100%) personnel records reviewed, it was revealed that the agency did not ensure that the initial orientation included the employee’s specific job duties. Agency Policy No. 1-002.1, Human Resources (11/2020) stated in part," All new employees will complete an orientation program including but not limited to a review of policies and procedures, position responsibilities and limitations.” Personnel Record 3: The Director of Clinical Services/Administrator was hired on 11/08/2023. The personnel record lacked a signed job description or other documented evidence of an initial orientation for the employee that addressed the employee’s specific job duties. Personnel Record 4: The Business Office Manager/Volunteer Coordinator was hired on 10/02/2023. The personnel record lacked a signed job description or other documented evidence of an initial orientation for the employee that addressed the employee’s specific job duties. Personnel Record 5: The Certified Nursing Assistant was hired on 02/05/2024. The personnel record lacked a signed job description or other documented evidence of an initial orientation for the employee that addressed the employee’s specific job duties. Personnel Record 6: The Registered Nurse was hired on 09/19/2024. The personnel record lacked a signed job description or other documented evidence of an initial orientation for the employee that addresses the employee’s specific job duties. The Administrator/Director of Clinical Services (DCS) was interviewed on 02/27/2025 and stated that they could not provide evidence the initial orientation included a review of the job duties. The employees have training via an online learning program but that does not address their specific job duties/responsibilities.

It is required that the hospice assesses the skills and competencies of all individuals providing It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 5 of 6 (83%) personnel files reviewed revealed that the agency did not ensure that an assessment of the skills and competencies of all individual's providing care was completed. Agency Policy No.1-025.1 Competency Program (11/2020), stated in part, "{Agency} will define and implement an objective, measurable assessment system to evaluate the competency of patient contact personnel. Personnel will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including an ability to perform specified duties determined by the organization. Skills will be maintained and improved through continuing education programs, based on the analysis of trends and outcomes identified through the competency program, on-site supervision, and established reviews.” Personnel Record 1: The employee was hired on 12/09/2024 as a Social Worker. There was no documented evidence of a competency assessment in the personnel file. Personnel Record 2: The employee was hired on 04/01/2024 as a Chaplain and Bereavement Coordinator. There was no documented evidence of a competency assessment in the personnel file for the Chaplain or Bereavement Coordinator. Personnel Record 3: The employee was hired on 11/08/2023 as the Director of Clinical Services and the Administrator. There was no documented evidence of a competency assessment in the personnel file for the Director of Clinical Services or the Administrator. Personnel Record 4: The employee was hired on 10/02/2023 as the Business Office Manager and the Volunteer Coordinator. There was no documented evidence of a competency assessment in the personnel file for the Volunteer Coordinator position. Personnel Record 6: The employee was hired on 09/19/2024 as a Registered Nurse. There was no documented evidence of a competency assessment in the personnel file. In an interview on 02/27/2025, the Administrator/Director of Clinical Services stated that she had been working as a staff nurse the majority of the time she has been in the role and had not completed the competencies.

It is required that a hospice may contract for durable medical equipment (DME) services with a Medicare-certified DME point-of-service (POS) supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards and has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. A review of the durable medical equipment contract revealed the agency did not ensure a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization was available. At the time of the exit conference the agency was unable to produce documented evidence that the DMEPOS supplier was accredited by a recognized accreditation organization.

It is required that short-term inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility. THIS IS A CONDITON LEVEL DEFICIENCY. This condition was not met as evidenced by document review and interviews with the Administrator/Director of Clinical Services, which revealed the hospice: Failed to ensure there was a contract for short-term inpatient care available for pain control, symptom management and respite purposes. {HSIC.5. D/L711}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.108: Short-term inpatient care. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. A review of the hospice contracts revealed that the agency did not ensure short-term inpatient care is available for pain control, symptom management, and respite purposes in a participating Medicare or Medicaid facility.

It is required that a hospice that provides short-term inpatient care under arrangement with a facility has a written agreement describing the arrangement and how the hospice coordinates the care. This standard was not met as evidenced by document review and interview. In review of the agency contracts, it was revealed that the agency did not ensure that a written agreement with a facility was available to provide short-term inpatient care for pain control, symptom management, and respite purposes. At the time of the exit conference the agency was unable to produce a contract to ensure that short term inpatient care was available for pain control, symptom management, and respite purposes. On 02/27/2025, the Administrator stated that they have no evidence of a contract for general in-patient care or respite care purposes.

