Every finding on record at Gracia Hospice Group Inc.

It is required that 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. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If 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. This exercise may include, but is not limited to: 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 that 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 IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by document review and interview. Review of the plan of correction binder and emergency disaster plan revealed that the agency did not ensure that that there was a community-based drills and no planning for a community-based drill every two years. Emergency Preparedness Plan: The Emergency Preparedness plan provided no evidence of a community-wide drill every two years and there is no evidence of coordination with community providers. The agency had a fire drill on 09/03/2025 that included 2 employees only with no evidence of care coordination. The agency was unable to provide any evidence of working toward a community-wide drill. The administrative assistant confirmed in an interview on 09/1/2025 that the fire drill on 09/03/2025 with 2 employees was an attempt to address the emergency disaster deficiency and did not include a plan for community involvement. Review of the plan of correction binder and emergency disaster plan revealed that the agency did not ensure that that there was a community based drills and no planning for a community based drill every two years.

It is required that the hospice takes action to improve performance; assesses the success of the action after implementing it and tracks ongoing results to ensure improvement is sustained. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by document review and interview. The agency did not ensure that there were actions taken to improve performance and tracking to ensure results were maintained. The QAPI binder and corrective action binder were provided to the site visitor as evidence of improvement. The agency did not have any identified performance improvement plans related to patient care. The only documented plans were related to the plan of correction. There were no QAPI meeting minutes since July 2025, prior to the site visit. The plan of correction noted that education and a QAPI meeting would be implemented by 09/03/2025. There was no evidence that a QAPI meeting had been held since the site visit. The director of nursing stated in a phone interview on 09/15/2025, "I think we only do QAPI meetings quarterly", after being asked about the QAPI plan of correction. The agency did not ensure that there were actions taken to improve performance and tracking to ensure results were maintained.

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 2 (50%) clinical records reviewed revealed that the nurse did not provide the aide with clear individualized direction on the aide's plan of care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 1: The patient was admitted on 08/11/2025. The SN assessment reported that the patient had a Foley catheter removed and was using a Purewick system for incontinence. The aide care plan developed by the RN on 08/11/2025 did not provide the aide with direction related to the Purewick incontinence system. Interview with the Director of Nursing (DON)via phone call on 09/15/2025, explained findings. The DON confirmed that the Purewick was not on the aide care plan.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record of the aide reviewed revealed that the agency did not ensure that the nurse made an annual on-site visit with the aide to observe and assess the visit in person. Personnel Record 2: The personnel record of the certified nursing assistant with a hire date 09/06/2023 revealed no documented evidence of an on-site RN visit with the aide. On 09/15/2025 the administrative assistant demonstrated an aide care plan for one patient and inquired, "Is this what you need? and then confirmed there were no further competency documents or an annual review that the nurse makes on site with the aide. The Director of Nursing confirmed in a phone interview on 09/1/2025 that an annual on-site visit had not been completed with the aide.

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 IS A REQUIRED CONTINUED ACTION This standard was not met as evidenced by document review and interview. Plan of Correction Binder: The plan of correction binder and volunteer information provided did not provide any evidence of progress toward meeting volunteer hours. The section of the plan of correction binder for HSLG.7. I was blank. There was no evidence in the QAPI book of a Performance Improvement Plan for Volunteer Hours. The Administrative assistant stated in an interview on 09/15/2025, I don't know anything about the volunteers because the volunteer coordinator is on vacation.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. THIS IS A REQUIRED CONTINUED ACTION. This standard was not met as evidenced by interview and personnel record review. In 1 of 6 (17%) clinical records reviewed revealed that the agency did not ensure that all personnel providing care had the competency assessed. Personnel Record 2: A personnel record review was conducted on 08/05/2025, for an employee with direct patient contact (Hospice Aide) hired on 09/06/2023, which revealed there was no documentation of skills competencies for 2024. The administrative assistant confirmed that there were no skills checklists in the employee file.

It is required that short-term inpatient care is available for respite purposes and is provided in a participating Medicare or Medicaid facility. THIS IS A CONTINUING CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview revealed the hospice: Failed to ensure that the agency had a written agreement for respite care {HSIC.2. I/L706/ 418.108(a)(1). 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.

It is required that hospice inpatient care for respite purposes is provided by one of the following a Medicare-certified hospital or a skilled-nursing facility that also meets the standards specified in §418.110(b) (requiring 24-hour nursing care); and §418.110(f) (regarding home-like patient areas). This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) respite contracts reviewed revealed that the agency did not ensure that the respite contract was signed and executed by all parties. THIS IS A CONTINUED REQUIRED ACTION Plan of Correction Binder: The agency did not have evidence of a fully executed contract for respite care. The respite care contract was not signed by the facility; therefore, it was not executed. In a review and interview with the administrative assistant, she confirmed that the respite contract was not signed by the provider. In a phone interview on 09/15/2025, the Director of Nursing stated, "Oh! I see what you mean" after being told that the respite contract was not valid if it was not signed by the facility.

