Every finding on record at Fort Bend Hospice and Palliative Care, LLC

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. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that an initial bereavement assessment was completed as part of the initial comprehensive assessment. AGENCY POLICY: The agency's policy "Bereavement Services Policy No. 9-023" dated December 2018 included that "...A Bereavement Risk Assessment will be completed by the hospice social worker at the time of admission to hospice..." The agency's policy "Bereavement Assessment Policy No. 1-021" dated December 2018 included that "...A Bereavement Risk Assessment will be completed by the hospice social worker at the time of admission to hospice...At a minimum, it will include patient and family/caregiver loss issues, survivor needs, social, spiritual, and cultural factors, services to be provided including individual counseling, support groups, and letters and cards, referrals to be made, grief risk factors and potential for pathological grief reactions. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan of intervention based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/19/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) on 03/19/2025 and by the Social Worker and Chaplain on 03/21/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/03/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN)04/03/2025, the Social Worker on 04/04/2025, and the Chaplain on 04/07/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/04/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) 04/03/2025, the Social Worker on 04/08/2025, and the Chaplain on 04/05/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/20/2025. The initial comprehensive visits were conducted by the Registered Nurse (RN) 05/20/2025, and by the Social Worker on 05/22/2025. There was no documented evidence that an initial bereavement risk assessment completed. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/02/2024 The initial comprehensive visits were conducted by the Registered Nurse (RN) 10/02/2024, and by the Social Worker on 10/04/2024. There was no documented evidence that an initial bereavement risk assessment completed. After a joint clinical record review and interview with the Director of Nursing (Personnel Record 3) on 10/15/2025, it was determined that the records listed in evidence did not have a documented bereavement risk assessment as part of the initial comprehensive assessment.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the Registered Nurse (RN) did not ensure the implementation of the interdisciplinary plan of care. AGENCY POLICY: The hospice's policy "Nursing Care Policy No. 9-019) dated December 2018 included that "...The Case Manager will assure that components of the plan of care are established and implemented by the Interdisciplinary Group. The Case Manager will determine the scope and frequency of services of services needed..." CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2024. The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and 09/17/2025 to 11/15/2025 were reviewed and included orders for the Chaplain to visit the patient once a week. Chaplain visits were documented on the following dates: 07/09/2025, 08/15/2025, 09/12/2025, and 10/02/2025, and not weekly as per orders. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 3: The patient elected th hospice benefit on 07/24/2023. The plans of care for the benefit periods from 07/13/2025 to 09/10/2025 and 09/11/2025 to 11/09/2025 were reviewed and included orders for the Chaplain to visit the patient once a month. There were no chaplain visits documented for July, August, or September as per the order. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/03/2025 . The plans of care for the benefit periods 06/03/2025 to 08/31/2025 and 09/01/2025 to 11/29/2025 were reviewed and included orders for the Social Worker to visit the patient once a month. There were no Social Worker visits or missed visits documented for June, July, August, or September. The plans of care included one PRN - as-needed visit for each benefit period. There were documented monthly Chaplain visits dated 06/05/205, 07/04/2025, 08/05/2025, and 09/03/2025, however there were no orders for the chaplain on the plan of care. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/07/2024. The plans of care for the benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the Chaplain and the Social Worker to visit the patient once a month. There were no Chaplain visits or missed visits documented. The Social Worker had visits documented on 07/23/2025 and 09/24/2025. There was no August visit or missed visit documented. There was no documented evidence that the IDG plan of care was implemented by the IDG designated RN. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, were reviewed and included orders for the Chaplain to visit the patient once a month. There were no documented Chaplain visits. After a joint clinical record review and interview with the Director of Nursing (DON) (Personnel Record 3) on 10/15/2025 and 10/16/2025 it was determined that the ordered frequency and visits cited in the clinical records in evidence did not match. The DON could provide this site visitor with the verbal frequencies of the psychosocial disciplines but agreed that the plans of care did not accurately reflect that information.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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, observation, and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the patient's individualized plans of care reflected all problems identified in the initial and updated assessments. CLINICAL RECORD 1/HOME VISIT1: The Registered Nurse's (RN) Recertification visit on 09/08/2025 included in part that the "...Patient is deaf in the left ear and hard of hearing in the right ear. One must get close to the patient's ear as if about to whisper before the patient could hear. Patient caregiver provides assistance in order to better communicate with the patient..." During the home visit observation with the registered nurse (RN) (Personnel Record 3) on 10/14/2025, the RN repeatedly struggled to communicate with the patient due to the patient's hearing. The nurse did state that the patient could read lips to some degree. The plan of care for the benefit period from 09/17/2025 to 11/15/2025 did not include an identified problem, intervention, or goal for the assessed communication difficulties secondary to the patient's hearing difficulty. CLINICAL RECORD 2/HOME VISIT 2: During the Registered Nurse's (RN)(Personnel Record 5) visit on 08/27/2025, the patient's pain was rated a 6, and it was noted that her pain occurred daily but not constantly. The nurse documented "...Reviewed pain management plan and instructed caregivers to administer PRN medications if signs of pain occur. SN will continue routine hospice visits to monitor...patient comfort..." The patient's pain was documented as a four during the RN visit on 09/03/2025. The patient's medication list included an order dated 05/05/2025 for Hydrocodone-Acetaminophen 10-325mg oral tablet: take one tablet by mouth twice daily for pain (scheduled). The patient's plan of care for the benefit period from 08/03/2025 to 10/31/2025 did not include the identified problem of pain with any intervention or goal for treatment. The medication list also included an order dated 05/05/2025 for Plavix 75mg: take one tablet orally once daily for anticoagulation. The patient's plan of care for the benefit period from 08/03/2025 to 10/31/2025 did not include the identified problem of pain with any intervention or goal for treatment. While there was a "Risk for Injury" problem identified on the plan of care, the problem, intervention, and goals did not address the patient's increased risk for bleeding secondary to Plavix in case of fall or injury. The findings were confirmed after joint record review and interview on 10/15/2025 with the Director of Nurses (Personnel Record 3).

