Every finding on record at Helping Hands Hospice, Inc.

Based on record review and interview, the facility did not provide Social Work services as directed by the Plan of Care for one of 13 sampled patients (Patient 12). This failure resulted in Patient 12 not having social service care as directed. --- Findings:Per the Plan of Care dated 3/29/2025, Patient 12 was admitted to service on 3/29/2025 with a diagnosis of frontotemporal neurocognitive disorder (a brain disorder causing changes in behavior, personality, and language ability).During a review of Patient 12’s plan of care, the record indicated Social Service visits were to be made once a month. Further review of Patient 12’s medical record indicated that no Social Service visits were documented.During an interview with the Director of Patient Care Services (DPCS) on 12/18/2025 at 3:45 P.M., the DPCS stated that if visits were not documented then they were not completed. The DPCS further stated that the visits were ordered so “we were not following the plan of care.”Per the agency’s policy titled Interdisciplinary Plan of Care Development and Management dated 1/01/25, the policy indicated “…Clinical Staff deliver care in accordance with the plan of care…Document services provided…”

Based on observation, interview, and record review, the agency failed to ensure the Director of Patient Care Services (DPCS) performed hand hygiene after handling soiled items for the 1 of 1 home visits conducted (Patient 2). This failure increased the risk of infection. --- Findings: Per the agency's Plan of Care (POC) for the certification period dated 9/19/25 through 12/17/25, Patient 2 was admitted to the agency on 9/19/25 with diagnoses that included prostate cancer (abnormal cell growth in the male reproductive system). Per the POC, Patient 2 was to be seen by the HA twice a week for personal care and assistance. On 12/17/25 at 1 P.M., a joint home visit was conducted with the DPCS. Patient 2 had soiled a brief with urine and bowel movement. The DPCS was observed with gloved hands, cleaned Patient 2. After the pericare, the DPCS applied cream on Patient 2's buttocks and lotion on Patient 2's legs and back without changing to new gloves. After the home visit, a follow-up interview was conducted with the DPCS. The DPCS stated he should have removed the soiled gloves and applied the new ones before applying the lotion and cream to prevent cross-contamination. Per the agency's policy and procedure, dated 1/1/25, titled Infection Control Policy, indicated "...Hand Hygiene before and after patient contact with potentially contaminated surfaces, and after removal of PPE [Personal Protective Equipment]..."

Based on interview and record review, the agency failed to ensure the post-bereavement (loss) assessment and services were available for 7 of 7 death records reviewed (Patient 7, 8, 9, 10, 11, 12, and 13).   This failure had the potential for the family members or loved ones not to receive assistance from the patient's death. --- Findings: On 12/17/25, a review of the agency’s Patient Discharge List was conducted. Per the list, the following data were entered:Patient 7 died on 12/12/25Patient 8 died on 5/12/25Patient 9 died on 11/6/25Patient 10 died on 8/26/25Patient 11 died on 10/23/25Patient 12 died on 3/29/25Patient 13 died on 9/23/25 A review of the patient's clinical record was conducted, and there was no documented evidence of the completed post-bereavement assessment. On 12/18/25 at 2 P.M., a joint interview and record reviews were conducted with the Director of Patient Care Services (DPCS). The DPCS stated the chaplain was responsible for performing the post-bereavement assessment, and all the documentation must be in the patient’s medical electronic record. The DPCS stated it was not documented, and it was not done. The Chaplain was not available for an interview. Per the agency's policy and procedure, dated 4/2012, titled Bereavement Services, "...After the death occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed...”

