Every finding on record at Jdtje Corporation

It is required that the written Patient Bill of Rights includes the right to have person and property treated with respect by anyone providing services on behalf of the hospice. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home visits completed, the agency did not ensure that the patient's right to be treated with respect by protecting the patient's privacy was protected. HOME VISIT 3: During a home visit observation on 03/19/2026 with the Hospice Aide (Personnel Record 3), the Hospice Aide was observed to remove patient's clothes and expose the patient by opening the patient door to the hallway with no covering over the patient's naked body. In an interview conducted with the Administrator on 03/19/2026, it was stated that the hospice aide did not follow the agency training which included to keep the patient covered and the door shut during personal care.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and observation. In 2 of 11 (18%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 03/02/2025 with a terminal diagnosis of cerebral atherosclerosis. The plan of care (POC) was reviewed for the dates of 03/12/2025-06/08/2025 and did not include a care plan for pain. The RN initial comprehensive assessment documented that the patient was not experiencing pain at the time of the assessment, but medications were ordered for pain and comfort. The patient had Morphine 5 mg PRN. A Visit note dated 06/06/2025 stated that patient's PAINAD was 1 due to increased stiffness and contractures and patient received Acetaminophen 650 mg twice a day for pain along with rest. CLINICAL RECORD 7: This patient elected the hospice benefit on 02/06/2026 with a terminal diagnosis of hemiplegia and hemiparesis and died on 02/10/2026. The initial RN comprehensive assessment dated 02/06/2026 documented a Kennedy terminal sacral ulcer, unstageable, and the nurse documented "Non-adhesive dressing applied for comfort and protection. No signs of acute infection noted. Treatment focused on comfort measures only. Patient Response to Treatment: Will continue to monitor and provide comfort-focused wound care". The plan of care dated 02/06/2026-02/10/2026 did not include a care plan for wound care. During an interview and joint review of the clinical record on 03/20/2026, the Administrator (Personnel Record 1) stated that there was no care plan for the wound and pain and stated, "I missed that one".

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by clinical record review, document review, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency Policy PC.120 Infection Control -Hand Hygiene and Bag Technique stated, in part: "Use of alcohol-based hand sanitizers is preferred (until dry). If antimicrobial soap is used, it must be for a period of 15 seconds. a. Before and after caring for patients, or when coming in contact with inanimate objects/equipment in the immediate vicinity of the patient.". CLINICAL RECORD 3/HOME VISIT 3: This patient elected the hospice benefit on 03/02/2025 with a terminal diagnosis of cerebral atherosclerosis During a home visit observation on 03/19/2026 with the Hospice Aide (Personnel Record 3), the Hospice Aide was observed to cleanse the patient's upper body, reach into the patient's drawer to remove an item, reach into her uniform pocket to obtain glasses, place glasses on her face, and wash the patient without sanitizing hands. The Hospice Aide was observed to place her dangling name tag under her uniform shirt after cleaning the patient's genitals without sanitizing her hands. She then completed the patient's bed bath by cleaning penis and lower legs and then rubbed the patient's head without removing gloves and sanitizing hands. During an interview conducted with the Administrator (Personnel Record 6) on 03/19/2026, it was stated that the Hospice Aide did not follow the agency hand hygiene policy.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records in which the patients were discharged by death, the agency did not ensure that there was a bereavement plan of care. CLINICAL RECORD 7: This patient elected the hospice benefit on 02/06/2026 for a terminal diagnosis of hemiplegia and hemiparesis. The patient died on 02/10/2026. The Bereavement Coordinator documented a bereavement visit on 02/07/2026 and documented that the patient's wife expressed a desire for ongoing chaplain support for continued grief processing. In review of the clinical record, there was no documented evidence of a bereavement care plan. CLINICAL RECORD 9: This patient elected the hospice benefit on 02/01/2025 with a terminal diagnosis of Alzheimer's Disease. The Bereavement Counselor completed a Post Bereavement Assessment on 05/23/2025 and a bereavement letter was sent to the bereaved offering assistance, but there was no documented evidence of a bereavement plan of care in the clinical record. In an interview conducted with the Administrator (Personnel Record 6) on 03/20/2026, it was stated that no bereavement care plan could be found in the clinical record.