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 9 of 14 (64%) clinical records reviewed revealed the agency did not ensure that the medical supplies necessary for the patient's needs were documented on the plan of care. AGENCY POLICY: Durable Medical Equipment and Supplies Policy No. 2-037 12/2018 All...supplies...will have an order from the physician ...Those supplies required for optimal comfort, care, and management of the hospice patient will be obtained..." CLINICAL RECORD 1: The patient's bowel and bladder incontinence was identified in the Registered Nurse's (RN) Recertification visits documented on 07/07/2025 and 09/08/2025. The Plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and 09/17/2025 to 11/15/2025 did not include incontinence supplies. CLINICAL RECORD 4: In the Hospice Medical Director's written certifications of terminal illness for the benefit periods 07/17/2025 to 09/14/2025 and 09/15/2025 to 11/15/2025, it was identified that the patient was incontinent of both bowel and bladder. The Plans of care for the same benefit periods did not include incontinence supplies. CLINICAL RECORD 6: The patient's bowel and bladder incontinence was identified in the Registered Nurse's (RN) Initial Assessment visit on 06/03/2025. The plans of care for the benefit periods 06/03/2025 to 08/31/2025 and 09/01/2025 to 11/29/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 8: The patient's bladder incontinence was identified in the Registered Nurse's (RN) Initial Assessment visit on 08/14/2025. The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 9: The patient's bowel and bladder incontinence was identified during the Registered Nurse's (RN) Initial Assessment on 07/18/2025. The plans of care for the benefit periods 07/01/2025 to 08/9/2025 and 08/30/2025 to 10/28/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 11: The patient's bladder incontinence was identified during the Registered Nurse's (RN) Initial Assessment visit on 05/20/2025. The plan of care for the benefit period from 05/20/2025 to 05/28/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 12: The patient's bowel and bladder incontinence was identified in the Registered Nurse's (RN) Initial Assessment visit on 10/02/2024 and during the Recertification visits documented on 12/17/2024 and 03/25/2025. The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025 were reviewed and included no incontinence supplies. CLINICAL RECORD 13: The patient's bowel and bladder incontinence was identified during the Registered Nurse's (RN) Initial Assessment visit on 05/21/2025. The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included no incontinence supplies. CLINICAL RECORD 14: The patient's bowel and bladder incontinence was identified during the Registered Nurse's (RN) Initial Assessment on 04/01/2025. The plans of care for the benefit periods 04/01/2025 to 06/29/2025 and 06/30/2025 to 09/09/2025 were reviewed and included no incontinence supplies. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 3) on 10/15/2025, she confirmed that the patient's medical supplies were not documented in the plan of care for each patient.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure that the patient's plan of care was updated at least every 15 days. AGENCY POLICY: The hospice's policy, "Interdisciplinary Group Meeting Policy No. 1-036" dated December 2018, included "...An interdisciplinary group meeting plan of care update form will be used for update of the patient...It will note changes, response to treatment, and progress toward targeted outcomes..." CLINICAL RECORD 3: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 06/06/2025 (28 days) 07/04/2025 (28 days) 08/01/2024(28 days) 08/15/2025, 09/12/2025 (28 days), 09/26/2025, and 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 6: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 06/03/2025, 07/04/2025 (31 days), 07/18/2025, 08/01/2025, 08/15/2025, 08/29/2025, 09/12/2025, 09/26/2025, 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 10: There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 04/16/2024,06/03/2025 (31 days) 07/04/2025931 days), 07/18/2025, 08/01/2025, 08/15/2025, 08/29/2025, 09/12/2025, 09/26/2025, 10/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/01/2025. There were Interdisciplinary Group Meetings/Plan of Care Updates documented on 04/01/2025, 05/23/2025(52 days, 06/30/2025 (38 days) and post-death on 07/10/2025. There was no documented evidence that the Interdisciplinary Group (IDG) plan of care was updated at least every 15 days. A joint clinical record review and interview were conducted with the Director of Nursing (DON) (Personnel Record 3) on 10/16/2025, confirming the absence of documented updates in the clinical records every 15 days.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel records reviewed revealed that the agency did not ensure that the Administrator and the Alternate Administrator had documentation of the annual twelve hours of state-required Administrator continuing education completed. STATE REGULATION: State Administrative Code: Title 26, Part 1, Chapter 558, Subchapter C, Division 3, Rule §558.260 - Continuing Education in Administration of Agencies included in part that "...an administrator and alternate administrator must complete 12 clock hours of continuing education within each 12-month period beginning with the date of designation..." The provisions of this §558.260 adopted to be effective May 1, 2008, 33 (State)Reg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 (State)Reg 1893; amended to be effective April 25, 2021, 46 (State)Reg 2427. PERSONNEL RECORD 1: The Medical Director/Administrator hired on 04/01/2018 had twelve hours of the annual state-required continuing administrative education documented on 09/24/2025, but none documented for years 2023 or 2024. PERSONNEL RECORD 2: The Alternate Administrator hired 04/01/2018 had twelve hours of the annual state-required continuing administrative education documented on 08/11/2025, but none documented for years 2023 or 2024. After a joint personnel record review and interview with the Office Administrator (Personnel Record 7) on 10/16/2025, the absence of the continuing Administrator hours required by the state for the Administrator and Alternate Administrator was confirmed.

It is required that counseling services include an organized program for providing 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 1 of 2 (50%) clinical records reviewed revealed the agency did not ensure that a bereavement plan of care was documented. The agency's policy, "Bereavement Assessment Policy No. 1-021" dated December 2018, included "...After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan of interventions based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions..." CLINICAL RECORD 13: The patient elected the hospice benefit on 05/21/2025 and died on hospice services on 06/13/2025. The Chaplain completed a post-death Bereavement Risk Assessment on the day of death, 06/13/2025, with a finding of low risk and noted that the patient's son would be followed by Bereavement. There was no Bereavement Plan of Care documented to indicate the scope and frequency of Bereavement Services/interventions. The finding was confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025. The Bereavement Coordinator (Personnel Record 6) was interviewed on 10/15/2025 and was surprised to learn of the missing bereavement plan of care. She stated she thought that the patient's son had refused bereavement services. The note of the post-death assessment indicating that indicated that the patient's son would be followed by bereavement was reviewed. The chart was reviewed and was confirmed that the patient's son declined bereavement services, and this was updated in the record.