Based on interview and record review, the agency failed to ensure a qualified registered nurse made supervisory visits to evaluate staff performance, patient care, and adherence to hospice policies provided by the hospice aide (HA) for 2 of 13 sampled patients (Patient 2, and 7), when the Director of Patient Care Services (DPCS) served concurrently as the HA, and the DPCS performed a self-supervision performance evaluation. As a result, there was no independent oversight of performance evaluations for these patients. --- Findings: 1. Per the agency’s Plan of Care (POC) for the certification period dated 9/19/25 through 12/17/25, Patient 2 was admitted to the agency on 9/19/25 with diagnoses that included prostate cancer (abnormal cell growth in the male reproductive system). Per the POC, Patient 2 was to be seen by the HA twice a week for personal care and assistance. A review of Patient 2’s clinical record was conducted on 12/16/25, and it was noted in the HA note that the HA that provided care to Patient 2 was the Director of Patient Care Service (DPCS). A further review of Patient 2’s clinical record was conducted, in the RN [Registered Nurse] Visit Note, dated 9/21/25, 9/22/25, 9/29/25, 10/6/25, 10/13/25, 10/20/25, 10/27/25, 11/3/25, 11/10/25, 11/17/25, 11/24/25, 12/1/25, and 12/8/25 under Supervisory Note, indicated that the DPCS and the HA were the same individual. Per the notes, the DPCS was effectively supervising and evaluating his own clinical work. 2. Per the agency’s Plan of Care (POC) for the certification period dated 11/19/25 through 2/16/26, Patient 7 was admitted to the agency on 11/19/25 with diagnoses that included malignant neoplasm of the overlapping sites of rectum, anus, and anus canal (cancer that starts in or spreads across the rectal area). A review of Patient 7’s clinical record was conducted on 12/17/25, and it was noted in the HA note that the HA provided care to Patient 7 was the DPCS. A further review of Patient 7’s clinical record was conducted in the RN Visit Note, dated 11/21/25, 11/24/25, and 12/1/25, under Supervisory Note, the DPCS performed a self-supervision performance evaluation. On 12/18/25 at 2 P.M., during an interview, the DPCS stated that because the agency did not employ a hospice aide, he performed the HA visits himself. The DPCS also stated that he did not realize the conflict of interest when completing the supervisory notes. Per the agency’s policy and procedure, dated 1/1/25, titled Clinical Supervision and Oversight, indicated “[the agency] provides ongoing supervision of all hospice personnel to ensure that patient care is delivered consistent with the Plan of Care, scope of practice, and hospice policies.”

Based on the interview and record review, the agency failed to ensure the clinical records were accurate and complete for 2 of 13 sampled patients (Patient 3 and 7), when (1) there was a documentation of supervisory assessment was performed but Patient 3 was not receiving HA visits, and (2) there was no documented evidence of the HA visit for Patient 7. These failures had the potential to result in unverified care delivery and inadequate coordination of services. --- Findings: 1. Per the agency’s Plan of Care (POC) for the certification period dated 10 /27/25 through 12/25/25, Patient 3 was admitted to the agency on 10/27/25 with malignant melanoma (skin cancer) of the face. Per the POC, Patient 3 declined HA services. A review of Patient 3’s clinical record was conducted. Per the Registered Nurse (RN) Visit Note, dated 11/3/25, 11/10/25, and 11/17/25, indicated that supervisory assessments were performed, even though, Patient 3 was not receiving an HA services. On 12/18/25 at 1:52 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 3 did not have an HA service, and the supervisory visit assessment was inaccurate. The DPCS further states that patients' medical records should be accurate. 2. Per the agency’s Plan of Care (POC) for the certification period dated 11/19/25 through 2/16/26, Patient 7 was admitted to the agency on 11/19/25 with diagnoses that included malignant neoplasm of the overlapping sites of rectum, anus, and anus canal (cancer that starts in or spreads across the rectal area). Per the POC, Patient 4 was to be seen by the HA twice a week for personal care and assistance. A review of Patient 7’s clinical record was conducted. For the week of 12/7/25 through 12/13/25, there was no documented evidence that the HA visited Patient 7.   On 12/18/25 at 2 P.M., a joint interview and record review was conducted with the DPCS. The DPCS stated his visit schedule with Patient 7 as HA was every Monday and Thursday. The DPCS further stated he forgot to document his HA visit, but he recalled visiting Patient 7 home for the HA service. The DPCS stated that the patients’ medical records should be complete with the HA visit note. Per the agency’s policy and procedure, dated 1/1/25, titled Required Contents of the Clinical Record, indicated, “...Entries are completed in a timely manner and authenticated by the author. All documentation reflects services provided in accordance with the Plan of Care...”