It is required that a social worker has: A Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; OR 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. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of the agency social worker revealed that the agency did not ensure that there was a master's prepared social worker on staff or that the BSW was supervised by an MSW. There was no documented evidence of a master’s degree social worker to provide supervision of the BSW. Personnel Record 1: The Bachelor of Social Work (BSW) (Personnel Record 1) was hired on 02/07/2025. The personnel record revealed a diploma for Bachelor of Social Work. The administrative assistant stated in an interview on 09/15/2025, " I am working on hiring a master’s degree social worker. There are two people I am interviewing." Confirmed there were no other social workers on staff.

It is required 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. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If 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. This exercise may include, but is not limited to: 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 that 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. The Agency's Emergency Preparedness Plan was reviewed with the Administrator on 08/07/2025. It did not include documentation of annual testing for 2023 or 2024. The Administrator stated that "he thought they had done a drill but couldn't find documentation." He further went on to state, "Maybe the previous leadership took the documentation." The Agency's Emergency Preparedness Plan was reviewed with the Administrator on 08/07/2025. It did not include documentation of annual testing for 2023 or 2024. The Administrator stated that "he thought they had done a drill, but couldn't find documentation." He further went on to state, "Maybe the previous leadership took the documentation."

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14 0%) clinical records reviewed revealed the agency did not ensure the patient was informed about the scope of services the hospice provides and any specific limitations on those services. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/26/2024 for a diagnosis of protein-calorie malnutrition. The notification of non-covered items was requested upon admission. There was no documented evidence that the notification of noncovered items given to the patient/representative. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/22/2024 for a diagnosis of combined systolic and diastolic heart failure. The notification of non-covered items was requested upon admission. There was no documented evidence that the notification of noncovered items given to the patient/representative. A joint clinical record review and interview was conducted on 08/07/2025 with the Administrator/Alternate Administrator, in which they stated, "We don't know where to locate those items. The past leaders may have taken them."

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the documented comprehensive assessment included 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. Home Visit 2: The patient elected the hospice benefit on 05/03/2024 for a diagnosis of Alzheimer's disease. The patient resided in an assisted living facility (ALF). During Home Visit 2 with the Hospice Aide (Personnel Record 7) on 08/07/2025, the hospice medication profile (printed on 08/05/2025) was compared to the ALF medication profile (printed on 08/07/2025). The following medications were listed on the hospice medication profile and were not listed on the ALF medication profile: Roxicodone 2.5 ml every 4 hours as needed for pain (ordered 08/02/2025); Zofran 4 mg 1 tablet (no frequency written)(ordered 08/02/2025); Bisacodyl 10 mg suppository daily as needed (ordered 05/15/2025). The following discrepancies were noted: Hospice list had Hydrocodone 5/325 mg continuously (ordered 04/15/2025) vs ALF Hydrocodone 5/325 mg every 4 hours as needed (ordered 06/17/2025). Hospice list had Senna 8.6 mg 1 tablet daily (ordered 05/16/2024) vs ALF Senna 8.6 mg 2 tablets twice daily (ordered 01/10/2024) . Hospice list had Seroquel 50 mg daily (ordered 07/21/2025) vs ALF Seroquel 50 mg twice daily (ordered 07/06/2025). CLINICAL RECORD 5: The patient elected the hospice benefit on 08/05/2024 for a diagnosis of senile degeneration of the brain. The patient died on 08/18/2024. A clinical record review on 08/07/2025 revealed that the comprehensive assessment did not include a list of medications. A joint clinical record review and interview was performed with the Administrator/Alternate Administrator on 08/07/2025, in which it was stated, "the medication lists should match."

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 and interview. In 10 of 14 (71%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/03/2024 for a diagnosis of Alzheimer's disease. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 08/01/2024 for a diagnosis of hypertensive heart disease. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/30/2023 for a diagnosis of hypertensive heart disease. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 08/05/2024 for a diagnosis of senile degeneration of the brain. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/26/2024 for a diagnosis of protein-calorie malnutrition. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/22/2024 for a diagnosis of combined systolic and diastolic heart failure. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 06/15/2023 for a diagnosis of chronic obstructive pyelonephritis. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/20/2023 for a diagnosis of malignant neoplasm of bronchus. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/17/2023 for a diagnosis of cerebral atherosclerosis. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 13: The patient elected the hospice benefit on 08/20/2024 for a diagnosis of hypertensive heart disease. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/04/2024 for a diagnosis of malignant neoplasm of the brain. A clinical record review on 08/06/2025 revealed that the comprehensive assessment did not include documentation of an initial bereavement assessment. A joint clinical record review and interview was conducted on 08/07/2025 with the Administrator/Alternate Administrator, during which they stated, "We have hired new staff and developed a plan for bereavement."

