Every finding on record at Morris Hospice, LLC

Based on record review and interview, the agency failed to ensure the hospice interdisciplinary group (IDG) (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days for 9 patients (#6, #8, #9, #11, #7, #10, #12, #13 and #14) out of a total sample of 14 patients.Findings include: --- 5. Patient #7 was admitted to the agency in 2/2024 with a primary diagnosis of senile degeneration of brain.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/25/25 through 4/24/25 and 4/25/25 through 6/21/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.6. Patient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the clinical record indicated IDG meetings were held for certification period of 3/25/25 through 5/23/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.7. Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/4/25 through 4/4/25 and 4/5/25 through 6/3/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.8. Patient #13 was admitted to the agency in 11/2023 with a primary diagnosis of Alzheimer’s disease.Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/24/25 through 4/24/25 and 4/25/25 through 6/23/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting.9. Patient #14 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the clinical record indicated IDG meetings were held for certification period of 3/5/25 through 5/2/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician. The attendance log indicated only the RN, Chaplain and SW were in attendance on the day of the meeting.*4/17/25: The SW. The attendance log indicated only the physician, RN, Chaplain and SW were in attendance on the day of the meeting.*5/1/25: The physician and SW. The attendance log indicated only the RN and Chaplain were in attendance on the day of the meeting. Review of the agency's policy entitled IDG Care Planning Process, revised February 2022, indicated the following:*The IDG included a physician member who is the Hospice Medical Director, or another Hospice Physician who is employed by or under contract with the Hospice, Registered Nurse (RN), Social Work (SW) and Pastoral or another counselor.*IDG members provide the care and services offered by Hospice and supervise the care and services.1.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranulcear Opthaloplegia (a condition that affects eye movement control due to brain damage).Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/12/25 through 4/12/25 and 4/13/25 through 6/11/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/6/25: The physician. *3/20/25: The physician, the RN, and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician and the RN. The attendance log indicated only the Chaplain and MSW were in attendance on the day of the meeting.*4/17/25: The physician and the SW. The attendance log indicated only the Chaplain and RN were in attendance on the day of the meeting.*5/1/25: The physician, the RN and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting. 2. Patient #8 was admitted to the agency in August 2024 with cerebrovascular disease (stroke related to impaired blood flow in the brain).Review of the clinical record indicated IDG meetings were held during the last 2 certification periods of 2/3/25 through 4/3/25 and 4/4/25 through 6/2/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*2/6/25: The physician.*2/20/25: The physician. *3/6/25: The physician.*3/20/25: The physician, the RN, the MSW and the SW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting. *4/3/25: The physician.*4/17/25: The physician. *5/1/25: The physician, the MSW and the RN. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.3. Patient #9 was admitted to the agency in March 2025 with a terminal diagnosis of senile degeneration of the brain (dementia).Review of the clinical record indicated IDG meetings were held during the certification period of 3/13/25 through 6/10/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*3/20/25: The physician, the RN and the MSW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.*4/3/25: The physician.*4/17/25: The physician and the MSW. *5/1/25: The physician, the MSW and the RN. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.4. Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer's disease.Review of the clinical record indicated IDG meetings were held during the certification period of 3/28/25 through 6/25/25. The following IDG meeting attendance logs indicated the required staff were not in attendance on the day of the meeting:*4/3/25: The physician and the RN. *4/17/25: The physician and the MSW. *5/1/25: The physician, the RN, and the MSW. The attendance log indicated only the Chaplain was in attendance on the day of the meeting.