Based on interview and record review, the agency failed to ensure the Medical Social Work (MSW) completed the post-bereavement (loss) assessment for two of the two death records reviewed. This failure had the potential for the family members or loved ones not to receive counseling assistance after the patient's death. --- Findings:1. Per the agency's Personal Information, Patient 8 died on 2/7/23. A review of Patient 8's clinical record was conducted, and there was no documented evidence of the completed post-bereavement assessment.2. Per the agency's Personal Information, Patient 9 died on 1/30/23. A review of Patient 9's clinical record was conducted, and there was no documented evidence of the completed post-bereavement assessment.On 5/24/23 at 10:30 A.M., a joint interview and record review was conducted with the Director of Business Management (DBM). The DBM stated the MSW was responsible for conducting the post-bereavement assessment, and there was no documented assessment for Patients 8 and 9.The MSW was not available for an interview.Per the agency's policy and procedure, titled Bereavement Assessment, dated 4/17, "...After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment..."

Based on interview and record review the agency failed to update the patient- specific comprehensive assessment every 15 days for three of 14 sampled patients (2,3, 4). As a result, changes or no changes of patient/family needs were not identified or documented . --- Findings: 1. Per the agency's Plan of Care for the certification period 4/26/23 through 7/24/23, Patient 2 was admitted to the agency on 4/26/23 with diagnoses which included heart failure. On 5/23/23 a review of Patient 2's record was conducted. The updated comprehensive care plan dated 5/23/23 did not document if there were changes or no changes in patients stage 2 pressure ulcer, hallucinations and cough related to COVID. There was no documentation of Patient 2's pressure ulcer and response to treatment for the comprehensive assessment dated 5/4/23, 5/18/23. 2. Per the agency's Plan of Care for the certification period 4/26/23 through 7/24/23, Patient 3 was admitted to the agency on 4/26/23 with diagnoses which included kidney disease. On 5/23/23 a review of Patient 3's record was conducted. The updated comprehensive care plan dated 5/23/23 did not document if there were changes or no changes in patients cardiac status related to hypertension, urinary frequency, generalized weakness, and pain. 3. Per the agency's Plan of Care for the certification period 4/21/23 through 7/19/23, Patient 4 was admitted to the agency on 4/21/23 with diagnoses which included respiratory failure. On 5/23/23 a review of Patient 4's record was conducted. The updated comprehensive care plan dated 5/23/23 did not document changes or no changes in patients pressure ulcer, pain and respiratory status related to low oxygen saturation level .There was no documentation of pressure ulcer response to treatment on 5/4/23, 5/18/23. On 5/24/23 at 10:44 A.M., an interview was conducted with Skilled Nurse (SN) 2. The SN 2 stated he conducted initial assessments for patients admitted to the hospice agency but did not know or completed a comprehensive assessment every 15 days. On 5/24/23 at 3:08 P.M., an interview was conducted with the Director of Patient Care & Services (DPCS) .The DPCS stated ,comprehensive assessments must be done at least every 15 days or if there were changes with patient/family condition or needs. The DPCS stated, staff should have documented patients response to care and treatment to accurately reflect the plan of care. Per the agencys policy, titled Comprehensive Assessment, revised April 2017, ";...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days...B. If no changes are needed, then that must be documented. C. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated..."