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepared a written plan of care (POC) for each patient. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/11/2024 for a diagnosis of hypertensive heart disease. The patient died on 08/16/2024. A clinical record review on 08/07/2025 revealed that the comprehensive assessment did not include documentation of a written plan of care. A joint clinical record review and interview was conducted on 08/07/2025 with the Administrator/Alternate Administrator in which they confirmed the patient did not have a documented plan of care.

It is required that the hospice takes action to improve performance; assesses the success of the action after implementing it; tracks ongoing results to ensure improvement is sustained. This standard was not met as evidenced by document review and interview. The QAPI Program was reviewed with the Administrator on 08/06/2025. There was no documentation of Performance Improvement programs for 2023 or 2024. The Administrator said he "believed the former leaders may have taken the binder." The QAPI Program was reviewed with the Administrator on 08/06/2025. There was no documentation of Performance Improvement programs for 2023 or 2024. The Administrator said he "believed the former leaders may have taken the binder."

It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. The hospice maintains documentation that demonstrates that the requirements for aide in-service training have been met for each aide. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) hospice aide personnel records reviewed revealed the agency did not ensure the hospice-maintained documentation that demonstrated that the requirements for aide in-service training had been met for each aide. Personnel Record 7: A personnel record review was conducted on 08/05/2025, for an employee with direct patient contact (Hospice Aide) hired on 09/06/2023, which revealed the hospice did not have documentation of the aide receiving 12 hours of annual in-service training in 2024. A joint personnel record review and interview was conducted with the Administrator and Alternative Administrator on 08/06/2025 in which it was explained the "previous leadership removed many items when they left."

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 11 (55%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan(s) dated 08/05/2025 included the following tasks: "complete bed bath, file fingernails/toes, shampoo hair, shave, shower." Aide frequency of twice weekly. All tasks were to be completed on every visit. The initial nursing assessment dated 08/03/2025 noted the patient to have a "Foley catheter". The aide's care plan did not provide the aide with specific instructions for the care of the Foley catheter. CLINICAL RECORD 2: The patient’s election of benefits was dated 05/03/2024 with diagnosis of: Alzheimer's disease. The patient resided in an assisted living facility (ALF). The hospice aide care plan(s) dated 08/05/2025 included the following tasks: "complete bed bath, file fingernails/toes, shampoo hair, shave, shower." Aide frequency of twice weekly. All tasks were to be completed on every visit. The aide's care plan did not provide the aide with specific instructions for the type of bath to be given. The hospice aide had documented visits for the patient twice weekly since admission on 05/03/2024 without a documented aide care plan. The aide plan of care was entered on 08/05/2025 when a copy was requested for Home Visit 2. CLINICAL RECORD 5: The patient’s EOB was dated 08/18/2024 with diagnosis of senile degeneration of brain. The patient resided in an ALF. A hospice aide visit dated 08/15/2024 noted "I gave her a bed bath, washed her hair with a shampoo cap, combed and dried her hair, put lotion on her body, put clean clothes on her, changed the sheets on her bed for clean ones, repositioned her in bed, put the towels, sheets and dirty clothes in the basket." There was no documented evidence for an aide care plan for this visit. CLINICAL RECORD 6: The initial nursing assessment dated 12/26/2024 noted: "Patient will benefit from an aide coming 2x week to assist with bathing and ADLs (activities of daily living)." Hospice aide visits were made on the following dates: 01/23/2025, 01/16/2025 (not doing well no tasks), 01/14/2025 (bed bath, lotion, clean clothes), 01/10/2025 (no bed bath as husband wasn't home), 01/03/2025 (introduction). There was no documented evidence for an aide care plan for these visits. CLINICAL RECORD 7: The patient’s election of benefits was dated 08/22/20245. A review pf the clinical record for 08/22/82024-0/29/2024 included hospice aide visits were made on the following dates: 08/23/2024 (gave him a sponge bath, put lotion on his body, put clean clothes on him, and put him in the wheelchair), 08/26/2024 (changed his shirt, washed his face, put lotion on his body, and repositioned him in bed. His blood sugar level was 408, his wife and son gave him insulin), 08/29/2024 (bed bath, washed hair with the shampoo cap, put lotion, put clean clothes, changed his sheets, and repositioned him). There was no documented evidence for an aide care plan for these visits. CLINICAL RECORD 12: The patient’s election of benefits was dated 01/17/2023. A review of the clinical record included a hospice aide care plan dated 01/30/2023 that included the following tasks: "shower and complete bed bath." Aide frequency of twice weekly. All tasks were to be completed on every visit. The aide's care plan did not provide the aide with specific instructions for the type of bath to be given. An interview and joint clinical record review with conducted with the Director of Nursing (DON) on 08/05/2025 in which she confirmed aide care plans had not been entered for Clinical Record 1 and Clinical Record 2. She responded, "I thought the aide did it." An interview and joint clinical record review with conducted with the Administrator on 08/06/2025 in which he responded that he "thought the previous leadership had completed these."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 11 (18%) clinical record review and home visits observed with a hospice aide revealed the agency did not ensure the aide provided services included in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/03/2025. The hospice aide visit dated 08/04/2025 noted the following: "cut nails and toenails during visit." The aide care plan was not entered until 08/05/2025, 1 day after the visit. HOME VISIT 2: The patient’s election of benefits was dated 05/03/2024 with diagnosis of: Alzheimer's disease. The patient resided in an assisted living facility (ALF). The hospice aide care plan(s) dated 08/05/2025 included the following tasks: "complete bed bath, file fingernails/toes, shampoo hair, shave, shower." The aide was ordered a frequency of twice weekly. All tasks were to be completed on every visit. Home Visit 2/Clinical Record 2 was conducted on 08/07/2025 with the Hospice Aide (Personnel Record 7). The aide was observed to shower the patient, shampoo her hair, assist to dress, and applied lotion to the patient. The aide was not observed to give the patient a complete bed bath, file her nails/toes or shave the patient. A review of the aide visit and interview was conducted with the Director of Nursing on 08/07/2025, in which she responded, "I will correct the aide care plan."