It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared the written home health aide care plan with clear and patient-specific directions {HCDT.15. I/L625/ 418.76(g)(1)}; Failed to ensure that the hospice aide provided visits and services as ordered by the Interdisciplinary Group. {HCDT.16.I/L626/ 418.76(g)(2)(i)}; Failed to ensure that all aides reported 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 {HCDT.18.I/L628/ 418.76(g)(4)} and Failed to ensure that the Registered Nurse (RN) documented supervision of the hospice aide every 14 days {HSRM.25. I/L629/ 418.76(h)(1)(i)}. 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 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

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 11 (10%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure patient-specific instructions were provided to the hospice aide. CLINICAL RECORD 2: The plans of care for the benefit periods 05/05/2025 to 08/02/2025 and 08/03/2025 to 10/31/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. During the Registered Nurse's (RN) visit on 08/27/2025, she noted the patient had bilateral wounds on each hip that were approximately the size of a quarter. A physician's order dated 09/02/2025 included wound care orders for a stage 2 pressure ulcer on both the patient's right and left hip. Cleanse both wounds with normal saline and betadine solution. Apply calcium alginate to the wound bed and cover with a hydrocolloid dressing twice weekly until healed. The active hospice aide plan of care at the time of record review was dated 08/03/2025. It included interventions to be performed at each visit: complete bed bath, perineal care, and incontinent care during each hospice aide visit, but there were no instructions provided to the hospice aide regarding the patient's wounds and what to do should the dressing become loose or soiled due to the patient's incontinence. The findings were confirmed following a joint clinical record review and an interview with the Director of Nursing (Personnel Record 3) on October 15, 2025.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 8 of 11 (73%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide provided visits and services as ordered by the Interdisciplinary Group. CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plans of care dated 07/19/2025 and 09/17/2025 included the following interventions to be performed during every hospice aide visit: complete shower, incontinent care, perineal care, skin care, foot care, nail care, oral hygiene/denture care, shave, check pressure areas on the patient's skin, document the date of the patient's last bowel movement, assist the patient to transfer, turn/position patient, change linen, and make the patient's bed. The following task were not marked as completed by the hospice aide during the visits documented on 8/18/2025, 09/01/2025, 09/17/2025, and 09/29/2025: incontinent care, nail care, shaving, checking the patient's skin for pressure areas, and noting the date of the patient's last bowel movement. CLINICAL RECORD 3: The plans of care for the benefit periods 07/13/2025 to 09/10/2025 and 09/11/2025 to 11/09/2025 were reviewed and included orders for the hospice aide) to visit the patient three times a week. There were no hospice aide visits documented, and no discontinuation order for hospice aide services documented. CLINICAL RECORD 8: The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed. Both included orders for the hospice aide to provide visits to the patient three times a week. The hospice aide plan of care dated 08/14/2025 included the following task to be performed every visit: complete shower, incontinent care, perineal care, shampoo hair, foot care, skin care, back rub/massage, oral hygiene/denture care, nail care, check pressure areas, comb hair, dress patient. During the hospice aide visits on 09/17/2025 and 09/26/2025, the hospice aide did not mark that incontinent care, nail care, checking pressure areas, and back rub/massage were completed. CLINICAL RECORD 9: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 08/30/2025 included the following task to be performed every visit: complete shower, shampoo hair, foot care, nail care, perineal care, incontinent care, skin care, check pressure areas, comb hair, oral hygiene/denture care, and dress patient. During the hospice aide visits on 09/01/2025 and 09/24/2025, the hospice aide did not document that foot care, nail care, incontinence care, or checking pressure areas were performed. On 10/06/2025, the interventions for perineal care, incontinence care, nail care, and checking pressure areas were not documented as having been completed. CLINICAL RECORD 10: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to provide visits to the patient three times a week. The hospice aide plan of care dated 07/01/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. During the hospice aide visit on 08/04/2025, the hospice aide did not mark shaving, incontinence care, nail care, and checking pressure areas as completed. On 08/22/2025, back rub/massage and incontinence care were not documented as having been performed. On both 09/08/2025 and 09/15/2025, the hospice aide did not document that the task of back rub/massage, checking pressure areas, incontinent care, or nail care were performed. Then, on 10/01/2025, foot care, perineal care, incontinent care, back rub/massage, check pressure areas, and nail care were not documented as completed. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, included orders for the hospice aide to provide visits to the patient three times a week. The first hospice aide visit was on 10/04/2024, and the last aide visit on 03/19/2025. There were no further hospice aide visits documented after 03/19/2025 until the patient's discharge from hospice care on 04/16/2025 and no order to discontinue hospice aide services. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to provide visits to the patient three times a week. The Patient died on hospice services on 06/13/2025. The hospice aide plan of care dated 05/21/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. The following task perineal care, incontinent care, and nail care were not marked as completed by the hospice aide during the visits documented on 05/26/2025, 06/02/2025, 06/06/2025, and 06/11/2025. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 04/01/2025 included the following interventions to be performed by the hospice aide every visit: complete bed bath, perineal care, foot care, shampooing hair, incontinent care, skin care, checking pressure areas, oral hygiene/denture care, nail care, shaving, and dressing the patient. On 04/23/2025, the hospice aide did not document that shaving, incontinent care, skin care, or checking of pressure areas were completed. On 06/03/2025 and 06/18/2025, perineal care, incontinence care, and checking pressure areas were not documented as completed. The last documented hospice aide visit was 06/30/2025. The patient died on hospice services on 07/09/2025. There was no order discontinuing hospice aide services, no missed visits documented, and no hospice aide visits were documented from 07/01/2025 to 07/09/2025. The findings were confirmed following a joint clinical record review and an interview with the Director of Nursing (Personnel Record 3) on October 15, 2025.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 6 of 11 (55%) clinical records reviewed for patients receiving aide services revealed that the agency did not ensure that the hospice aide reported to the Registered Nurse (RN) when the hospice aide plan of care was not followed as directed by the RN. CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plans of care dated 07/19/2025 and 09/17/2025 included the following task to be performed during every hospice aide visit: complete shower, incontinent care, perineal care, skin care, foot care, nail care, oral hygiene/denture care, shave, check pressure areas on the patient's skin, document the date of the patient's last bowel movement, assist the patient to transfer, turn/position patient, change linen, and make the patient's bed. The following task were not marked as completed by the hospice aide during the visits documented on 8/18/2025, 09/01/2025, 09/17/2025, and 09/29/2025: incontinent care, nail care, shaving, checking the patient's skin for pressure areas, and noting the date of the patient's last bowel movement. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 8: The plan of care for the benefit period from 08/14/2025 to 10/12/2025 was reviewed. Both included orders for the hospice aide to visit the patient three times a week. hospice aide plan of care dated 08/14/2025 included the following interventions to be performed every visit: complete shower, incontinent care, perineal care, shampoo hair, foot care, skin care, back rub/massage, oral hygiene/denture care, nail care, check pressure areas, comb hair, dress patient. During the hospice aide visits on 09/17/2025 and 09/26/2025, the hospice aide did not mark that incontinent care, nail care, checking pressure areas, and back rub/massage were completed. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 9: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 08/30/2025 included the following tasks to be performed every visit: complete shower, shampoo hair, foot care, nail care, perineal care, incontinent care, skin care, check pressure areas, comb hair, oral hygiene/denture care, and dress patient. During the hospice aide visits on 09/01/2025 and 09/24/2025, the hospice aide did not document that foot care, nail care, incontinence care, or checking pressure areas were performed. On 10/06/2025, the interventions for perineal care, incontinence care, nail care, and checking pressure areas were not documented as having been completed. There was no documentation by the hospice aide that the Registered Nurse (RN) was notified that the care plan was not completed as written. CLINICAL RECORD 10: The plans of care for the benefit periods from 07/01/2025 to 08/29/2025 and from 08/30/2025 to 10/28/2025 were reviewed. Both included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 07/01/2025 included the following task to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. During the hospice aide visit on 08/04/2025, the hospice aide did not mark shaving, incontinence care, nail care, and checking pressure areas as completed. On 08/22/2025, back rub/massage and incontinence care were not documented as having been performed. On both 09/08/2025 and 09/15/2025, the hospice aide did not document that the interventions of back rub/massage, checking pressure areas, incontinent care, or nail care were performed. Then, on 10/01/2025, foot care, perineal care, incontinent care, back rub/massage, check pressure areas, and nail care were not documented as completed. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The Patient died on hospice services on 06/13/2025. The hospice aide plan of care dated 05/21/2025 included the following tasks to be performed during every hospice aide visit: complete shower, perineal care, incontinent care, shampoo hair, comb hair, foot/skin care, nail care, oral hygiene/denture care, check pressure areas, shaving, back rub/massage, and dressing the patient. The following interventions were not marked as completed by the hospice aide during the visits documented on 05/26/2025, 06/02/2025, 06/06/2025, and 06/11/2025: perineal care, incontinent care, and nail care. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The hospice aide plan of care dated 04/01/2025 included the following tasks to be performed by the hospice aide every visit: complete bed bath, perineal care, foot care, shampoo hair, incontinent care, skin care, checking pressure areas, oral hygiene/denture care, nail care, shaving, and dressing the patient. On 04/23/2025, the hospice aide did not mark that shaving, incontinent care, skin care, or checking pressure areas were done. On 06/03/2025 and 06/18/2025, perineal care, incontinence care, and checking pressure areas were not documented as performed. There was no documentation by the hospice aide indicating that the Registered Nurse (RN) was notified that the care plan had not been completed as written. The findings were confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 11 of 11 (100%) clinical records reviewed for patients receiving home health services revealed the agency did not ensure that the Registered Nurse (RN) documented supervision of the hospice aide every 14 days. CLINICAL RECORD 1: The plans of care for benefit periods 05/20/2025 to 07/18/2025, 07/19/2025 to 09/16/2025, and 09/17/2025 to 11/15/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/28/2025, 06/27/2025 (30 days), 07/28/2025 (31 days), and 08/27/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 2: The plans of care for the benefit periods 05/05/2025 to 08/02/2025 and 08/03/2025 to 10/31/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. The first aide visit was on 05/06/2025. Documented hospice aide supervision by the Registered Nurse (RN) occurred: 06/05/2025 (30 days), 08/07/2025 (63 days), 09/05/2025(29 days), and 10/06/2025 (31 days). CLINICAL RECORD 4: The plans of care for the benefit periods 05/18/2025 to 07/16/2025, 07/17/2025 - 09/14/2025, and 09/15/2025 - 11/13/2025 included orders for the hospice aide to visit the patient three to five times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/20/2025, 06/13/2025 (27 days), 07/14/2025 (28 days), 08/13/2025(30 days), and 09/12/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 5: The plans of care for benefit periods 04/03/2025 to 07/01/2025 and 07/02/2025 to 09/29/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 05/07/2025, 06/06/2025 (30 days), 08/06/2025(61 days),8/27/2025 (21 days) and 09/05/2025. The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 7: The plans of care for benefit periods 06/15/2025 to 08/13/2025 and 08/13/2025 to 10/12/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 06/23/205, 07/28/2025 (35 days) 08/27/2025 (30 days), and 09/26/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 8: The plan of care for the benefit period 08/14/2025 to 10/12/2025 was reviewed and included orders for the Hospice Aide (HA) to visit the patient three times a week. The first aide visit was on 08/15/2025. The only documented HA supervision by the Registered Nurse (RN) occurred on 09/15/2025 (31days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 9: The plans of care for benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 07/30/2025, 08/29/2025 (30 days), and 09/29/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 10: The plans of care for benefit periods 07/01/2025 to 08/29/2025 and 08/30/2025 to 10/28/2025 were reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 07/28/2025, 08/27/2025 (30 days), and 09/26/2025 (30 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 12: The plans of care for the benefit periods 10/02/2024 to 12/30/2024 and 12/31/2024 to 03/30/2025, as well as 03/31/2025 to 04/16/2025, included orders for the hospice aide to visit the patient three times a week. The first aide visit was on 10/04/2024. Documented aide supervision by the Registered Nurse (RN) occurred: 11/04/2024(31 days), 12/04/2024(30 days), 01/01/2025 (28 days), 01/31/2025(30 days), and 03/03/2025 (31 days). The nurse did not supervise the hospice aide every fourteen days. CLINICAL RECORD 13: The plan of care for the benefit period 05/21/2025 to 06/13/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. The first aide visit was 05/21/2025, and there was no documented aide supervision by the Registered Nurse (RN). The Patient died on hospice services on 06/13/2025. CLINICAL RECORD 14: The plan of care for the benefit period 04/01/2025 to 06/29/2025 was reviewed and included orders for the hospice aide to visit the patient three times a week. Documented aide supervision by the Registered Nurse (RN) occurred: 04/30/2025, 05/29/2025 (29 days). The nurse did not supervise the hospice aide every fourteen days. The finding was confirmed following a joint record review and interview with the Director of Nurses (Personnel Record 3) on 10/15/2025. She stated that she misunderstood the requirement to mean that supervision was required after fourteen aide visits, not every fourteen days.