Based on interview and record review the agency failed to ensure pressure ulcers were measured per the plan of care for one of 14 sampled patients (4). As a result, the progress or lack of progress of Patient 4s wound treatment was unknown. --- Findings: Per the agency's Plan of Care for the certification period 4/21/23 through 7/19/23, Patient 4 was admitted to the agency on 4/21/23 with diagnoses which included respiratory failure. On 5/23/23 a review of Patient 4 visits record was conducted. - On 4/26/23 – an LVN visited the patient and documented wound care/treatment to the left ankle with drainage. Wound care/treatment to coccyx with no bleeding. There was no wound measurement and response to wound treatment documented . - On 5/5/23 – an RN visited the patient and documented that Patient 4 had three different wounds. The RN documented wound care /treatment was completed to sacral area, abdomen and bilateral heels. There was no wound measurement and response to wound treatment documented . - On 5/12/23 – an RN visited the patient and documented wound care to coccyx. There was no wound measurement and response to wound treatment documented . - On 5/17/23 – an LVN visited the patient and documented wound care/treatment to left ankle and coccyx. There was no wound measurement and response to wound treatment documented . - On 5/19/23 – an RN visited and documented wound care/treatment to coccyx x2 and ankle. There was no wound measurement and response to wound treatment documented . On 5/24/23 at 11:50 A.M., an interview was conducted with Skilled Nurse (SN) 2. The SN 2 stated that there were no documented wound measurements found in Patient 2 record. The SN 2 stated at every SN visits the wound should have been measured and documented to know the progress or lack of progress to treatment. On 5/24/23 at 3:08 P.M., an interview was conducted with the Director of Patient Care & Services (DPCS). The DPCS stated, the wound should have been measured and documented to ensure treatments were effective. A review of the agencys policy, titled Pressure Ulcer Treatment, revised 01/2023 ";...A. 1. Assess pressure ulcer by using wound assessment form weekly and change of condition...D. 1. Monitor skin surfaces each visit .2. Document in appropriate facility form..."

Based on interview and record review, the agency failed to accurately document social worker visit frequencies per the needs of the patients for two of 14 sampled patients (11, 12). As a result, the plan of care did not reflect the care provided to the patients. --- Findings: 1 Per the agency's Plan of Care for the certification period 4/25/23 through 7/23/23, Patient 11 was admitted to the agency on 4/25/23 with diagnoses which included heart failure. Patient 11 had an order on 4/25/23 for the social worker to visit one time per month. 2 Per the agency's Plan of Care for the certification period 4/25/23 through 7/23/23, Patient 12 was admitted to the agency on 4/25/23 with diagnoses which included heart failure. Patient 12 had an order on 4/25/23 for the social worker to visit one time per month. On 5/23/23 at 11:30 A.M., a concurrent interview and record review was conducted with the Director of Business Management (DBM). The DBM stated, Patient 11 and Patient 12 refused social services, but their case manager incorrectly entered a social worker visit frequency into the plan of care. The DBM further stated, the case manager no longer worked at the agency. The social worker was not available for interview. The agency did not have a policy on accuracy of documentation.

Based on interview and record review the agency failed to ensure the plan of care was updated to reflect the care and services provided for one of 14 sampled patients ( 2 ). As a result, services provided by the wound care specialist was not included in the plan of care --- Findings: Per the agency's Plan of Care for the certification period 4/26/23 through 7/24/23, Patient 2 was admitted to the agency on 4/26/23 with diagnoses which included heart failure. On 5/23/23 a review of Patient 2 record was conducted. Patient 2 had Stage 2 pressure ulcer in the coccyx area. There was no documentation in the plan of care and comprehensive assessment regarding the wound care specialist managing Patient 2s wound care. On 5/24/23 at 1:39 P.M., an interview was conducted with Skilled Nurse (SN) 11. SN 11 stated that the wound care specialist visited the patient weekly and responsible for wound monitoring. On 5/24/23 at 3:08 P.M., an interview was conducted with the Director of Patient Care & Services (DPCS). The DPCS stated plan of care should reflect the care and services patient received . A review of the agencys policy, titled, The Plan of Care, revised April 2017 ";...a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program...4. The plan of care will identify the patients needs and services to meet those need...7. Each patient will be monitored for his/her response to care or services provided..."