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; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure the registered nurse performed an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/03/2024 for a diagnosis of Alzheimer's disease. The hospice aide had documented visits for the patient twice weekly since admission on 05/03/2024 without a documented aide care plan. The registered nurse supervisory visits documented that "the aide was following the plan of care," although a plan of care had not been established. The aide plan of care was entered on 08/05/2025 when a copy was requested for Home Visit 2. CLINICAL RECORD 6: The initial nursing assessment dated 12/26/2024 noted: "Patient will benefit from an aide coming 2x week to assist with bathing and ADLs (activities of daily living)." Hospice aide visits were made on the following dates: 01/23/2025, 01/16/2025 (not doing well no tasks), 01/14/2025 (bed bath, lotion, clean clothes), 01/10/2025 (no bed bath as husband wasn't home), 01/03/2025 (introduction). There was no documentation of an aide care plan for these visits. The registered nurse supervisory visits documented that "the aide was following the plan of care," although a plan of care had not been established. A joint personnel record review and interview was conducted with the Administrator and Alternative Administrator on 08/07/2025, who agreed that the aide care plans were not present.

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) hospice aide personnel records reviewed revealed the agency did not ensure a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. Personnel Record 7: A personnel record review was conducted on 08/05/2025, for an employee with direct patient contact (Hospice Aide) hired on 09/06/2023, which revealed there was no documentation of a registered nurse conducting an annual supervisory visit for 2024. A joint personnel record review and interview was conducted with the Administrator and Alternative Administrator on 08/06/2025 in which it was explained the "previous leadership removed many items when they left."

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. A review of the volunteer program was conducted with the Administrator/Volunteer Coordinator on 08/07/2025, during which time they were unable to produce a volunteer percentage for 2024. With the hiring of the Volunteer Coordinator in 2025, they have been tracking volunteer hours. The Administrator stated, "We will be under the percentage anyway." A review of the volunteer program was conducted with the Administrator/Volunteer Coordinator on 08/07/2025, during which time they were unable to produce a volunteer percentage for 2024. With the hiring of the Volunteer Coordinator in 2025, they have been tracking volunteer hours. The Administrator stated, "We will be under the percentage anyway."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 8 (12%) personnel records reviewed revealed the agency did not ensure the skills and competencies had been assessed. Document 3: Agency Policy titled "Clinical Competency Program. Scope of the Program. Policy No 3-001.1 Dated 1995, Revised April 2019" stated in relevant part: "2. Hospice will establish and annually evaluate a group of specific skills related to patient care responsibilities and the complexity of care provided by staff. 3. In the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter." Personnel Record 7: A personnel record review was conducted on 08/05/2025, for an employee with direct patient contact (Hospice Aide) hired on 09/06/2023, which revealed there was no documentation of skills competencies for 2024. A joint personnel record review and interview was conducted with the Administrator and Alternative Administrator on 08/06/2025 in which it was explained the "previous leadership removed many items when they left."