Based on record review and interview, the agency failed to ensure staff communicated with the physician when services were not provided in as orderd for 6 patients (#5, #10, #12, #6, #9 and #11) out a total sample of 14 patients.Findings included: --- 1. For Patient #5, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.   - For the week of 4/20/25 - 4/26/25, only 2 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.2. For Patient #10, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 3/30/25 - 4/5/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.3. For Patient #12, the agency failed to ensure there was communication shared with the physician when services were not provided, as orderedPatient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits. Review of the agency's policy entitled Physician Orders, revised June 2019, indicated the following:*Nursing and other services that require a physician's order will be provided in accordance with the physician's order.*Care and services provided will be in accordance with the physician orders.*Physicians shall be notified of any variance of ordered visit frequencies.1. For Patient #5, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #5 was admitted to the agency in March 2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide visits (HAVs) 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care (POC).- For the week of 4/6/25 - 4/12/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 HAVs were provided instead of the 5 as ordered.   - For the week of 4/20/25 - 4/26/25, only 2 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.2. For Patient #10, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #10 was admitted to the agency in May 2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for HAVs 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the POC.- For the week of 3/30/25 - 4/5/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.3. For Patient #12, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered.Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for HAVs 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the POC:- For the week of 4/6/25 - 4/12/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 HAVs were provided instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 HAVs were provided instead of the 5 as ordered.Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits.4. For Patient #6, the agency failed to ensure there was communication shared with the physician when HAVs were not provided as ordered.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranuclear Ophthalmoplegia (a condition that affects eye movement control due to brain damage).Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HAV: 5 times a week for 9 weeks (beginning 2/12/25 through 4/12/25).Review of the clinical record indicated for the weeks of 3/9/25 through 3/15/25 and 3/30/25 through 4/4/25, only 4 HAVs were provided each week, not 5 as ordered. The record did not include documentation of the missed visits nor whether the physician was notified.5. For Patient #9, the agency failed to ensure that there was communication shared with the physician when (a) HA, (b) Medical Social Worker (MSW) and (c) Skilled Nursing (SN) visits (Vs) were not provided as orderedPatient #9 was admitted to the agency in March 2025 with a terminal diagnosis senile degeneration of the brain.Review of the physician’s ordered POC for certification period 3/13/25 through 6/10/25, included the following:(a) *HAVs: 5 times a week for 13 weeks (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25, only 3 HAVs were provided, not 5 as ordered.(b) *MSW: Assess and evaluate 3/13/25 through 3/18/25.*MSWV: 1 time a month for 3 months (beginning 4/1/25 through 6/10/25).Review of the clinical record indicated there was not a MSWV provided for the month of April 2025.(c) *SN: Assess and evaluate 3/13/25 through 3/14/25.*SNVs: 1 time a week for 13 weeks and 3 as needed (PRN) visits (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated that for the weeks of 3/16/25 through 3/22/25, 3/30/25 through 4/5/25, 4/20/25 through 4/26/25, and 4/27/25 through 5/3/25, 2 SNVs were provided, not one as ordered. The nursing notes indicated they were nursing routine and supervisory visits. Further review of the record did not include documentation that staff notified the physician of the missed HAVs and MSWV, nor the additional SNVs provided.6. For Patient #11, the agency failed to ensure HAVs were provided as ordered.Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer's Disease.Review of the physician’s ordered POC for certification period 3/28/25 through 6/25/25, included the following:*HAV: 5 times a week for 9 weeks (beginning 3/29/25 through 6/21/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25 25, only 4 HHAVs were provided, not 5 as ordered. The record did not include documentation that the physician was notified of the missed HAV.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ charts and said that she could not find any documentation that the physician was notified of missed visits. She also said staff should have also notified the physician when 2 SNVs were provided for the 4 weeks noted above , not one as ordered, for Patient #9.

Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care (POC), for 6 patients (#6, #9, and #11, #5, #10, #12), out of a total sample of 14 patients. Findings include: --- 4. For Patient #5, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the current physician orders for the certification period of 4/1/25 - 6/29/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.   - For the week of 4/20/25 - 4/26/25, only 2 Hospice Aide visits were conducted instead of the 5 as ordered.5. For Patient #10, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #10 was admitted to the agency in 5/2024 with a primary diagnosis of cerebrovascular disease.Review of the current physician orders for the certification period of 3/15/25 - 5/23/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 3/30/25 - 4/5/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/13/25 - 4/19/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.6. For Patient #12, the Agency failed to follow the plan of care relative to Hospice Aide visits.Patient #12 was admitted to the agency in 8/2024 with a primary diagnosis of Alzheimer’s disease.Review of the current physician orders for the certification period of 4/5/25 - 6/3/25, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care:- For the week of 4/6/25 - 4/12/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/20/25 - 4/26/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.- For the week of 4/27/25 - 5/3/25, only 4 Hospice Aide visits were conducted instead of the 5 as ordered.During an interview on 5/7/25 at 2:45 P.M., the Clinical Manager reviewed the patients’ chart and said that the Hospice Aide visits were not provided as ordered and there was no documentation to indicate why. 1.For Patient #6, the agency failed to ensure Hospice Health Aide Visits (HHAVs) were provided as ordered.Patient #6 was admitted to the agency in August 2024 with a terminal diagnosis of Supranuclear Opthalmoplegia (a condition that affects eye movement control due to brain damage).Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HHAV: 5 times a week for 9 weeks (beginning 2/12/25 through 4/12/25).Review of the clinical record indicated for the weeks of 3/9/25 through 3/15/25 and 3/30/25 through 4/4/25, only 4 HHAVs were provided each week, not 5 as ordered.2. For Patient #9, the agency failed to ensure that (a) HHAVs, (b) Medical Social Worker Visits (MSWVs) and (c) Skilled Nursing Visits (SNVs) were provided as ordered.Patient #9 was admitted to the agency in March 2025 with a terminal diagnosis senile degeneration of the brain.Review of the physician’s ordered POC for certification period 3/13/25 through 6/10/25, included the following:(    (a) *HHAV: 5 times a week for 13 weeks (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25, only 3 HHAVs were provided, not 5 as ordered.(b) *MSW: Assess and evaluate 3/13/25 through 3/18/25.*MSWV: 1 time a month for 3 months (beginning 4/1/25 through 6/10/25).Review of the clinical record indicated there was not a MSWV provided for the month of April 2025.(c) *SN: Assess and evaluate 3/13/25 through 3/14/25.*SNVs: 1 time a week for 13 weeks and 3 as needed (PRN) visits (beginning 3/14/25 through 6/7/25).Review of the clinical record indicated that for the weeks of 3/16/25 through 3/22/25, 3/30/25 through 4/5/25, 4/20/25 through 4/26/25, and 4/27/25 through 5/3/25, 2 SNVs were provided, not one as ordered. The nursing notes indicated they were nursing routine and supervisory visits. None of the notes indicated they were coded as PRN visits.3. For Patient #11, the agency failed to ensure HHAVs were provided as ordered.Patient #11 was admitted to the agency in March 2025 with a terminal diagnosis of Alzheimer's Disease.Review of the physician’s ordered POC for certification period 2/12/25 through 4/12/25, included the following:*HHAV: 5 times a week for 9 weeks (beginning 3/29/25 through 6/21/25).Review of the clinical record indicated for the week of 4/20/25 through 4/26/25 25, only 4 HHAVs were provided, not 5 as ordered.During an interview on 5/7/25 at 12:25 P.M, the Clinic Manager (CM), said for Patient #6, HHAVs were not provided as ordered and there was no documentation to indicate why the POC was not followed.During an interview on 5/7/25 at 2:15 P.M., the CM said, for Patient #9, HHAVs, SNVs and MSWV were not provided as ordered. She said there was no documentation of why visits were missed or why extra SNVs were made. She said for Patient #11, the HHAVs were not provided as ordered and there was no documentation to indicate why. She also said the POCs for Patient #9 and #11 were followed as ordered.

Based on observation and staff interview, the agency failed to ensure that infection control guidelines were followed for one patient (#5) of 3 home visits conducted in a total sample of 14 records.  Findings include: --- Review of the agency’s policy titled “Hand Hygiene Policy and Compliance Program”; revised July 2021 indicated the following:*Hand hygiene will be done by all employees, volunteers and contract staff to reduce transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms.*Indications for hand hygiene are:-before and after direct patient care-before and after each patient’s procedure-when hands are soiled*Hospice will follow the Centers for Disease Control and Prevention guidelines for hand hygiene.CDC Hand Hygiene Guidelines:*Indicators for hand washing and hand antisepsis-visible dirt, blood or body fluids on the hands of health care workers.-after removing gloves.-after contact with blood, body fluids, mucus membranes, non-intact skin and wound dressing.-moving from contaminated patient body site to clean site during patient care.Review of the agency’s policy titled “Standard Precautions”; revised July 2021 indicated the following:*All healthcare workers will routinely use appropriate barrier precautions to prevent skin and mucus membrane exposure when contact with blood or other bloody fluids of any patients is anticipated.-gloves will be worn before touching blood and body fluids, mucus membranes, or non-intact skin of all patients.-gloves will be changed and hand wash after contact with each patient. Patient #5 was admitted to the agency in 3/2025 with a primary diagnosis of Alzheimer’s Disease.Review of the Hospice Aide Care plan for certification period of 4/1/25-6/29/25, indicated that Patient #5 is dependent on staff with daily care including hygiene (bed bath and perineal care).On 5/7/25 at 9:30 A.M., a home visit was conducted with Home Health Aide (HHA) #5, and HHA #6 to perform personal care for Patient #5. The surveyor observed HHA #5 and #6 perform hand hygiene and put gloves on and remove the patient's soiled diaper. HHA #6 began performing perineal care to Patient #5 who was incontinent with feces. Without changing her gloves, HHA #6 reached in her carry-on luggage to get a jar of zinc oxide, opened it and took a swipe of ointment with her contaminated gloves and applied it to Patient #5’s peri area. Without changing the same gloves, she put her hand back into the bag to return the jar of ointment. At this point, the Clinical Manager (CM) who was also observing interrupted to tell HHA #6 that she needed to change her gloves and wash her hands.During an interview on 5/7/25 at 9:45 A.M., the CM said that HHA #6 cannot be reaching in and out of her bag with contaminated gloves. She said that HHA #6 needs to wash her hands and change gloves every time.