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 observation. In 2 of 11 (18%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide were clear and complete. CLINICAL RECORD 3: This patient elected the hospice benefit on 03/02/2025 with a diagnosis of cerebral atherosclerosis. The plan of care dated 02/27/2026-04/27/2026 included a care plan for seizure disorder and hospice aide services two times a week (2XW). The patient was taking Levetiracetam Oral Solution 100 mg/ml give 7.5ml by mouth twice a day for seizure management. The F2F narrative dated 01/28/2026 stated patient had a recent seizure. The hospice aide care plan was reviewed for the dates of 03/02/2025-03/19/2026 and did not include specific instructions to the hospice aide related to the care for potential for seizures while providing tasks. CLINICAL RECORD 4: This patient elected the hospice benefit 03/09/2026 with a terminal diagnosis of Alzheimer's Disease. The hospice plan of care included orders for hospice aide visits two times a week (2XW). The hospice aide care plan dated 03/09/2026 instructed the hospice aide to shave "as needed" and to change linens "every visit or as needed". This did not provide for complete and specific instructions for the hospice aide. An interview was conducted with the Administrator (Personnel Record 6) on 03/20/2026 and she stated that she needed to work on completing the hospice aide care plans to be more specific.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home observations, the agency did not ensure that hospice aide services were provided as ordered by the IDG and included in the plan of care. CLINICAL RECORD 3/ HOME VISIT 3: This patient elected the hospice benefit on 03/02/2025 with a terminal diagnosis of cerebral atherosclerosis. A home visit was conducted on 03/19/2026 to observe the Hospice Aide (Personnel record 3) provide personal care. The Hospice Aide was observed to apply Calmoseptine Cream to the patient's coccyx area. The hospice aide care plan dated 02/25/2026-03/19/2026 did not include instructions for the hospice aide to apply cream to the patient's coccyx area. In an interview conducted with the Administrator on 03/19/2026, it was stated that the hospice aide care plan did not include instructions for the Hospice Aide to apply cream to the patient's coccyx.

It is required that the supervising registered nurse assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include but are not limited to demonstrating competency with assigned tasks. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records for the hospice aide, the agency did not ensure that all required tasks were observed. PERSONNEL RECORD 3: This hospice aide was hired on 12/20/2025. The hospice aide skills validation that was conducted on 12/20/2025 did not document the Hospice Aide's ability to demonstrate initial satisfactory performance in completing a bed bath. During an interview with the Administrator conducted on 03/19/2026, it was stated that the competency for bed baths was not present in the personnel record.

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 which revealed that the volunteer utilization for the year of 2025 did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview was conducted with the Volunteer Coordinator (VC) (Personnel Record 8) on 03/20/2026. A report to the Governing Body dated 03/18/2026 revealed that the volunteer utilization for the year of 2025 did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The VC stated that there was a 'lot of documentation that got siloed with previous employees", so the current VC was working to pull all the documentation together for a report. The VC stated, "There is a lot of evidence that it is more than zero, but I don't have the accurate number". There were two specific performance improvement plans to address the deficiency in the Volunteer Program. This VC had previous volunteer experience and expressed excitement to develop a thriving and successful volunteer program. An interview was conducted with the Volunteer Coordinator (VC) on 03/20/2026. A report to the Governing Body dated 03/18/2026 revealed that the volunteer utilization for the year of 2025 did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The VC stated that there was a 'lot of documentation that got siloed with previous employees", so the current VC was working to pull all the documentation together for a report. The VC stated, "There is a lot of evidence that it is more than zero, but I don't have the accurate number". There were two specific performance improvement plans to address the deficiency in the Volunteer Program. This VC had previous volunteer experience and expressed excitement to develop a thriving and successful volunteer program.

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. The medication review process includes the identification of the following: The effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that all medications were included as part of the documented comprehensive assessment. Agency Policy, "PC.M55 Medication Profile", stated in part, "A patient specific medication profile is maintained for each patient and reviewed every 15 days." Clinical Record 4: The 03/10/2023 physician's order for Morphine was discussed at the 03/16/2023 interdisciplinary team meeting and was included in the 03/10/2023 registered nurse visit documentation. The Morphine had not been added to the medication profile at the time of survey. Since the Morphine was not added to the medication profile, it was not included as part of the complete medication regimen review. During an interview 05/18/2023, Administrator reviewed the associated clinical record and stated the medication had inadvertently been omitted from the medication profile and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that the patient’s individualized written plan of care (POC) included the treatment necessary to meet the needs of the patient. Clinical Record 4: The hospice POC dated 02/23/2023 included orders to change the patient's Foley catheter and irrigate as needed. The POC did not include documentation of the indications or reasons for the as needed catheter irrigation. The order also did not include documentation of physician orders related to the Foley type and size and did not include what solution and the specific amount of irrigation solution to be used. During an interview on 05/18/2023, the Administrator stated that the Foley catheter orders were incomplete and have since been corrected.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. 4 of 5 (80%) clinical records reviewed revealed the agency did not ensure that all entries included credentials with the associated clinician signature and date. Clinical Record 1: Registered Nurse (RN) visit note documentation dated 03/25/2023 through 04/11/2023, the Spiritual Counselor Bereavement Risk Assessment and Spiritual Assessment dated 3/10/2023, and the aide visit note documentation dated 03/21/2023 through 05/11/2023, did not include documented evidence of staff credentials with the associated signatures and dates. Clinical Record 2: Aide visit note documentation dated 04/18/2023 through 05/11/2023 did not include documented evidence of the aide’s credentials with the associated signatures and dates. Clinical Record 3: Aide visit note documentation dated 03/23/2023 through 05/11/2023 did not include documented evidence of the aide’s credentials with the associated signatures and dates. Clinical Record 4: The 03/10/2023 Spiritual Counselor visit documentation, the 02/25/2023 aide visit note documentation, and the 03/10/2023 physician order entered by the registered nurse did not include documented evidence of staff credentials with the associated signatures and dates. During an interview on 05/18/2023, the Administrator stated the associated credentials were missing and have since been corrected.