It is required that a patient's clinical record contains correct clinical information that is available to the patient’s attending physician and hospice staff, including: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 clinical records reviewed the agency did not ensure signed copies of the patient’s rights and hospice election statement were included in the clinical record. CLINICAL RECORD 8: The patient elected the hospice benefit on 08/11/2024 for a diagnosis of hypertensive heart disease. The patient died on 08/16/2024. There was no documented evidence of signed patient rights and the hospice election statement in the clinical record. A joint clinical record review and interview was conducted with the Administrator/Alternate Administrator on 08/07/2025, in which he stated, "The patient was on for such a short time. Looks like we forgot to scan the consents."

It is required that a patient's clinical record contains correct clinical information that is available to the patient’s attending physician and hospice staff, including: responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the clinical record contained medications, responses to medications, symptom management, treatments, and services. CLINICAL RECORD 6: A nurse's visit dated 01/15/2025 noted "PRN (as-needed) opioid and bowel regimen initiated, Patient on continuous oxygen at 2 liters." These medications were not documented in the clinical record, other than the nursing visit. A joint clinical record review and interview was conducted with the Administrator/Alternate Administrator on 08/07/2025, in which they confirmed the clinical record did not contain a medication list.

It is required that short-term inpatient care is available for respite purposes and is provided in a participating Medicare or Medicaid facility. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interview revealed the hospice: Failed to ensure that the agency had a written agreement for respite care {HSIC.2. I/L706/ 418.108(a)(1). 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.

It is required that short-term inpatient care is available for pain control, symptom management, and respite purposes. This standard was not met as evidenced by document review and interview. A review of the Agency's contracts on 08/06/2025 and 08/07/2025 with the Administrator revealed the contracts provided for respite at two separate skilled nursing facilities (SNF) had not been signed by the SNF representatives. The Administrator advised, "We have previously used one of those facilities for respite." He was unable to produce a fully executed contract or to provide the letter of agreement for respite care. A review of the Agency's contracts on 08/06/2025 and 08/07/2025 with the Administrator revealed the contracts provided for respite at two separate skilled nursing facilities (SNF) had not been signed by the SNF representatives. The Administrator advised, "We have previously used one of those facilities for respite." He was unable to produce a fully executed contract or to provide the letter of agreement for respite.