It is required that Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 5 (60%) clinical records reviewed revealed the agency did not ensure the plan of care accurately reflected he scope and frequency of volunteer services. AGENCY POLICY: The hospice's policy "Volunteer Services Policy No. 9-024" dated December 2018 included that "...The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care..." CLINICAL RECORD 1: The plans of care for the benefit periods from 07/19/2025 to 09/16/2025 and from 09/17/2025 to 11/15/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a month. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. CLINICAL RECORD 3: The plans of care for the benefit periods from 07/13/2025 to 09/10/2025 and from 09/11/2025 to 11/09/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a week. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. CLINICAL RECORD 4: The plans of care for the benefit periods from 07/17/2025 to 09/14/2025 and from 09/15/2025 to 11/13/2025 were reviewed. Both included orders for a Volunteer to visit the patient once a month. However, there were no Volunteer visits documented, and there was no evidence of communication or Interdisciplinary Meeting notes addressing the discrepancy in the visit order. During a joint clinical record review and interview with the Director of Nursing (DON) (Personnel Record 3) on 10/16/2025, the documented findings were confirmed, and the issue was revealed to be a documentation issue versus Volunteer visit orders with no visits made. The DON observed the evidence and agreed that the ordered frequency appeared to reflect that visits should be made; however, with her knowledge of the patients, she stated that this was not correct, and the documentation would be brought into compliance to reflect the services to be provided accurately.