Based on employee file review, policy review and interview, the agency failed to ensure that 2 of 2 hospice home aides (HHA # 6 and #5) reviewed received at least l2 hours of in-service training during each 12-month period.Findings include: --- 2. Employee # 5 was hired on 4/21/22.Review of the employee filed indicated Employe#5 did not receive monthly in-service training in 2024 for the months of April, May, June, September, October, November and December.During an interview on 5/7/25 at 2:30 P.M., the Chief Executive Officer (CEO) said staff, including HHAs, receive monthly in-service training. She said the in-service trainings are about an hour long, so this would allow for the HHA to get the required 12 hours of training. She said Employee #5 did not get the required 12 hours of in-service training based on her review of the employee's file. Review of the agency's policy titled “Inservice Education”, dated February 2021, indicated the following:-Each Hospice Aide must receive at least 12 hours of in-servicing training during each 12-month period. Hospice may fulfill the annual 12-hour in-service training requirement on a calendar year basis, an employment anniversary basis or rolling 12-month basis as long as each aide meets this in-service training requirement.1.Employee # 6 was hired on 9/7/23.Review of the employee filed indicated Employee #6 did not receive monthly in-service training in 2024 for the months of May, June, September, October, November and December.During an interview on 5/7/25 at 2:30 P.M., the Chief Executive Officer (CEO) said staff, including HHAs, receive monthly in-service training. She said the in-service trainings are about an hour long, so this would allow for the HHA to get the required 12 hours of training. She said Employee #5 did not get the required 12 hours of in-service training based on her review of the employee's file.

Based on record review and interview, the Hospice agency failed to ensure that a Registered Nurse (RN) supervised the Hospice aides at least every 14 days for 2 of 14 sampled patients (#5 and #8) receiving these services in a total sample of 14 patients.Findings include: --- 2. Patient #8 was admitted to the agency in August 2024 with a terminal diagnosis of unspecified sequelae of cerebral infarction (lack of blood supply to the brain that causes brain tissue to die).Review of the physician ordered Plan of Care for certification period 2/3/25 through 4/3/25, indicated the following:*HHAVs: 5 times a week for 9 weeks.*SNVs: 1 time a week for 9 weeks.Review of the clinical record indicated the last documented HHA supervisory visit by the nurse was 3/3/25. Nursing did not provide HHA supervision for the weeks of 3/16/25 through 3/22/25, nor the week of 3/30/25 through 4/3/25.During an interview on 5/7/25 at 12:25 P.M., the Clinical Manager said nursing did not complete the required HHA supervision every 14 days after their last one on 3/3/25.   Findings include:  Review of the agency policy titled “Hospice Aide Supervision”, dated June 2019, indicated the following: -Hospice Aides are closely supervised to ensure their competence in providing care. At least every fo14 days the Registered Nurse makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence.  1. Patient #5 was admitted to Hospice services on 4/2025. The physician's orders for the certification period of 4/1/25 - 6/29/25 indicated the patient was to receive Hospice Aide services 5 times a week for 13 weeks. Review of the clinical record indicated Hospice Aide visits were made to patient #5, 16 times from 4/1/25 to 5/1/25. There was no evidence of documented Hospice Aide supervisory visits conducted by the RN for this period and not every 14 days as required. During an interview on 5/7/25 at 2:45 P.M., the Clinical Director said that Hospice Aide supervisory visit is done at least every 14 days with or without the Hospice Aide present. She reviewed patient # 5’s clinical record and said that she cannot locate any evidence of the Hospice Aide supervisory visits.

Observed in Emergency Management Session. During the emergency management session and discussion with the leadership team, the surveyor noted the organization had not shown evidence it had evaluated the effectiveness of its Emergency Operations Plan. For example, the organization had not conducted and exercise that incorporated a likely disaster scenario that allowed it to evaluate its plan. An emergency preparedness in-service and fire drill for the office was conducted, but no additional exercise of a likely disaster was conducted or documented. This was validated by the CEO and Clinical Director.