It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) social workers revealed the agency did not ensure the social worker who holds a bachelor's degree was supervised by a master’s level social worker. A review of the Social Worker’s (hired on 02/07/2025) personnel record revealed the Social Worker held a bachelor's degree and had been seeing Clinical Record 1 (admitted 05/03/2024) and Clinical Record 2 (admitted 08/03/2025) without supervision from a master’s prepared social worker. The agency only had 1 social worker (BSW) from 02/07/2025 to present (08/05/2025). An interview with the Administrator was held on 08/06/2025 during which time he stated, "We are hiring another social worker who has a master’s degree." A personnel record review was conducted on 08/05/2025, for an employee with direct patient contact (Social Worker) hired on 02/07/2025, which revealed they held a bachelor's degree and had been seeing Clinical Record 1 (admitted 05/03/2024) and Clinical Record 2 (admitted 08/03/2025) without supervision from a Master's prepared social worker. The agency only had 1 social worker (BSW) from 02/07/2025 to present (08/05/2025). An interview with the Administrator was held on 08/06/2025 during which time he stated, "We are hiring another social worker who has a Master's degree."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 4 (25%) applicable clinical records of patients who received nursing visits completed by a Licensed Practical Nurse (LPN), the hospice did not ensure documented evidence that the LPN was consistently supervised by a Registered Nurse (RN), as described in agency practice and in accordance with the state’s nurse practice act. The state’s “Nurse Practice Act Scope of Practice for Licensed Practical Nurses (LPNs)” states: “The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the RN or MD for further or "full" assessment.” Record 5: This patient was admitted to hospice on 3/26/2021. Licensed Practical Nurse (LPN) visits were documented as completed 5/23/2022, 6/29/2022, 7/17/2022 and 8/24/2022. There was no documented evidence of an RN visit that included supervision of the LPN within the agency's expected time frame of every two weeks, as described by the Director of Nursing. During the visits made on 6/29/2022 and 7/17/2022, to “assess” and address Foley catheter issues, there was no evidence that the RN or physician was contacted to receive a report from the LPN regarding the patient’s status so an RN could complete an assessment of the patient. During the visit on 6/29/22, the patient was noted to have a leaking Foley catheter which was then flushed by the LPN with no discussion of the patient’s status with the RN. During the visit on 7/17/22, the caregiver requested a visit for problems with leaking and plugging of the Foley catheter. Again, there was no evidence that the RN was contacted to receive a report on the patient’s status when the catheter could not be flushed and was replaced. The Director of Nursing was interviewed on 9/30/2022 and agreed, there was no documented evidence of LPN supervisory visits made by an RN. The Director of Nursing stated, “You won’t find any in the records because we haven’t thought to do this.” The Director of Nursing stated LPN supervisory visits should have been completed every two weeks along with the hospice aide supervisory visits. The Executive Director was interviewed on 9/30/2022 and confirmed this finding, also stating, “The LPN can’t assess and should have notified the RN or MD.” Record 4: This patient was admitted to hospice on 9/18/2019. A Licensed Practical Nurse (LPN) visit was documented on 3/17/2022. There was no documented evidence of an RN supervisory visit to supervise the LPN. Record 5: This patient was admitted to hospice on 3/26/2021. A Licensed Practical Nurse (LPN) visit was documented on 5/23/2022, 6/29/2022, 7/17/2022 and 8/24/2022. There was no documented evidence of an RN supervisory visit to supervise the LPN. Record 8: This patient was admitted to hospice on 8/22/2022. A Licensed Practical Nurse (LPN) visit was documented on 8/22/2022. There was no documented evidence of an RN supervisory visit to supervise the LPN. Record 9: This patient was admitted to hospice on 7/19/2022. A Licensed Practical Nurse (LPN) visit was documented on 8/12/2022. There was no documented evidence of an RN supervisory visit to supervise the LPN. The Director of Nursing was interviewed on 9/30/2022 and agreed, there were no LPN supervisory visits made by an RN in the records identified. The Director of Nursing was interviewed on 9/30/2022 and stated, “you won’t find any in the records because we haven’t thought to do this.” The Director of Nursing stated, the LPN supervisory visits should be completed every two weeks with the hospice aide supervisory visits. The Executive Director was interviewed on 9/30/2022 and confirmed this finding.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by interviews and review of personnel records. In 2 of 2 (100%) applicable personnel records of hospice aides reviewed, the hospice did not ensure that a competency assessment was completed upon hire. Record 7 (Hospice Aide): hire date 8/29/2022. There was no documented evidence that a competency evaluation was completed upon hire. Record 8 (Hospice Aide): hire date 8/2/2022. There was no documented evidence that a competency evaluation was completed upon hire. The Executive Director was interviewed on 9/29/2022 and agreed, there was no documented evidence that the competency evaluations were completed upon hire. The Executive Director confirmed the staff identified have been making visits and stated, “These should have been completed before the staff was making visits on their own.”

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. In 3 of 9 (33%) applicable clinical records reviewed of patients who received hospice aide services, the hospice did not ensure the registered nurse developed hospice aide plans of care with specific instructions for completing assigned tasks, requiring hospice aides to make a decision regarding what tasks to complete, which exceeds their scope of practice. Record 1: This patient was admitted to hospice on 8/20/2022. The hospice aide plan of care completed by the RN on 8/22/2022 assigned the aide to provide a "complete bed bath, partial bed bath, shower", and did not specifically describe criteria for designating the type of bath the aide was to complete during each visit. Review of the patient's diagnoses revealed metabolic encephalopathy and unspecified dementia, which would require the aide to make the decision regarding the type of bath to provide, which exceeds the aide's scope of practice. Record 7: This patient was admitted to hospice on 4/20/2022. The hospice aide plan of care completed by the RN on 4/27/2022 assigned the aide to provide a "complete bed bath, partial bed bath, shower", and did not specifically describe criteria for designating the type of bath the aide was to complete during each visit. Review of the patient's diagnoses revealed neurocognitive disorder with Lewy bodies and traumatic brain injury, which would require the aide to make the decision regarding the type of bath to provide, which exceeds the aide's scope of practice. Record 10: This patient was admitted to hospice on 6/22/2022. The hospice aide plan of care completed by the RN on 6/22/2022 assigned the aide to provide a "complete bed bath, partial bed bath, shower", and did not specifically describe criteria for designating the type of bath the aide was to complete during each visit. Review of the patient's diagnoses revealed senile degeneration of the brain, which would require the aide to make the decision regarding the type of bath to provide, which exceeds the aide's scope of practice. The Director of Nursing was interviewed on 9/29/2022 and agreed, the RN did not assign specific instructions for the aide to follow in the records identified. The Executive Director was interviewed on 9/29/2022 and confirmed this finding. Record 1: This patient was admitted to hospice on 8/20/2022. The hospice aide plan of care completed by the RN on 8/22/2022 assigned complete bed bath, partial bed bath, shower. Review of the patient diagnoses revealed metabolic encephalopathy and unspecified dementia. Record 7: This patient was admitted to hospice on 4/20/2022. The hospice aide plan of care completed by the RN on 4/27/2022 assigned complete bed bath, partial bed bath, shower. Review of the patient diagnoses revealed neurocognitive disorder with lewy bodies and traumatic brain injury. Record 10: This patient was admitted to hospice on 6/22/2022. The hospice aide plan of care completed by the RN on 6/22/2022 assigned complete bed bath, partial bed bath, shower. Review of the patient diagnoses revealed senile degeneration of the brain. The Director of Nursing was interviewed on 9/29/2022 and agreed, the RN did not assign specific instructions for the aide to follow in the records identified. The Executive Director was interviewed on 9/29/2022 and confirmed this finding.

