Every finding on record at Hospice T L C, Inc

Based on record reviews and interviews, the hospice agency failed to ensure an initial bereavement assessment was completed for 14 (#1-14) of 14 patient records reviewed.Findings: --- Record review for Patients #1-#14 revealed no documented evidence an initial bereavement assessment was completed for these patients upon admission. An interview on 03/04/2026 at 8:45 a.m. with S1Administrator revealed the provider has not had a bereavement coordinator since January 2026.  S1Administrator confirmed the agency failed to complete an initial bereavement assessment on Patients #1-14 upon admission.

Based on record reviews and staff interviews, the hospice agency failed to develop a bereavement plan of care that included the kind of bereavement services offered and the frequency of service delivered for 14 (#1-14) of 14 patient records reviewed. Findings: --- Review of the agency’s current Bereavement Services policy and procedure, revised May 2023, revealed the following, in part:A bereavement file will be maintained on each family/caregiver unit of care.Each file will contain:A bereavement plan of care.Record review revealed patient`s #1 – 14 did not have a completed initial bereavement assessment. Further review of patient`s #1-14`s records revealed there was not an ongoing bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery.On 03/04/2026 at 8:45 a.m., an interview with S1Administrator revealed the provider has not had a bereavement coordinator since January 2026.  S1Administrator confirmed the agency failed to develop an ongoing bereavement plan of care that included the kind of bereavement services to be offered and the frequency of service delivery for Patient`s #1 -14.

Based on record review and interview, the Hospice Agency failed to meet the requirements of the Condition of Participation: Volunteers by failing to failing to use volunteers in defined roles and under the supervision of a designated hospice employee. This deficient practice was evidenced by the Hospice Agency failing to have documentation of:1.) Ongoing efforts to recruit and retain volunteers (L0645);2.) The cost savings achieved through the use of volunteers (L0646);3.) Volunteers providing day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff (L0647).Findings: --- See findings in L0645, L0646, L0647.

Based on record review and interview, the Hospice Agency failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers.Findings: --- Review of the list of active employees revealed no record of a volunteer coordinator or volunteers.The provider failed to provide documentation to demonstrate viable and ongoing efforts to recruit and retain volunteers from 12/31/2023 (when the Covid Public Health Emergency waiver for volunteers ended) - 03/02/2026.During an interview on 03/02/2026 at 10:30 a.m., S1Administrator confirmed the Hospice Agency did not have a volunteer coordinator or any volunteers. S1Administrator confirmed the Hospice Agency had not used volunteers since 2020. S1Administrator also reported the Hospice Agency had not attempted to recruit volunteers in the past year.

Based on record review and interview, the Hospice Agency failed to document the cost savings achieved through the use of volunteers.Findings: --- Review of the list of active employees revealed no record of a volunteer coordinator or volunteers.During an interview on 03/02/2026 at 10:30 a.m., S1Administrator confirmed the Hospice Agency did not have any volunteers currently and the provider had not used volunteers since 2020.The hospice's failure to use volunteers in direct patient care and/or administrative activities resulted in the provider being unable to record cost savings through the use of volunteers from 12/31/2023 (when the Covid Public Health Emergency waiver for volunteers ended) - 03/02/2026.

Based on record review and interview, the facility failed to use volunteers to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff.  Findings: --- Review of the list of active employees revealed no record of a volunteer coordinator or volunteers. The provider failed to provide documentation that the Hospice agency had used volunteers to equal 5 percent of the total patient care hours of all paid hospice employees and contract staff from 12/31/2023 (when the Covid Public Health Emergency waiver for volunteers ended) - 03/02/2026. During an interview on 03/02/2026 at 10:30 a.m., S1Administrator revealed the Hospice Agency did not have any volunteers currently and had not used volunteers since 2020.

Based on observation, interview, and record review, the hospice agency failed to provide hospice care that optimized patient comfort consistent with patient needs and goals for 1 (#2) of 3 sampled patients who received a home visit.Findings: --- Record review revealed Patient #2 had diagnoses that included cerebral palsy and chronic obstructive pulmonary disease.  Patient #2 had a start of care date of 09/18/2021 and a current certification period of 01/06/2026 – 03/06/2026.Review of Patient #2’s active orders revealed an order for Hydrocodone – Acetaminophen10-325 milligrams every 3 hours as needed for pain. Review of Patient #2’s active care plans revealed the following, in part:1)    Assess patient`s ongoing medications and provide medication information/education as needed to maintain patient therapeutic response as well as patient/family safety; and 2)    Assess needed ongoing treatments; collaborate with physician for order changes and patient response.On 03/03/2026 at 9:50 a.m., a home visit was conducted at Patient #2`s home with S4LPN.  S4LPN asked Patient #2 if he was hurting anywhere, and patient reported he was hurting all over, then S4LPN whispered to the surveyor, “he says that all the time.”  S4LPN did not review Patient #2’s medications or ask the patient or the family if his pain medication was available or when the last time his pain medication was administered.   A family member then reported to S4LPN the last bowel movement Patient #2 had was on 02/27/2026, and S4LPN stated “that’s good” with no further questions to the patient/family regarding his last bowel movement (4 days ago).  The home visit ended on 03/03/2026 at 9:50 a.m.  On 03/04/2025 at 11:20 a.m., an interview with S2DON was conducted in her office. I informed S2DON of the findings of my home visit at Patient#2`s home with S4LPN.  S2DON confirmed S4LPN should have reviewed Patient #2`s medications while in the patient’s home and questioned patient and family about his pain medication usage.  S2DON also confirmed S4LPN should have further assessed Patient #2’s last bowel movement, which was 4 days earlier.

Based on record reviews and interviews, the hospice agency failed to ensure that all unlicensed persons seeking employment with the hospice agency had a national criminal background check completed prior to being hired for 1 (S5Chaplain) of 3 unlicensed personnel records reviewed. --- Review of the personnel records revealed S5Chaplain was hired on 01/05/2026.  Further review of the record revealed there was no documented evidence a national criminal background check was completed prior to his hire date.  On 03/04/2026 at 3:40 p.m. S1Administrator confirmed the agency failed to complete a nationwide criminal background check prior to hire for S5Chaplain.

Based on record reviews and interviews, the provider failed to ensure that all unlicensed persons seeking employment with the hospice agency had a criminal background check completed prior to being hired for 1 (S6Chaplin) of 4 (S6Chaplin, S8Homemaker, S9Hospice Aide, and S10Hospice Aide) unlicensed personnel records reviewed. Findings: Review of the personnel records revealed S6Chaplin's date of hire was 07/31/2023. Further review revealed there was no documentation of a criminal background check being completed to ensure S6Chaplin did not have a finding that barred employment. On 08/09/2023 at 10:50 a.m., S2Office Manager reported that S6Chaplin had previously been employed with the provider in the capacity of a volunteer, but she had not worked for the agency since the COVID-19 outbreak in 2020. S2Office Manager further reported that S6Chaplin was rehired on 07/31/2023 in the official capacity of a Chaplin. S2Office Manager confirmed that she had not obtained a criminal background check upon hire. On 08/09/2023 at 11:28 a.m., S1Administrator was notified of the findings.