Observed in Emergency Management Session. During the Emergency Management Session with the leadership team, the organization failed to demonstrate it had evaluated all emergency response exercises and all responses to actual emergencies including the identification of deficiencies and opportunities for improvement. For example, since the organization failed to test its emergency operations plan as it only conducted a fire drill on site, they were unable to show evidence of an evaluation that included documentation of deficiencies or opportunities for improvement. There was no documentation or process in place. This was validated by the CEO and Clinical Director.

Observed in Individual Tracer. In 2 of 2 patient records with a length of stay greater than thirty days, HV3, RR5, during the home visit and record review the surveyor noted the organization had not shown evidence the updated comprehensive assessment was based on changes that have taken place since the initial assessment and included information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. For example, HV3 (SOC 3/7/22), RR5 (SOC 3/18/22) the patients had been receiving hospice services and documentation in the comprehensive assessment, stated goals partially met. However, it did not address any specific problem or goals and the progress related to them. The documentation in the record was broad and general. In addition, the plan of care did not include progress toward goals by the other disciplines. This was validated by the Clinical Director.

Observed in Individual Tracer. In 8 of 8 patient records reviewed, HV2, during the home visit and record review, the surveyor noted the written plan of care did not demonstrate it was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example in all records, the plan of care did not reflect measurable goals and all goals were identified to be achieved at the end of the certification period. For example HV2 the nonverbal patient with Alzheimer goal stated: patient achieves feelings of spiritual comfort; patient/family will demonstrate ability to cope with limitations; patient maintains vital signs within baseline range however, no range identified. HV3, promote skin integrity did not include objective, measurable language in order to identify how it would be achieved. This was validated by the Clinical Director.

Observed in Individual Tracer. In 1 of 4 home visits conducted, HV2, during the home visit, the surveyor noted the organization failed to demonstrate it used standard precautions, including the use of personal protective equipment, to reduce the risk of infection. For example, HV2 the aide was observed to have her protective eye goggles on the top of her head rather than covering her eyes while feeding the patient. This was not compliant with the organization's Infection Control Standard Precautions policy or the facility policy during an active outbreak of COVID-19 at the time in the facility. This was validated by the Clinical Director. Observed in Individual Tracer. In 1 of 4 home visits conducted, HV3, during the home visit the surveyor noted the organization failed to implement its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. For example, the nurse stored her equipment in a Ziploc baggie, which she removed from her nurse bag and placed on the barrier. However, after cleaning her equipment, she moved it (baggie) off the barrier and placed it directly on a facility owned binder on the counter before she returned it back to her bag. This was not compliant with the organization's bag technique policy and validated by the Clinical Director.

Observed in Individual Tracer. In 3 of 8 patient records reviewed, During HV1, HV2, RR5 the surveyor noted the organization had not shown evidence it had prepared written patient care instructions for the hospice aide, including parameters to report to the nurse. For example, HV2, the patient's assessment indicated she had Alzheimer diagnosis, was dependent for feeding, was on anticoagulation therapy and low back pain, however, the aide assignment sheet did not include parameters for reporting pain to the nurse or bleeding precautions identified on the assignment sheet. RR5, the patient assessment included aspiration risk precautions that were not identified on the aide assignment sheet. This was validated by the Clinical Director.

Observed in Individual Tracer. In 1 of 1 skilled nursing home visits conducted, HV3, during the home visit, the surveyor noted the organization failed to demonstrate the patient record contained a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, during the medication reconciliation process, there were several medications on the organization's medication list that did not match the medication profile at the facility. As an example: Enema Mineral oil 100% rectal enema was ordered, however the facility listed Enema with sodium phosphate; Depakote 125 mg orally three times a day on the organization list did not reconcile with the facility: Depakote sprinkles 125 mg orally three times a day; Donepril at the facility was ordered at bedtime, however, this was not listed on the organization's medication list. Loratadine 10 mg on the medication list for itching vs Facility for itchy eyes; Magnesium hydroxide 24% oral concentrate was listed on the organization profile was listed compared to Milk of Magnesia 400 mg/5ml 30 ml orally every 24 hrs. on the facility's list. This was not compliant with the medication management policy and validated by the Clinical Director and nurse.

Observed in Leadership Session. In 1 of 3 contracts reviewed, During contract review, the surveyor noted the organization failed to show evidence the Pharmacy agreement included language that the vendor would complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was validated by the CEO.