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 interviews and review of personnel records. In 3 of 9 (33%) applicable personnel records reviewed, the hospice did not ensure that a skills competency assessment was completed at the time of hire. Record 9 (Registered Nurse): hire date 2/9/2022. There was no documented evidence that a skills competency assessment was completed upon hire. Record 10 (Volunteer): hire date 1/31/2022. There was no documented evidence that a skills competency assessment was completed upon hire. Record 11 (Licensed Practical Nurse): hire date 8/26/2020. There was no documented evidence that a competency assessment was completed upon hire. The Executive Director was interviewed on 9/29/2022 and agreed there was no documented evidence that skills competency assessments were completed upon hire. The Executive Director confirmed the staff identified have been making patient visits and stated, “These should have been completed before the staff was making visits on their own.” Record 2: (Director of Nursing): hire date 5/3/2022. There was no documented evidence that a competency was completed upon hire. Record 7: (Hospice Aide): hire date 8/29/2022. There was no documented evidence that a competency was completed upon hire. Record 8: (Hospice Aide): hire date 8/2/2022. There was no documented evidence that a competency was completed upon hire. Record 9: (Registered Nurse): hire date 2/9/2022. There was no documented evidence that a competency was completed upon hire. Record 10: (Volunteer): hire date 1/31/2022. There was no documented evidence that a competency was completed upon hire. Record 11: (Licensed Practical Nurse): hire date 8/26/2020. There was no documented evidence that a competency was completed upon hire. The Executive Director was interviewed on 9/29/2022 and agreed, there was no documented evidence that the competencies were completed upon hire. The Executive Director confirmed the staff identified have been making visits and stated, “these should have been completed before the staff was making visits on their own.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 3 (100%) clinical records reviewed with a foley catheter the hospice did not ensure the clinical record included a physician’s order for the foley catheter. Record 3: This patient was admitted to hospice on 5/11/2022. The Registered Nurse documentation on 7/23/2022 stated that a size 16 FR Foley catheter was inserted and irrigated. There was no documented evidence of a physician order for the foley catheter insertion and irrigation. Record 5: This patient was admitted to hospice on 3/26/2021. The Licensed Practical Nursing documentation on 5/23/2022 stated that a size 16 FR Foley catheter was inserted. Also, the Registered Nurse documentation on 5/11/2022 stated that a size 18 FR Foley catheter was inserted. There was no documented evidence of physician orders for either Foley catheter insertion. Record 9: This patient was admitted to hospice on 7/19/2022. The Registered Nurse documentation on 7/27/2022 stated the patient had a Foley catheter in place. There was no documented evidence of a physician order for the Foley catheter. The Director of Nursing was interviewed on 9/29/2022 and agreed there were no physician orders present for the Foley catheters in the records identified. The Executive Director was interviewed on 9/29/2022 and confirmed this finding. Record 3: This patient was admitted to hospice on 5/11/2022. The Registered Nurse documentation on 7/23/2022 revealed, 16 FR catheter inserted and irrigated. There was no documented evidence of a physican’s order for the foley catheter. Record 5: This patient was admitted to hospice on 3/26/2021. The Licensed Practical Nursing documentation on 5/23/2022 revealed, 16 FR catheter inserted. The Registered Nurse documentation on 5/11/2022 revealed, 18 FR catheter inserted. There was no documented evidence of a physican’s order for the foley catheter. Record 9: This patient was admitted to hospice on 7/19/2022. The Registered Nurse documentation on 7/27/2022 revealed, foley catheter in place. There was no documented evidence of a physican’s order for the foley catheter. The Director of Nursing was interviewed on 9/29/2022 and agreed, there were no physician’s orders for the foley catheter in the records identified. The Executive Director was interviewed on 9/29/2022 and confirmed this finding.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) applicable clinical records reviewed of patients who were discharged alive from hospice, the hospice did not ensure that a copy of the discharge summary was sent to the patient’s attending physician. Record 10: This patient was admitted to hospice on 11/16/2021 and discharged from hospice on 7/13/2022 with the reason, no longer appropriate. There was no documented evidence the discharge summary was sent to the attending physician. Record 11: This patient was admitted to hospice on 2/25/2022 and discharged from hospice on 6/28/2022 with the reason, due to CMS regulations for hospice coverage. There was no documented evidence the discharge summary was sent to the attending physician. The Executive Director was interviewed on 9/29/2022 and agreed, there was no documented evidence the discharge summaries were sent to the attending physicians. Record 10: This patient was admitted to hospice on 11/16/2021. The discharge was reviewed and revealed the patient was discharged on 7/13/2022 with the reason, no longer appropriate. There was no documented evidence the discharge summary was sent to the attending. Record 11: This patient was admitted to hospice on 2/25/2022. The discharge was reviewed and revealed the patient was discharged on 6/28/2022 with the reason, due to cms regulation. There was no documented evidence the discharge summary was sent to the attending. The Executive Director was interviewed on 9/29/2022 and agreed, there was no documented evidence the discharge summary was sent to the attending.