Based on observation, interview, and record review, the agency failed to ensure care and services were provided per the plan of care for four of 14 sampled patients (1, 5, 7, and 8). This failure could lead to inconsistency in patient care. --- Findings:1. Per the agency's Plan of Care for the certification period dated 4/24/23 through 7/22/23, Patient 5 was admitted to the agency on 4/24/23 with diagnoses which included cerebrovascular disease (medical conditions that affect the blood vessel of the brain). A review of Patient 5's clinical record was conducted. Per the Visit Note, dated 5/19/23, the Nurse Practitioner (NP) documented a "new foley catheter (a flexible tube that inserted to the urethra to drain urine) ...bedside drainage [bag] positioned below [the] level of the bladder..." There was no physician order to insert a foley catheter noted in Patient 5's clinical record. On 5/23/23 at 1:38 P.M., Patient 5 was observed with a foley catheter. On 5/24/23 at 10:30 A.M., a joint interview and record review was conducted with the Director of Business Management (DBM). The DBM stated there was no physician's order, verbal or written, regarding the foley catheter insertion. The DBM further stated the plan of care was not updated as well. On 5/24/23 at 3:30 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the NP should have written an order for the foley cath and updated the plan of care. 2. Per the agency's Plan of Care for the certification period dated 4/21/23 through 7/19/23, Patient 7 was admitted to the agency on 4/21/23 with diagnoses which included malignant neoplasm (cancer) of the lining of the uterus. The Certified Home Health Aide (CHHA) should have visited Patient 7 three times a week. A review of Patient 7's clinical record was conducted. Patient 7 was visited by the CHHA twice during the week of 5/7/23 through 5/13/23 instead of three. On 5/24/23 at 2:15 P.M., an interview was conducted with CHHA 1. CHHA 1 stated she visited Patient 7 but forgot to document. CHHA 1 further stated she should have entered a note so the plan of care was followed. On 5/24/23 at 3:30 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the staff should have documented and followed the plan of care. 3. Per the agency's Plan of Care for the certification period dated 12/21/22 through 3/20/23, Patient 8 was admitted to the agency on 12/21/22 with diagnoses which included malignant neoplasm (cancer) of the lung. A review of Patient 8's clinical record was conducted. Per the Visit Note, the Certified Home Health Aide (CHHA) visited Patient 8 on 1/6/23, 1/12/23, 1/19/23, and 1/25/23. No physician order was noted in Patient 8's clinical record about the CHHA visits. The registered nurse was unavailable for the interview. On 5/24/23 at 10:30 A.M., a joint interview and record review was conducted with the DBM. The DBM stated there should have been a physician's order for the home visits, and the registered nurse should have entered the order. Per the agency's policy and procedure, titled The Plan of Care, dated 4/17, "...The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and ongoing process..." 4.Per the agency's Plan of Care for the certification period 4/21/23 through 7/19/23, Patient 1 was admitted to the agency on 4/21/23 with diagnoses which included Alzheimers disease ( brain disorder that affects memory & thinking) . On 5/24/23 at 10:24 A.M., a concurrent record review and interview was conducted with the Administrative Assistant (AA) . Patient 1 had an order for MSW ( Medical Social Worker) visit for one per month and one PRN (as needed) visit per IDT meeting. The AA further stated that she was unable to find documentation that MSW visited patient/family from the time of admission, 4/21/23 through 5/24/23 On 5/24/23 at 3:08 P.M., an interview was conducted with the Director of Patient Care & Services (DPCS). The DPCS stated if MSW missed the visit. There must be a documentation of why a visit was not made. The MSW was not available for interview. Per the agencys policy, titled Missed Visits, revised April 17, 2017 ";... missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week as possible. Missed visits will be documented in the clinical record.2. If a visit is missed and not rescheduled the clinician will : A. Notify the IDG and clinical Supervisor of the missed visit and reason for missed visit. B . Document in the patients clinical record ..."

