Every finding on record at Prestige Devotion Hospice LLC

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 clinical record review and interview. In 4 of 10 (40%) clinical records reviewed, in which a spiritual counselor was accepted, the agency did not ensure that the spiritual counselor when requested, provided a full spiritual assessment in the first 5 days after the election of the hospice benefit. CLINICAL RECORD 1: Election of the hospice benefit was 04/06/2026 with a primary diagnosis of Alzheimer's disease. The initial comprehensive assessment was documented 04/06/2026 with a request for spiritual services. There was no documented contact from the spiritual counselor. The Interdisciplinary Group documented twice monthly spiritual counselor visits without an initial assessment. CLINICAL RECORD 2: Election of the hospice benefit was 04/05/2026 with a primary diagnosis of Multiple myeloma. The initial comprehensive assessment was documented 04/05/2026 with a request for spiritual services. There was no documented contact from the spiritual counselor evident in the record. CLINICAL RECORD 9: Election of the hospice benefit was 04/06/2026 with a primary diagnosis of Hemiplegia following cerebral infarction. The initial comprehensive assessment was documented 04/06/2026 with a request for spiritual services. There was no documented contact from the spiritual counselor evident in the record, nor was an initial spiritual assessment completed by the registered nurse. CLINICAL RECORD 10: Election of the hospice benefit was 04/04/2026 with a primary diagnosis of Heart failure. The initial comprehensive assessment was documented 04/04/2026 with a request for spiritual services. There was no documented contact from the spiritual counselor evident in the record. An interview was conducted with the Administrator on 04/28/2026 regarding the initial spiritual counselor visits not being completed. The Administrator advised the "spiritual counselor had been receiving additional training and was still 'missing the mark'. They had decided and made a job offer to a replacement spiritual counselor who would be coming on in less than 1 month."

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by document review, personnel record review, and interview which revealed the agency: Failed to provide training for all employees, including contractors, in Emergency Preparedness Training at least annually, according to agency policy{ HSEP.5.D/E37/418.113(d)(1)}; and Failed to test the emergency preparedness plan annually, as required by agency policy[HSEP.6.I/E39/418.113(d)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation, CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice maintain an emergency preparedness training 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 the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and 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 10 of 10 (100%) personnel records reviewed revealed that the agency did not ensure to provide training for all employees, including contractors, in Emergency Preparedness Training at least annually, according to agency policy. DOCUMENT 2: Agency Policy, Emergency Disaster Management, AD.E10, stated in part, "Hospice employees receive annual in-service training on the Emergency Disaster Management Plan and their roles and responsibilities." DOCUMENT 3: Agency Policy, Emergency Preparedness Plan, 6.1, stated in part, "All employees, including contractors, are oriented about their responsibilities on the Agency Emergency Preparedness and Response Plan upon hire, and the plan is reviewed at least annually with an emergency drill performed. Training will include emergency preparedness training at least annually, and maintain documentation of all emergency preparedness training." PERSONNEL RECORD 1: The Administrator/Director of Nursing/Registered Nurse/Volunteer Coordinator was hired on 05/24/2022. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2023-03/16/2026 as required by agency policy. PERSONNEL RECORD 2: The Alternate Administrator/Alternate Director of Nursing/Registered Nurse was hired on 05/24/2022. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2023-03/16/2026 as required by agency policy. PERSONNEL RECORD 3: The Hospice Medical Director was hired on 01/03/2024. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 01/01/2025-03/16/2026 as required by agency policy. PERSONNEL RECORD 4: The Alternate Medical Director was hired on 11/02/2022. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2023-03/16/2026 as required by agency policy. PERSONNEL RECORD 5: The Hospice Aide (CNA) was hired on 12/21/2022. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2023-03/16/2026 as required by agency policy. PERSONNEL RECORD 6: The Chaplain was hired on 07/21/2023. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 07/01/2024-03/16/2026 as required by agency policy. PERSONNEL RECORD 7: The Master Social Worker/Bereavement Coordinator was hired on 05/30/2023. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2024-03/16/2026 as required by agency policy. PERSONNEL RECORD 8: The Nurse Practitioner was hired on 10/07/2024. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 01/01/2025-03/16/2026 as required by agency policy. PERSONNEL RECORD 9: The Registered Nurse was hired on 01/30/2023. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 06/01/2023-03/16/2026 as required by agency policy. PERSONNEL RECORD 10: The Volunteer was hired on 10/03/2023. The new hire orientation included education about their responsibilities on the Agency Emergency Preparedness and Response Plan. There was no documented evidence of Emergency Preparedness training annually between 01/01/2024-03/16/2026 as required by agency policy. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the employees received training in Emergency Preparedness annually as required by agency policy. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats."

