Every finding on record at Hospice Company

Based on record review and interview, the agency failed to conduct exercises to test the emergency plan annually in 1 of 1 agencies surveyed.Findings include: --- 1. During a review of the Emergency Preparedness Program on 01/06/2026, the agency failed to provide documentation showing it conducted annual exercises to test the emergency plan. 2. During an interview on 01/06/2026 at 3:27 PM, the Clinical Director indicated that staff had not conducted emergency preparedness exercises for some time. Organizers struggle to gather all employees into a single area for the exercises. The organization has not held a community-based exercise in a few years because they struggle to find suitable opportunities or coordinators.

Based on observation, record review, and interview, the agency failed to prevent the transmission of infectious agents during 1 of 1 RN home visits (RN 1) and also during a personnel file review of 1 of 2 volunteers. (Volunteer 2)Findings include: --- 1. According to the "Health/Physical Requirements" policy (HR.H10), all employees and volunteers must complete the two-step Tuberculin Skin Test (TST) if more than one year has passed since their last test. Staff performed the second test within one to three weeks of the first test. 2. According to the "Infection Control - Standard and Transmission - Based Precautions" policy (P.C.I50), standard precautions include, but are not limited to: cleaning and disinfection of contaminated surfaces, equipment, and other objects. 3. According to the "Bag Technique" policy, the clean area contained unused or clean supplies and equipment, and the dirty area contained soap, alcohol-based hand cleaners, and cleaning wipes. After completing the visit, the staff cleaned reusable equipment and returned it to the bag. 4. During a personnel file review for Volunteer 2, hired on 01/11/2025, the agency administered a one-step TST on 01/13/2025. The file failed to evidence that the agency administered a second-step TST within 1-3 weeks of the first. 5. During an interview on 01/09/2026 at 11:30 AM, the Clinical Director stated that staff completed a two-step TST upon hire and repeated the TB screening yearly. 6. During a home visit with Patient #1 on 01/06/2026 at 9:10 AM, RN 1 obtained the patient's vital signs and placed dirty equipment onto a clean field. RN 1 then cleaned the equipment, placed it on the contaminated field to dry, and returned it to the nursing bag. 7. During an interview on 01/06/2026 at 9:20 AM, RN 1 stated that she only placed dirty equipment onto the barrier and did not mix it with clean equipment.

Based on record review and interview, the agency failed to provide a criminal background check in the personnel records of 1 of 2 volunteer files reviewed. (Volunteer 2)Findings include: --- 1. According to the "Criminal Background Check" policy (HR.C25), the agency required all employees (including volunteers) and contracted staff who provided direct patient care or had access to patient records to complete criminal background checks. 2. During a personnel record review for Volunteer 2, hired on 01/11/2025, the agency failed to provide documentation showing it conducted a limited criminal background check upon hire. 3. During an interview on 01/08/2026 at 3:30 PM, the Assistant Clinical Director stated that she could not find a background check for Volunteer 2. She also stated that Volunteer 2 was a student and that the college completed a background check before Volunteer 2 started volunteering with the agency. 4. During an interview on January 9, 2026, at 11:52 AM, the Administrator stated that Volunteer 2 was a student at a local college and that the college conducted a background check before Volunteer 2 started at the agency. The agency did not have a copy of the criminal background check at that time.

Based on record review, observation, and interview the hospice failed to follow their COVID-19 vaccination policy for exempt employees' use of alternate Personal Protective Equipment (PPE) to prevent the transmission of infections and communicable diseases, in 1 (Patient 9) of 3 observation home visits. Findings include: --- 1. A review of an agency policy titled, 'Policy Number: HR.C20 COVID-19 Vaccination,' evidenced the policy stated, "...13. For staff who receive an exemption, N-95 mask will be required to be worn while in the office areas, facilities, and/or patient's homes ... " 2. On 12/15/22 at 10:00 AM, during a skilled nursing facility visit for Patient 9, LPN 1, a COVID-19 vaccine-exempt employee, was witnessed wearing a blue surgical mask for the duration of Patient #9's care visit. 3. On 12/15/22 at 3:56 PM, during an interview with the Administrator and Clinical Manager, the visit with LPN 1 was reviewed. The Administrator and Clinical Manager remained silent when informed of the LPN wearing a surgical mask rather than an N-95 mask as required by hospice policy. The Administrator indicated the agency issued N-95 masks for their employee's use.