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 a review of documents and interviews, which revealed the agency did not ensure the EP plan was reviewed and updated at least every two years. A review of the emergency preparedness (EP) plan binder labeled "2019-2020" and the governing body meeting minutes agendas and sign-in sheets dated 2020, 2021, and 2022 revealed no evidence that the emergency plan was reviewed or updated since 2019. There was no evidence that the hospice established strategies, plans or policies and procedures for addressing the management of the consequences of the emerging infectious disease of COVID-19 that place the health and safety of patients and employees at risk. During an interview on 1/25/23, the Administrator (staff 8) confirmed the finding and reported that there was no other place the documented emergency plan review or updates would be located. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure the emergency plan was reviewed and updated at least every two years.

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. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all- hazards” approach specific to the geography and population served, includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk, and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by a review of documents and interviews which revealed the agency did not ensure the EP plan was updated at least every two (2) years and based on an "all-hazards" approach specific to the geographic area. A review of the agency's document "Hazard Vulnerability Risk Assessment" form revealed that the "2019-2020 ….. Emergency Preparedness Plan" did not include the completion date. There was no evidence that the risk assessment was updated after 2019. There was no evidence that the hospice established strategies, plans or policies and procedures for addressing the management of the consequences of the emerging infectious disease of COVID-19 that placed the health and safety of patients and employees at risk. During an interview on 1/25/23, the Administrator (staff 8) confirmed the finding and stated that there were no other hazard risk assessments and that she believed this was completed in 2019. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure the emergency plan was reviewed and updated at least every two years, nor was it based on an "all-hazards" approach specific to the geographic area that had been completed within the last two years.

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 a review of documents and interviews, which revealed the agency did not ensure the emergency preparedness policies and procedures were reviewed every two (2) years based on the emergency plan, risk assessment, and communication plan. A review of the agency's policy #4-001, "Emergency Management Plan" (no date), revealed the policy did not include the date of implementation or the review date. There was no evidence that the policies and procedures were updated at least every two (2) years. The administrator confirmed the finding on 1/25/23 and stated that the last time the emergency plan, including policies, was reviewed was "probably 2019." This standard was not met as evidenced by a review of documents and interviews which revealed the agency did not ensure the emergency preparedness policies and procedures were reviewed every 2 years, based on the emergency plan, risk assessment, and communication plan.

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 a review of documents and interviews, which revealed the agency did not ensure that the emergency preparedness communication plan was reviewed and updated at least every two (2) years. A review of the agency's binder " 2019-2020 Emergency Preparedness (EP) Plan" revealed a communication plan that did not include a date. There was no evidence that the 2019-2020 EP plan, including the communication plan, was updated at least every two (2) years. There was no evidence that the hospice established strategies, plans or policies and procedures for addressing the management of the consequences of the emerging infectious disease of COVID-19 that placed the health and safety of patients and employees at risk. During an interview on 1/25/23, the Administrator confirmed the finding that the communication plan was not reviewed and updated within the last two years. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure that the agency maintained an emergency preparedness communication plan which was reviewed and updated at least every two (2) years.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state, and local laws. The communication plan includes names and contact information for hospice employees, patients’ physicians, entities providing services under arrangement, and other hospices. This standard was not met as evidenced by a review of documents and interviews, which revealed the agency did not ensure that the communication plan included names and contact information for hospice employees. A review of the agency's emergency preparedness (EP) plan binder revealed the communication plan did not include hospice employees' names and contact information. During an interview and a joint review of the EP plan on 1/25/23, the Administer confirmed that the EP plan had not been updated with the employee information. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure that the communication plan included hospice employee names or contact information.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes contact information for the federal, state, tribal, regional, local emergency preparedness staff, and other sources of assistance. This standard was not met as evidenced by a review of documents and interviews, which revealed the agency did not ensure that the communication plan included contact information for federal, state, tribal, regional, local emergency preparedness staff or other sources of assistance. A review of administrative documents and the emergency preparedness binder revealed the communication plan did not include contact information for the federal, state, tribal, regional, local emergency preparedness staff, and other sources of assistance. During an interview on 1/25/23, the Administer confirmed that the emergency binder had not been updated with this information. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure that the communication plan included contact information for federal, state, tribal, regional, local emergency preparedness staff or other sources of assistance.

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan includes how information and medical documentation for patients under the hospice’s care is shared, as necessary, with other healthcare providers to maintain the continuity of care, and information in the event of an evacuation concerning how to release patient information, including their general condition and location, as permitted by the Health Insurance Portability and Accountability Act (HIPAA). This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure that the communication plan included how the agency would share information and patient documentation during an emergency. A review of the agency's Emergency Preparedness Plan revealed the agency did not ensure the communication plan met all of the requirements required for how information and medical documentation for patients under the hospice's care would be shared. The agency's Emergency Preparedness Plan did not specifically describe how information and medical documentation for patients under the hospice’s care would be shared with other healthcare providers to maintain the continuity of care, and specifically how information would be released in the event of an evacuation as permitted by the Health Insurance Portability and Accountability Act (HIPAA). During an interview on 1/25/23, the Administer confirmed that the emergency binder had not been updated with this information. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure that the communication plan included how the agency would share information and patient documentation during an emergency, as permitted by HIPAA.

