Every finding on record at Montgomery Hospice Inc

It is required that the hospice maintains an emergency preparedness training (EP) program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 12 (8%) The agency did not ensure that staff and volunteers were trained in Emergency Preparedness on hire and a minimum of every two years. AGENCY POLICY: Agency policy AD.E15 Emergency Preparedness Training and Testing states in part that, "Hospice's emergency preparedness training program provides for the following: (a) initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles, and (b) emergency preparedness training at least every two years". PERSONNEL RECORD 11: The volunteer with a hire date of 6/16/2023 was missing the initial EP training for 2023. Interviews with Executive Director, HR staff, and Volunteer Coordinator on 9/19/2025, they agreed that agency staff and volunteers were not trained in emergency preparedness a minimum of every two years, although staff did have initial emergency preparedness training. Suggestions were made to incorporate this training into the current on-line educational program.

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 and interview. In 2 of 9 (22%) clinical records reviewed of community patients who accepted hospice aide services, the agency did not ensure that the hospice aide followed all the task assigned in the hospice aide's plan of care. CLINICAL RECORD 1: Hospice Aide assignment updated 12/04/2024 to include task to complete bed bath and oral care every visit. The following dates of care these task areas are blank with no explanation for why the care was not provided - 02/26/2025, 03/14/2025, and 4/16/2025. Then the following visits they are marked as N/A (not applicable) with no explanation for what this why it would be not applicable: 06/06/2025, 06/18/2025, 08/27/2025 and 09/10/2025. CLINICAL RECORD 16: The Hospice aide assignment was documented 09/09/2025 with a task for bed bath every visit. The hospice aide visit on 09/11/2025, and 09/12/2025 documented in the bed bath task N/A. There was no documented explanation why the bath was not provided. During interview with the Executive Director (ED) (Personnel Record 9), the ED stated that the option for N/A was not an option that should be used.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed of community patients who accepted hospice aide services, the agency did not ensure that the aide contacted the RN case manager when the assigned tasks were not completed related to the patient condition. CLINICAL RECORD 1: The Hospice Aide assignment updated 12/04/2024 to include task of complete bed bath and oral care every visit. The following dates of care this task areas are blank with no explanation for why the care was not provided - 02/26/2025, 03/14/2025, 4/16/2025. Then the following visits they are marked as N/A (not applicable) with no explanation for what not applicable meant: 06/06/2025, 06/18/2025, 08/27/2025 and 09/10/2025. The changed care for the patient was not documented as reported to the nurse. CLINICAL RECORD 16: The Hospice aide assignment was documented 09/09/2025 with a task for bed bath. The hospice aide visit on 09/11/2025, and 09/12/2025 documented in the bed bath task N/A (not applicable). There was no documented explanation for why the bath was not provided. The changed care for the patient was not documented as reported to the nurse. During interview on 09/18/2025, the Executive Director (ED) (Personnel Record 9) stated that the documentation of notification to the nurse was not in the record.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) clinical records reviewed of the community program who accepted hospice aide services the agency did not ensure that RN supervision was documented every 14 days. CLINICAL RECORD 1: The hospice aide ordered on the initial plan of care dated 10/23/2024 included an order for the aide two times a week (2 x week) and continued until 08/19/2025 when it changed to 3 times a week. A documented aide supervisory visit was dated 02/10/2025 then 03/11/2025 (29 days) then 04/10/2025 (29 days) then 05/07/2025 (27 days) then 05/19/2025 then 06/16/2026 (28 days). The last documented aide supervisor visit in the record was dated 8/21/2025 then there were no addition supervisory visits as of review date 09/17/2025 (27 days). CLINICAL RECORD 9: The patient’s election of the hospice benefit was 07/18/2024 with diagnosis of Senile degeneration of the brain. The first hospice aide visit was 07/22/2024. The first supervision was 8/12/2024 (21 days) then 09/10/2024 (30 days). CLINICAL RECORD 17: The hospice aide assignment on 08/14/2025 with a frequency two times a week (2 x week). The first aide visit was 08/30/2025. There was no documented evidence of an aide supervisory visit as of 09/17/2025 (18 days). During an interview on 08/19/2025, the Executive Director (ED) (Personnel Record 9) stated that supervision was recently identified as a process improvement project.

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; The patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviewed of patients that revoked hospice care, the agency did not ensure that the updated plan of care was sent to the attending physician. CLINICAL RECORD 20: The revocation date was 08/15/2025. A discharge summary was completed but not documented as sent to the primary care physician as of 09/18/2025. The revocation form was dated on 08/15/2025. During interview on 09/17/2025, the clinical supervisor stated that the summary had not been sent.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records. 1 of 20 (5%) records reviewed revealed that the hospice did not ensure that the comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record #12: The patient elected hospice care on 8/22/2022. The social work assessment visit and documentation was completed on 8/23/22. The bereavement assessment was not documented as completed until 9/2/2022 with no documentation found for the delay.