It is required that the hospice and SNF/NF or ICF/IID have a written agreement that specifies the provision of hospice services in the facility. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) home visit observations, completed in a Skilled Nursing Facility, it was revealed that the agency did not ensure there was a written agreement with the facility. The contract list did not include Skilled Nursing Facilities (SNF) contracts. A copy of the contract for the SNF in which the patient resided was requested on multiple occasions. At the time of the exit conference the agency was unable to produce the SNF contract. In an interview on 02/27/2025 the Administrator/Director of Clinical Services stated that she knew they had contracts at one time but that neither she nor the Business Office Manager could locate them. aaaa

It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by personnel record review, document review, and interviews with the Director of Clinical Services/Administrator and Business Office Manager, which revealed that the agency failed to ensure the hospice professionals met the personnel qualification requirements in the following areas: Failed to ensure the Social Worker had a Master’s Degree (MSW), or baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification {HSRM.7.D/L787}; and Failed to ensure the hospice obtained criminal checks on hospice employees who have direct patient contact or access to patient records in 6 of 6 (100%) of the personnel records reviewed {HSRM.16.I/L795}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.114: Personnel Qualifications. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. aaa

It is required that a social worker has: 1. A Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; OR 2. A baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; OR 3. A baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above; AND 4. At least one (1) year of social work experience in a health care setting. OR 5. A baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by personnel record review, document review, and interview. In 1 of 1 (100%) personnel record reviewed, for a Social Worker, it was revealed that the agency did not ensure there was documentation that the Social Worker met the regulatory and state qualifications. The state regulations require the social worker to be licensed. The requirements of licensure and practice for {state} Licensed Social Worker (LSW) or {state} Licensed Clinical Social Worker (LCSW) licensure are provided by the ACT (225 {state code} 20) and the RULES in Administrative Code (68 IAC Part 1470). Agency Policy No.1-005.3, Qualifications of Organization Personnel (11/2020), stated in part, “Social Worker A. Holds a master's degree from a school of social work accredited by the Council on Social Work Education and B. Has one year of social work experience in a healthcare setting.” Agency Policy No. 1-002.1, Human Resources, “Professional personnel will submit copies of their diplomas or transcripts showing successful completion of the approved/accredited programs, the copies will be retained in the individual personnel file.” Personnel Record 1: The employee was hired on 12/09/2024 as a Social Worker. The job description signed by the Social Worker was a Bachelor of Social Work (BSW) position. The record lacked documented evidence that the Social Worker had a master’s degree or was licensed as required by the state. There was no documented evidence of supervision for this social worker by an MSW. The record lacked evidence of the degree held by this employee. At the time of the exit conference the agency was unable to provide primary source license verification, a copy of the degree, or any other evidence to prove this employee’s qualifications. In an interview with the Business Office Manager on 02/27/2025, they were unable to explain why the information was not available. Per the Business Office Manager this was the only social worker employed for the agency.

It is required that the hospice obtains 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. Criminal background checks are obtained in accordance with state requirements and in the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 6 of 6 (100%) personnel record reviewed, it was revealed that the agency did not ensure criminal background checks were obtained in accordance with state requirements. Agency Policy No.1-002.1, Human Resources (11/2020), read in part, “Prior to hire, the organization will secure multiple reference checks, health reports as required by the state or policy, criminal background checks when required by law, and proof of citizenship or documentation of resident status.” The {State} Health Care Worker Background Check Act (225 {state code} 46) requires criminal background checks for workers that provide care for or have access to patient's records. Personnel Record 1: The employee was hired on 12/09/2024 as a Social Worker. The personnel record lacked evidence of a background check. Personnel Record 2: The employee was hired on 04/01/2024 as a Chaplain/Bereavement Coordinator. The personnel record lacked evidence of a background check. Personnel Record 3: The employee was hired on 11/08/2023 as a Director of Clinical Services/Administrator. The personnel record lacked evidence of a background check. Personnel Record 4: The employee was hired on 10/02/2023 as a Business Office Manager/Volunteer Coordinator. The personnel record lacked evidence of a background check. Personnel Record 5: The employee was hired on 02/05/2024 as a Certified Nursing Assistant. The personnel record lacked evidence of a background check. Personnel Record 6: The employee was hired on 09/19/2024 as a Registered Nurse. The personnel record lacked evidence of a background check. The Business Office Manager was interviewed on 02/27/2025 and stated that the criminal background checks had not been done but did not provide an explanation.