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. This standard was not met as evidenced by a review of documents and interview which revealed that the agency did not ensure the emergency preparedness training program was reviewed and updated at least every two (2) years. A review of the agency's emergency preparedness (EP) plan revealed there was no evidence that the training program had been reviewed and updated since 2019. The training program was not updated to include the COVID-19 public health emergency. During an interview and a joint review of the EP plan on 1/25/23, the Administrator confirmed that the binder provided for review contained all the emergency plan-related items, including the training plan, and said that she believed it was last reviewed in 2019. This standard was not met as evidenced by a review of documents and staff interview which revealed that the agency did not ensure the emergency preparedness training program was reviewed and updated at least every two (2) years.

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 EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by a review of personnel records and interviews. 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure that emergency preparedness training was provided to all hospice employees at least every two (2) years. Staff 4: The registered nurse (RN) was hired on 9/17/2020. A review of the personnel record revealed emergency preparedness training was on 9/17/2020. There was no evidence of emergency preparedness training at least every two years and training related to the COVID-19 public health emergency. The Administrator confirmed the finding on 1/26/23, stating the agency could not locate any other EP training for this employee. This standard was not met as evidenced by a review of personnel records and staff interviews which revealed that the agency did not ensure that emergency preparedness training was provided to all hospice employees at least every two (2) years.

It is required that 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 11 (9%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment related to spiritual needs was completed no later than five calendar days after the election of hospice care. Clinical Record 8: The patient elected the hospice benefit on 1/4/23. The physician's order dated 1/4/23 ordered: "chaplain... initial within 5 days of admit for spiritual assessment." The initial chaplain assessment was completed on 1/23/23, 19 days after the election of hospice care. During an interview on 1/26/23, the Administrator and the Director of Nursing (staff #2) confirmed that the agency could not provide additional documentation regarding why the spiritual assessment was not completed on time.

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. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure the drug profile included oxygen. Clinical Record 3: The patient elected the hospice benefit on 10/1/22 with a diagnosis of atherosclerotic heart disease. During the home visit on 1/24/23, the patient was observed using oxygen at 3 liters via nasal cannula. A clinical record review revealed a physician's order dated 10/3/22 ordered: "oxygen at 3 liters PRN for shortness of breath." The drug profile, current as of 1/24/23, did not include oxygen. Clinical Record 11: The patient elected the hospice benefit on 10/10/22 with a diagnosis of congestive heart failure. The RN visit note dated 10/24/22 documented, "Pt is on O2 at 4 liters per minute." A clinical record review revealed a physician's order dated 10/10/22 ordered: "Oxygen at 4 liters continuous via nasal cannula." The drug profile, effective 10/10/22 through 10/28/22 (patient's death), did not include oxygen. The Director of Nursing confirmed in an interview on 1/26/23, that the oxygen had not been entered into the drug profiles for these patients and should have been.

It is required that the plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the agency did not ensure the plan of care addressed the patient's specific needs related to falls. Clinical Record 2: The patient elected the hospice benefit on 1/4/23 with the diagnoses of atherosclerotic heart disease and history of falls. The initial comprehensive assessment completed by the registered nurse (RN) on 1/4/23 documented a fall risk assessment score total of "9" with guidance that "a score of 4 or greater is considered at risk for falling." The admission visit note dated 1/4/23 documented, "facial bruises as result of falls are not open." The plan of care, dated 1/4/23 through 1/24/23, did not include a problem, goal, or intervention related to the patient's fall risk and safety as identified in the comprehensive assessment. During the interview conducted on 1/24/23, the Director of Nursing confirmed that the plan of care did not address the patient's safety needs/fall risk.

It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations and adverse events. This standard was not met as evidenced by a document review and interviews. The hospice did not ensure to measure, analyze, and track quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse events. A review of the QAPI documents presented by the Administrator revealed data collected for 2022 included: volunteer hours, the average length of stay, discharges, HIS (Hospice Item Set) transmission success rates, and crisis care hours. A binder the Director of Nursing (DON) provided included "Adverse Event" forms completed for the last 2 years. The DON stated that the adverse events and patient infections were tracked and discussed in the IDG (Interdisciplinary group meetings) meetings. The DON stated the discussions were not documented. There was no documented evidence of trending and analysis of the data collected to assess for improvement opportunities. There was no documented evidence of data collection for 2020. There was no documented evidence that the adverse events and infections were tracked, measured, and analyzed in relation to the COVID-19 PHE (Public Health Emergency). During an interview on 1/26/2023, the Director of Nursing stated that for 2022 adverse events, infections, and concerns are tracked, investigated, and reported during IDG meetings, but there were no meeting minutes. This standard was not met as evidenced by a review of documents and staff interviews which revealed the agency did not ensure the QAPI program measured, analyzed, and tracked quality indicators of performance related to adverse events which was still required under Hospice 1135 Waiver.

It is required that performance improvement activities track adverse patient events, analyze the causes, implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews and interviews. The agency did not ensure that performance improvement activities included tracking and analyzing patient adverse events for their causes. A review of the administrative documents provided by the agency revealed completed "Adverse Event" forms for the last two years. The adverse event forms documented the investigation and evaluation of adverse patient events. During the interview on 1/26/23, the Director of Nursing (staff 2) stated that she reviewed the forms at the IDT (interdisciplinary team meetings) and looked for trends but could not provide documentation to support that tracking and trending occurred. There was no evidence that tracking and analyzing adverse events led to the implementation of preventive actions as part of a performance improvement plan. There was no documented evidence that the adverse events were tracked and analyzed for causes related to the COVID-19 PHE (Public Health Emergency). The Administrator present for the interview with the Director of Nursing confirmed that the adverse events were not being tracked, trended, and analyzed as they should be. This standard was not met as evidenced by a review of documents and staff interviews it was revealed that the agency did not ensure that the tracking of adverse patient events was documented.