Based on record review and interview, the agency failed to document evidence the Governing Body assumed full authority and responsibility for the management and review of the QAPI Program (Quality Assurance and Performance Improvement )for 1 of 1 Governing Body and the Governing body failed to ensure the Administrator was approved by and reported directly to the Governing Body for 1 of 1 Governing Body and Administrator. Findings include: --- 3. A review of documents received from the agency on 12/16/2022 at 10:21 AM, titled, "Hospice Governing Minutes" dated March 17th, 2022, May 17th, 2022, August 12th, 2022, and November 14th, 2022, failed to evidence the Governing Body reviewed or discussed the agency's QAPI program in the four quarterly meetings in 2022. A document received from the agency on 12/16/22 at 2:30 PM, titled ";Governing Body Meeting Minutes" dated November 14, 2022, under subsection ";Current Issues" states the following, ";Meeting was called to discuss hiring Employee # 2 as Administrator..." The meeting failed to provide proof that an administrator was appointed. No other meeting minutes were provided appointing an administrator. 4. During an interview on 12/16/22 at 10:42 AM, Employee # 2, Administrator to be appointed, confirmed there are no Governing Body meeting minutes naming him as the administrator. 1. Review of an undated agency policy titled 'Policy Number AD.G10 Governing Body" page 1 stated, "POLICY: The Board of Directors is the governing body of Keystone Hospice that operates in accordance with its bylaws, and assumes full legal and financial authority and responsibility for determining, implementing, and monitoring policies governing the hospice's total operation including its quality assessment and performance improvement (QAPI) program...PROCEDURES: ... 4. Responsibilities of the Board of Directors, include but are not limited to: a. appointing a qualified hospice administrator and delegating him/her authority and responsibility for the daily operations of the hospice... e. defining the corporate structure and clearly defining and clearly indicating lines of authority; f. ... ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, maintained and evaluated annually;..." Paged 2 stated, "...g. ensuring that the hospices QAPI program addresses priorities for improved quality of care and patient safety, and that all improved actions are evaluated for effectiveness and results documented in the minutes of the Board meetings; ... i. Approving the frequency and detail of data collection in the hospice QAPI program; j. periodically assessing the performance of the board itself; and k. ensuring the integrity of service provision through: ... iv. ensuring that the Corporate Compliance and QAPI programs function as intended." Review of an undated agency document titled 'Policy Number AD.A15 ADMINISTRATOR' stated, "PROCEDURES: ... 4. The hospice Administrator is the chief administrator of the hospice program...reports to the Board of Directors..." Review of an undated agency document titled 'Hospice Governing Board' stated, "Stuart Reed, President" and "Jonathan Ward, Secretary". No other persons were listed in this document. 2. On 12/16/22 at 11:13 AM in an interview with Suzanne Stuart, who identified herself as the agency's Executive Director, when queried as to what capacity she served in when in attendance for QAPI meetings, indicated she was the Executive Director, then later indicated she "represented all aspects". When queried as to who the members of the governing body were, she indicated that Stuart Reed, Jonathan Ward "the CFO of Magnolia", and herself were all members. When queried as to what would constitute a quorum, she indicated "my husband (Stuart) and I", then later indicated "2 out of 3" would constitute a quorum. On 12/16/22 at 2:43 PM, in an interview with the Administrator yet to be appointed was queried as to the origins of the agency document titled 'Hospice Governing Board' which listed only 2 names; Stuart Reed and Johnathan Ward. When queried further, he indicated this number was accurate. When queried as to whom he, as the Administrator reports to, he indicated Suzanne Reed the Executive Director, and indicated further that Suzanne Reed, "reports to her husband". When queried as to who had created the document, the Administrator to be appointed indicated that he himself had created it and that Johnathan Ward, "the treasurer/secretary" had provided the information.

Based on record review and interviews, the hospice agency failed to ensure hospice orientation was completed with SNF/ICF staff that provided care to hospice patients in 1 (Entity 1) of 18 facilities reviewed. Findings include: --- 4. During an interview on 12/15/22 at 8:40 AM at Entity 1 with Other Persons 6 and 7 regarding hospice orientation the agency provides to their staff, they both stated they had not seen or heard of the agency providing hospice orientation to the staff. During an interview on 12/15/22 at 8:53 AM with Other Person 2 at Entity 1, when queried about hospice orientation from the agency, they stated they had not received hospice orientation from the agency. During an interview on 12/15/22 at 8:55 AM with Other Person 3, when queried about hospice orientation from the agency, they stated they had not received hospice orientation from the agency. 3. During an interview on 12/15/22 at 1:05 PM, the Clinical Manager reported that tracking education has ";not gone well", and was unable to provide evidence of training of staff in long-term care or skilled nursing 1. Review of an undated standard agency contract for Skilled Nursing Facilities (SNF) titled, 'Hospice Service Agreement' stated, "2. SERVICES TO BE PROVIDED BY HOSPICE...2.4 Hospice Care Training. Hospice shall provide orientation and ongoing hospice training to Facility's personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control, and symptom management as well as principles about death and dying, individual responses to death, patient rights, infection control, appropriate forms and record-keeping requirements." "A Registered Nurse will be assigned to coordinate and supervise care and services for patients and families; responsibilities include: ... 3. Teaching patients/families and facility staff to ensure that care to the hospice patients is oriented to the hospice philosophy of care, pain control, symptom management, principles about death and dying, patient's rights and documentation requirements." 2. On 12/12/22 at 11:00 AM during an interview with Person 11 of Entity 10, when queried as to how an agency would go about setting up an in-service/training for the facility, he stated such arrangements would go through himself and the facility's Director of Nursing. When queried as to whether the hospice agency had performed any such training with the facility, he indicated there had not been such training provided by the agency recently. On 12/16/22 at 12:45 PM in an interview with the Clinical Manager when queried about training and education about hospice that was given to facilities, she indicated that she did not provide a presentation to the facilities. She stated she provided a training binder for the facilities to complete, and asks that the facility incorporate it into orientation for new all facility staff as well. On 12/16/22 at 1:05 PM, the Clinical Manager was unable to provide any agency documentation of completed hospice training in-services, nor tracking of same. She further indicated that in the past, when she had done hospice training in-services in person at the facilities, these "were not working". Then the agency switched tactics and "went to self-study" which she indicated was also not working. She indicated there was now a plan in place between herself and the Administrator not yet appointed, to create a hospice training video for the facilities, but that this was currently only in the planning stages.