Based on interview and record review, the agency failed to ensure the individualized written plan of care (POC) included all services necessary for the palliation and management of the terminal illness and related conditions; the agency failed to provide a detailed statement of the scope and frequency of services necessary to meet the specific needs of the patient for one of one patients receiving physical therapy (PT) and skilled nursing services. (Patient #1) Findings include: 1. The clinical record for Patient #1 was reviewed on 8/2/22. The patient was admitted to hospice care and services on 4/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease. The POC for the certification periods dated, 2/22/22 to 4/22/22, 4/23/22 to 6/21/22, and 6/22/22 to 8/20/22 included orders for skilled nursing (SN) services once a week for assessments, certified nurse aide (CNA) services twice a week for assistance with personal care, medical social worker (MSW) services twice a month for psychosocial support and Chaplain services monthly for spiritual support. a) The hospice failed to ensure the POC included a detailed statement of the duration and frequency of services for PT. Review of the POC's dated 3/30/22, 4/30/22, 5/31/22, 6/30/22, and 7/31/22 failed to reveal any scope or frequency of services for PT. Review of the physician orders dated 9/2/21 to 5/2/22 revealed a physician order dated 1/12/22 for PT to evaluate for safety, due to progressive weakness and fatigue. Review of the clinical documentation from 1/12/22 to present (8/2/22) revealed the PT conducted visits for Patient #1, 12 times, on 3/3/22, 3/9/22, 3/14/22, 3/28/22, 4/7/22, 4/12/22, 4/25/22, 5/9/22, 5/16/22, 6/13/22 and 7/28/22. During an interview on 8/3/22 at 8:45 a.m., Employee #1 stated she was not able to find any orders for PT, only the evaluation order. She further stated that what needed to happen was that a conversation needed to take place between the PT and skilled nurse. During an interview on 8/3/22 at 9:02 a.m., PT #6 stated she always had a conversation with the registered nurse (RN) case manager on her cases to inform them she knew her plans and frequency. PT #6 further stated she was not sure why no order was obtained and why her goals and interventions were not on the POC. b) The hospice failed to ensure discipline visits were provided in accordance with Patient #1's POC. Review of the plan of care dated 2/22/22 to 4/22/22, revealed physician orders for SN services once a week for assessments. Review of the SN visit schedule dated 4/25/22 to present (8/2/22) revealed the SN conducted visits for Patient #1 twice a week. Review of physician orders dated 9/7/21 to 5/2/22, revealed no evidence of physician's orders increasing the number of SN visits for Patient #1. Review of the clinical record from 4/1/22 to present 8/2/22 revealed 9 weeks of twice a week nursing visits. Routine nursing visits were completed on 4/4/22, 4/7/22, 4/18/22, 4/21/22.4/25/22, 4/28/22, 5/2/22, 5/5/22, 5/9/22, 5/12/22, 5/17/22, 5/20/22, 5/23/22, 5/26/22, 5/30/22, 6/2/22, 6/6/22, 6/9/22, 7/6/22, and 7/8/22. During an interview on 8/3/22 at 8:57 a.m., Employee #1 stated, she was not able to find an order for the change in frequency. She further stated the SN assigned to Patient #1 in April and May no longer worked for the agency, however that did not excuse them from having the correct frequency.