It is required that the hospice must document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. This standard was not met as evidenced by document review and interviews. The agency did not ensure to document the performance improvement projects being conducted, the reasons for conducting the projects, and the measurable progress achieved on the projects. The performance improvement projects (PIP) documented as provided for 2022 included: Quarter One (1): January - Adequate communication; February - Safety measures; March - Prevention of skin breakdown; Quarter Two (2): April - Adequate communication; May - Safety education; June - Adequate communication; Quarter Three (3): July - Fall education; August - Flu education; September - Safety education; and Quarter Four (4): October - Nutrition education; November - Infection control techniques given to patient and families; December - Safety education. The PIP documents lacked detail describing the reason for conducting the performance improvement projects and the measurable progress achieved on the projects. There were no PIP documents provided for 2020 and 2021. During the interview on 1/26/23, the administrator confirmed that there was no other PIP documentation and agreed that the PIPs provided should have included measurable progress of the project. This standard was not met as evidenced by a review documents and staff interviews which revealed the agency did not ensure that performance improvement projects were conducted annually, nor did they reflect the scope, complexity or past performance of the hospice's services and operations. Under the Hospice 1135 Waiver agencies were still expected to have improvements that focused on the public health emergency (infection control and adverse events) and a data-driven quality assessment and performance improvement program.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document reviews and interviews which revealed the hospice did not ensure that the QAPI program was implemented, maintained, and evaluated annually by the hospice's governance. A review of the agency's governing body meeting agendas, and sign in sheets for 2020, 2021, and 2022 revealed no evidence that the governing body defined, implemented, maintained, and evaluated the agency's ongoing performance improvement and patient safety program annually. During an interview on 1/26/23, the Administrator confirmed that there was no documentation to support that the governing body had maintained responsibility and evaluated the QAPI program annually. This standard was not met as evidenced by review of documents and staff interviews which revealed the agency did not ensure the governing body responsibilities included establishment of defined data details, including any infection control data or adverse events, nor was there documented approval.

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 documents, interviews, and observations. 1 of 3 (33%) home visits revealed the agency did not ensure that staff followed the agency's hand hygiene policy. The agency's policy #C: 2-048.1 "Hand Hygiene" stated in relevant parts, "Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC guidelines for hand hygiene in healthcare settings. Hand decontamination using an alcohol-based hand rub should be performed...before having direct contact with patients...After contact with a patient's intact skin...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient... After removing gloves." Home Visit 1: During the home visit (record 1) conducted on 1/24/23, the registered nurse (RN) (staff #2) donned exam gloves, performed vital signs, doffed gloves, reached into the visit bag and retrieved an item, then assisted the patient with putting on a sweater. Hand hygiene was not completed after removal of gloves or re-entry into the visit bag as per the agency's policy. During an interview conducted on 1/24/23, the Director of Nursing (staff #2), present at the visit, and the Administrator (staff 8), confirmed that the agency policy needed to be followed.

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 a review of clinical records and interviews. 6 of 11 (55%) clinical records reviewed of patients that received hospice aide services revealed the agency did not ensure that the written patient care instructions prepared by the RN provided the hospice aide clear and specific instructions related to the assigned tasks. Clinical Record 2: The patient elected hospice care on 1/4/23. The hospice aide care plan effective 1/5/23, assigned the hospice aide the tasks: "complete bed bath as needed if shower is refused; shampoo hair as needed; partial bath/shower if refuses complete shower; shave as needed." The hospice aide did not receive specific instructions regarding the frequency of the shampoo, shaving, and type of bath. Clinical Record 3: The patient elected hospice care on 10/1/22. The hospice aide care plan effective 12/30/22 through 1/26/23, assigned the hospice aide the tasks: "nail care as needed; partial bath/shower as needed only if complete bed bath cannot be done; shave as needed; complete shower as needed only if complete bed bath cannot be done." The hospice aide did not receive specific instructions regarding the frequency of shaving and nail care, and type of bath. Clinical Record 5: The patient elected hospice care on 10/24/22. The hospice aide care plan effective 10/24/22 through 1/26/23, assigned the hospice aide the tasks: "complete bed bath as needed if shower is refused; shampoo hair as needed; nail care as needed; partial bath/shower as needed if complete shower is refused; shave as needed; light housekeeping as needed; assist in ambulation as needed; assist in transfer as needed." The hospice aide did not receive specific instructions regarding the frequency of the shampoo, shaving, ambulation, transfers, nail care, housekeeping, and the type of bath and transfer. Clinical Record 6: The patient elected hospice care on 12/12/22. The hospice aide care plan effective 12/12/22 through 1/26/23, assigned the hospice aide the tasks: "complete bed bath as needed if shower is refused; back rub/massage as needed; nail care as needed; partial bath/shower if refuses complete shower; shave as needed. The hospice aide did not receive specific instructions regarding the frequency of shaving, back rub/massage, nail care, and type of bath. Clinical Record 7: The patient elected hospice care on 9/30/22. The hospice aide care plan effective 12/29/22 through 1/26/23, assigned the hospice aide the tasks: "Nail care report problems; partial bath/shower as needed if complete shower is refused; complete shower as needed; complete bed bath at every visit; assist in transfer as needed." The hospice aide documented completion of bed bath on all visits reviewed from 12/29/22 to present. The hospice aide did not receive specific instructions regarding the frequency and type of transfers and bath. There were no specific instructions regarding nail care problems. Clinical Record 8: The patient elected hospice care on 1/4/23. The hospice aide care plan effective 1/4/23 through 1/26/23, assigned the hospice aide the tasks: "complete bed bath as needed if shower is refused; shampoo hair as needed; back rub/massage as needed; nail care as needed; partial bath/shower as needed if complete shower is refused; shave as needed; assist in ambulation as needed; assist in transfer as needed. The hospice aide did not receive specific instructions regarding the frequency of the shampoo, shaving, ambulation, transfers, nail care, and back rub/massage, and the type of bath and transfer. During an interview on 1/26/23, the Director of Nursing confirmed that records identified did not provide specific instructions to the aide.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of documents and interviews, which revealed the failure of the Administrator to inform the governing body about ongoing operations and QAPI activities [HSLG.3.I/L651]; failure to ensure the Emergency Preparedness (EP) plan was reviewed and updated to provide evidence of plans, policies and processes for addressing the management of the consequences of the emerging infectious disease of COVID-19 that placed the health and safety of patients and employees at risk [HSEP.2.D/E4]; failure to ensure the EP plan was updated and based on an "all-hazards" approach that included the emerging infectious disease of COVID-19 that place the health and safety of patients and employees at risk.[HSEP.2.D/E6]; failure by the hospice Governing Body to assume responsibility for the organization’s overall management and operations and ongoing performance improvement and patient safety program that is defined, implemented, maintained and evaluated annually [HSLG.2.I/L651]; failure to ensure that continuous performance improvement and patient safety were defined, implemented, and maintained [HSLG.2.I/L574]; failure to ensure that the emergency preparedness policies and procedures were reviewed every two (2) years [HSEP.3.D/E13]; failure to ensure that the emergency preparedness communication plan was reviewed and updated at least every two (2) years [HSEP.4.D/E29]; failure to ensure that emergency preparedness training was provided to all hospice employees at least every two (2) years, including strategies related to the COVID-19 PHE [HSEP.5.D/E37]; failure to ensure the emergency preparedness training program was reviewed and updated at least every two (2) years and included strategies related to the emerging infectious disease of COVID-19 that placed the health and safety of patients and employees at risk [HSEP.5.D/E36]; and failure to ensure documented evidence that adverse events and patient and employee infections related to the COVID-19 PHE (Public Health Emergency) were tracked, measured, and analyzed [HQPI.4.I/L562]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operation of the hospice. This standard was not met as evidenced by a review of documents and interviews. The hospice did not ensure that the Administrator Informed the governing body about ongoing operations, including QAPI activities and emergency preparedness. A review of the governing body meeting agendas, and sign in sheets for 2020, 2021, and 2022 revealed no evidence that the governing body defined, implemented, maintained, and evaluated the agency's ongoing performance improvement and patient safety program annually. A review of the QAPI information, including an "Adverse Event" binder provided by the Administrator and the Director of Nursing (DON) revealed data was collected for 2022 that included: adverse events, infections, volunteer hours, average length of stay, discharges, HIS (Hospice Item Set) transmission success rates, and crisis care hours. There was no documented evidence that the data collected was measured, analyzed or trended to enable the assessment of processes of care, hospice services, operations, and adverse events for 2020 and 2021. There was no documented evidence that the governing body reviewed and approved the QAPI activities and the EP plan. During an interview on 1/26/23, the Administrator confirmed that there was no documentation to support that the governing body had maintained responsibility and evaluated the QAPI program annually.