Based on interview and record review the facility failed to provide documented evidence of the agencys performance improvement projects. This failure had the potential for areas of improvement to not be identified or addressed. --- Findings: On 5/24/23 a review of the agencys Quality Assessment and Performance Improvement (QAPI) minutes and QAPI binder was conducted. There were no QAPI minutes found for 2022 and there was no documented evidence that the agency was working on a performance improvement project. On 5/24/23 at 4:21 P.M., an interview with the Director of Patient Care Services (DPCS), Director of Business Management (DBM) and Administrative Assistant (AA) was conducted. The DBM stated the agency did not have a documented performance improvement project. Per the agencys undated QAPI program, " [name of the hospice] conducts a continuing, comprehensive, hospice wide integrated assessment of the quality, safety and appropriateness of care provided..."

Based on observation, interview, and record review, the agency failed to ensure the Certified Home Health Aide (CHHA) followed the infection control standards for one of three home visits conducted when CHHA 1 did not decontaminate (remove or neutralize germs) hands between tasks. This failure increased the risk of cross-contamination. --- Findings: Per the agency's Plan of Care for the certification period dated 4/24/23 through 7/22/23, Patient 5 was admitted to the agency on 4/24/23 with diagnoses which included cerebrovascular disease (medical conditions that affect the blood vessels of the brain).On 5/23/23 at 1:38 P.M., CHHA 1 was observed with gloved hands. CHHA 1 cleansed, washed, and dried Patient 5's hair and face. CHHA 1 then bathed, washed, and dried Patient 5's body with the same gloves. Afterward, CHHA 1 transferred the indwelling catheter to the other side of the bed with the same gloves. Next, CHHA 1 bathed Patient 5's lower extremities and dressed Patient 5. Finally, CHHA 1 completed Patient 5's bed bath, arranged beddings, and disposed of used linens with one pair of gloves.On 5/23/23 at 2:18 P.M., a follow-up interview was conducted with CHHA 1. CHHA 1 stated that she used one pair of gloves during the entire home visit and should have changed the gloves between tasks.On 5/24/23 at 3:30 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPSC stated CHHA 1 should have removed gloves between tasks and performed hand hygiene to prevent cross-contamination of bacteria.Per the agency's policy and procedure titled Hand Hygiene, dated 4/12, "...Hand decontamination using an alcohol hand rub should be performed:... C. After contact with a patient's intact skin... E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient..."

Based on interview and record review, the facility failed to assess the competency for two of five sampled employees. As a result, there was the risk of employees providing poor patient care. --- Findings: On 5/24/23 at 4 P.M., a concurrent interview and record review was conducted with the Director of Business Management (DBM). Certified Home Health Aide (CHHA) 1 was hired on 4/5/22, and Skilled Nurse (SN) 2 was hired on 6/9/22. The DBM stated, she was not able to find evidence of an initial competency evaluation being completed for CHHA 1 or SN 2. The DBM further stated, the RN supervisor who was responsible for completing their initial competency evaluations no longer worked for the agency. Per the agencys policy, titled Core Competency Skills, revised April 2012, ";...1. Hospice will define the mandatory core competency skills for each discipline based upon the nature of their job responsibilities and complexity of care required. 2. Core competency skills will be reviewed with new personnel during their orientation..."

