Every finding on record at Hannah Hospice and Palitive Care Inc

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 document review, interview and personnel record review. In 1 of 1 (100%) personnel records reviewed revealed the agency did not ensure 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. Document 2: Agency policy titled "Hospice Aide Supervisory Visits Policy No. 1-013.1 dated January 2021" stated in relevant parts: "2. The overall performance of the hospice aide is evaluated at least annually for competency by an on site visit with the aide. 3. The registered nurse will be responsible for: E. annual skills competency evaluations and supervisory reports." Personnel Record 7: A review of the personnel record was conducted on 12/30/2025 for an employee (hospice aide) hired on 01/05/2021 revealed there was not documentation of an on site aide supervisory visit for 2025 by a registered nurse. A joint personnel record review and interview was conducted with the director of nurse who advised they only had a "patient on for a short time in 2025" and hadn't completed a supervisory visit during that time.

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 of all individuals providing care, including volunteers were assessed.   Document 1: Agency policy titled "Competency Assessment Policy No 1-008.1 dated January 2021" stated in relevant parts: "Policy. The competence of all hospice staff (employed and contract, and volunteers) will be assessed during orientation, during the probationary period, periodically throughout the course of a year, when job duties or responsibilities or duties change and during the annual performance evaluation." Personnel Record 8: A personnel record review was conducted on 12/30/2025 and 12/31/2025, which revealed that there were no documented skills competencies in 2023, 2024, or 2025 for a volunteer who started on 10/10/2022. An interview and joint personnel record review was conducted with the Administrator on 12/31/2025 during which time it was confirmed there were no documented competencies. The administrator stated "We didn't know he needed it because we didn't have him seeing patients."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) clinical record reviewed identified that the agency did not ensure that the discharge summary was forwarded to the patient's attending physician. Clinical Record 1: The record was reviewed and revealed that the patient was admitted on 9/1/2022 and revoked hospice services on 9/14/2022. A discharge summary was not forwarded to the patient's attending physician. Clinical Record 2: The record was reviewed and revealed that the patient was admitted on 10/1/2022 and discharged from hospice services on 10/10/2022. A discharge summary was not forwarded to the patient's attending physician. The Director of Nurses was interviewed during a joint review of the clinical record on 11/29/22 and confirmed the finding.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 5 (100%) revealed that the agency did not ensure the Interdisciplinary Group (IDG) determined the ability of the patient and/or family to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 1: Record was reviewed and identified the patient elected hospice on 9/1/22. The plan of care dated 9/1/22 and the IDG dated 9/8/22 did not document the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 2: Record was reviewed and identified the patient elected hospice on 10/1/22. The plan of care dated 10/1/22 and the IDG dated 10/6/22 did not document the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 3: Record was reviewed and identified the patient elected hospice on 10/21/22. The plan of care dated 10/21/22 and the IDG dated 11/3/22 did not document the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 4: Record was reviewed and identified the patient elected hospice on 10/31/22. The plan of care dated 10/31/22 and the IDG dated 11/3/22 did not document the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 5: Record was reviewed and identified the patient elected hospice on 10/24/22. The plan of care dated 10/24/22 and the IDG dated 11/3/22 did not document the patient and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. The Director of Nurses was interviewed during a joint review of the clinical record on 11/30/22 and confirmed the IDGs did not determine the patients/family ability to administer drugs and/or biologicals safely in their home.