It is required that if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary and the patient's clinical record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) clinical records reviewed of patients transferred to the hospital revealed the agency did not ensure that a copy of the discharge summary was forwarded to the receiving facility. Clinical Record 9: The patient elected the hospice benefit on 11/16/21. The live discharge dated 10/21/22 documented that the patient revoked hospice services, per the daughter's request, "to have the patient admitted to the hospital for a hip fracture." A clinical record review revealed no evidence that a discharge summary was forwarded to the receiving hospital. Clinical Record 10: The patient elected the hospice benefit on 9/9/22. The live discharge dated 11/14/22 documented the patient was admitted to a non-contracted hospital for a non-hospice-related surgical procedure. A clinical record review revealed a note dated 11/9/22 that documented the communication between the urologist/surgeon and hospice medical director regarding the upcoming surgery. There was no evidence that a discharge summary was forwarded to the receiving hospital. During an interview on 1/26/23, the Director of Nursing confirmed that the clinical records did not include documentation of the information provided to the receiving facilities.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) clinical records reviewed of discharged patients revealed the agency did not ensure the discharge summary included a summary of the patient's hospice stay, current plan of care, and latest physician orders. Clinical Record 9: The patient elected the hospice benefit on 11/16/21. The live discharge dated 10/21/22 documented that the patient revoked hospice services, per the daughter's request, "to have the patient admitted to the hospital for a hip fracture." A clinical record review revealed no evidence that a discharge summary was completed as of 1/26/23. Clinical Record 10: The patient elected the hospice benefit on 9/9/22. The live discharge dated 11/14/22 documented the patient was admitted to a non-contracted hospital for a non-hospice-related surgical procedure. A clinical record review revealed a note dated 11/9/22 that documented the communication between the urologist/surgeon and hospice medical director regarding the upcoming surgery. There was no evidence that a discharge summary was completed as of 1/26/23. During an interview on 1/26/23, the Director of Nursing confirmed that questioned what all components were required to be included within the discharge summary and confirmed that the agency did not have such a document to provide. It was also confirmed that the clinical records did not contain documentation that the any of the required elements (plan of care, physician orders, summary of hospice stay) were provided in any other method.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by interviews and observation. The agency did not ensure that medical supplies were checked for expiration dates. During a tour of the agency's supply room conducted on 1/26/23, a review of medical supplies revealed that six (6) Indwelling Catheter Trays had an expiration date of 2/28/2022. The Director of Nursing (staff #2) present during the tour and review of the supplies, confirmed that the catheter trays had expired. This standard was not met as evidenced by a tour of the supply room, during the observation it was revealed the agency did not ensure that the items were inspected for expiration dates and removed/discarded if expired. Six (6) Indwelling Catheter Trays all contained an expiration date of 2/28/2022. The director of nursing (staff 2) was present during the inspection of the supplies, which occurred on 1/26/2023, and confirmed that the catheter trays had expired.

It is required that the hospice and SNF/NF or ICF/IDF have a written agreement that specifies the provision of hospice services in the facility. The agreement includes the following provisions: the hospice will report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice, to the SNF/NF or ICF/IDF administrator within 24 hours of the hospice becoming aware of the alleged violation. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that the agreement with the skilled nursing facility (SNF) contained all of the required provisions. The agency's SNF contract for the provision of general In-patient care (GIP), and respite care (RC) executed on 3/31/2019, did not include the provision stating, "the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF or ICF/MR administrator within 24 hours of the hospice becoming aware of the alleged violation." During an interview and a joint review of the agreement on 1/25/23, the Administrator confirmed that the agreement did not contain the required provision relating to reporting alleged violations.

It is required that organization policy and procedure state the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes: documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications; and a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications; and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. This standard was not met as evidenced by a review of documents and interviews. A review of the agency's document "COVID-19 Plan" revealed the plan did not include a policy that contained verbiage that defined the requirements for a medical or spiritual exemption to being fully vaccinated. The Administrator presented a spreadsheet that showed that currently 100% of employees and contracted physicians had been vaccinated and they did not have any exemptions. During an interview on 1/26/23, the Administrator (Staff 8)confirmed the finding that the agency policy had not been updated to reflect regulatory changes. This standard was not met as evidenced by a review of the document titled "COVID-19 Plan" which revealed the agency did not ensure the policy stated the requirements for a medical or spiritual exemption to be fully vaccinated for COVID-19 per state and federal law and regulation. The document "COVID-19 Plan" did not include any defined process or criteria that would be followed to request a medical or spiritual exemption. This was confirmed during interview with the administrator (Staff 8) on 1/26/23 as the agency policy had not been updated to reflect regulatory changes under 418.60. The administrator did present a spreadsheet that showed that currently 100% of employees and contracted physicians had been vaccinated and they did not have any exemptions.