Based on interview and record review, the agency failed to obtain a physician order for the treatment of the pressure ulcer for two of 14 sampled patients (2,4). As a result, there was a risk of increased infection and ineffective treatment of the pressure ulcer. --- Findings: 1.Per the agency's Plan of Care for the certification period 4/26/23 through 7/24/23, Patient 2 was admitted to the agency on 4/26/23 with diagnoses which included heart failure. 2.Per the agency's Plan of Care for the certification period 4/21/23 through 7/19/23, Patient 4 was admitted to the agency on 4/21/23 with diagnoses which included respiratory failure. On 5/24/23 at 10:44 A.M., a concurrent record review and interview was conducted with the Skilled Nurse (SN) 2. SN 2 stated there was no physician order found in the plan of care summary for the treatment of the pressure ulcer. SN 2 stated physicians order should have been obtained for the pressure ulcer treatment and should have been documented in the plan of care under Medication and Treatment. On 5/24/23 at 1:39 P.M., a phone interview was conducted with SN 11. SN 11 stated that she did not see the physician order for the treatment . She followed the treatment written in the RN narrative notes during the initial assessment visit. SN 11 stated she did not know the frequency of the treatment, but she changed the dressing every time she visited the patient. On 5/24/23 at 3:08 P.M., an interview was conducted with the Director of Patient Care & Services (DPCS). The DPCS stated the SNs should have had treatment orders for the pressure ulcers and followed the plan of care. Per the agencys policy and procedure, titled Pressure Ulcer Treatment ,revised 1/2023 ";...C. Follow established treatment program ..."

Based on interview and record review, the agency failed to ensure the clinical records were clear and complete for four of 14 sample patients (5, 6, 7, and 8). This failure could lead to confusion among the healthcare team. --- Findings: On 5/23/23, clinical record reviews were conducted. Per the CTI (Certificate of Terminal Illness) Physician's Certification for Hospice Benefits form, the physician "have been encouraged to participate in the IDG [Interdisciplinary Group] meetings and Plan of Care if I [the physician] choose to follow the Patient..." Upon further review, the CTI forms were found to have the following inconsistency: 1. Per Patient 5's CTI form, under follow-up, both boxes had check marks indicating the physician wished to be contacted by the agency directly should the need arise for a change in the current plan of care and did not wish to follow the patient and sign the death certificate. 2. Per Patient 6's CTI form, under follow-up, both boxes had check marks indicating the physician wished to be contacted by the agency directly should the need arise for a change in the current plan of care and did not wish to follow the patient and sign the death certificate. 3. Per Patient 7's CTI form, under follow-up, both boxes had check marks indicating the physician wished to be contacted by the agency directly should the need arise for a change in the current plan of care and did not wish to follow the patient and sign the death certificate. 4a. Per Patient 8's CTI form, under follow-up, both boxes were not marked. On 5/24/23 at 10:30 A.M., a joint interview and record review was conducted with the Director of Business Management (DBM). The DBM stated the patients' CTI form needed to be more consistent to avoid confusion. The DBM stated the physician was responsible for completing the form correctly before signing. On 5/24/23 at 3:30 P.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the registered nurse was the one who initiated the form and was responsible to ensure only one box was marked. The DPCS further stated checking one box that applied to the patient ensured the accuracy of the documentation. 4b. Per the agency's Personal Information, Patient 8 died on 2/7/23. A review of Patient 8's clinical record was conducted. Per the IDG (Interdisciplinary Group) Review Note, dated 2/9/23, the RN documented Patient 8 was in "Imminent dying End of life..." The RN was not available for an interview. On 5/24/23 at 3:30 P.M., an interview was conducted with the DPCS. The DPCS stated the registered nurse should have documented the familys care needs after Patient 8s death. The agency did not have a policy to address documentation accuracy in the patient's clinical record. Per the agency's policy and procedure, titled Interdisciplinary Group Meeting, dated 4/17, "...An interdisciplinary group meeting plan of care update will be used for update of the patient and family/caregiver and the attending physician. It will note changes, responses to treatment and progress..."

Based on interview and record review, the agency failed to require a background check to be completed for one sampled contracted employee. As a result, the contracted employees background was unknown. --- Findings: On 5/24/23 at 4 P.M., a concurrent interview and record review was conducted with the Director of Business Management (DBM). The DBM stated, she was unable to find evidence of a completed background check for the Medical Director. Per the agencys Medical Director Agreement for Consulting, signed 3/29/22, there was not a requirement for a background check to be completed. The agency was not able to provide a policy on background checks.