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including: Participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years, opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to: A second full-scale exercise that is community-based or a facility-based functional exercise; or A mock disaster drill; or A tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met, as evidenced by document review and interview. A review of the Emergency Preparedness Binder revealed that the agency did not ensure to test the emergency preparedness plan annually, as required by agency policy. DOCUMENT 3: Agency Policy, Emergency Preparedness Plan, 6.1, stated in part, "The Agency will conduct exercises to test the Emergency Plan at least annually." DOCUMENT 5: The Emergency Preparedness Binder revealed that there was no documented evidence that the emergency preparedness plan was tested at least annually between 06/01/2023-03/16/2026. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the agency tested the Emergency Preparedness Plan annually as required by agency policy. Additionally, the Administrator stated, "We last tested in 2022. I was in the field a lot, providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats." A review of the Emergency Preparedness Binder revealed that the agency did not ensure to test the emergency preparedness plan annually, as required by agency policy.

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but at a minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 14 (14%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included an updated medication profile that contained the patient's current medications. CLINICAL RECORD 3/HOME VISIT 2: The patient elected the hospice benefit on 02/04/2025 with a diagnosis of Senile Degeneration of the Brain. The patient resided in a Skilled Nursing Facility (SNF). During the home visit with the Registered Nurse (RN) (Personnel Record 9) on 03/17/2026, the patient's hospice medication profile (printed on 03/16/2026) and SNF medication profile were compared. The hospice medication profile revealed the patient is receiving Vitamin C 500mg 1 x day and Melatonin 5mg at bedtime. The SNF medication profile revealed Vitamin C 500mg 2 x day (02/04/2025) and Melatonin 6mg at bedtime (02/04/2025). The hospice medication profile revealed Metformin 1000mg 2 x day; the SNF discontinued the Metformin on 03/26/2025. The hospice medication profile revealed Clonidine 0.1mg every 6 hours prn systolic greater than 185; the SNF discontinued the Clonidine on 03/26/2025. During the visit, the Registered Nurse stated, "I didn't realize these weren't updated. I will get them updated right away." CLINICAL RECORD 6/HOME VISIT 1: The patient elected the hospice benefit on 01/02/2026 with a diagnosis of Chronic Obstructive Pulmonary disease. The patient resided in an Assisted Living Facility (ALF). During the home visit with the Hospice Aide (HA) (Personnel Record 5) on 03/17/2026, the patient's hospice medication profile (printed on 03/16/2026) and ALF medication profile were compared. The hospice medication profile revealed Tramadol 50mg every 6 hours as needed for pain (01/15/2026) and Loperamide 2mg four times a day as needed for loose stool (01/30/2026). The ALF medication profile did not include Tramadol or Loperamide. The ALF medication profile revealed Bisacodyl 10mg suppository one daily as needed for constipation (10/17/2025). The hospice medication profile did not include Bisacodyl. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that the medication profiles were not updated with the medications identified. Additionally, the Administrator stated, "The nurse should be checking during visits, but these weren't updated; we need to discuss expectations with the nurses."

It is required that each patient’s individualized written plan of care: Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met, as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure that the plan of care included measurable outcomes for the problems identified. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/07/2025 with a diagnosis of Diastolic (congestive) Heart Failure. The Plan of Care (POC) identified pain as a problem on 04/07/2025 with a goal "patient's quality of life will be at an optimal level." The patient's optimal quality of life was not identified. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/04/2025 with a diagnosis of Senile Degeneration of the Brain. The Plan of Care (POC) identified pain as a problem on 02/04/2025 with the goal "Patient's quality of life will be at an optimal level." The patient's optimal quality of life was not identified. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/21/2025 and was discharged on 04/19/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease. The Plan of Care (POC) identified pain as a problem on 01/22/2025 with the goal "patient's quality of life will be at an optimal level." The patient's optimal quality of life was not identified. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/13/2025 and was discharged on 07/12/2025 with a diagnosis of Cirrhosis of the liver. The Plan of Care (POC) identified pain as a problem on 2/13/2025 with the goal "patient's quality of life will be at an optimal level." The patient's optimal quality of life was not identified. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that the patient's optimal quality of life was not identified. Additionally, the Administrator stated, "These aren't measurable. We are updating them now."

It is required that performance improvement activities track adverse patient events, analyze the causes, implement preventive action, and mechanisms that include feedback and learning throughout the hospice. This standard was not met, as evidenced by document review and interview. A review of the QAPI Binder revealed that the agency did not ensure to analyze the causes of adverse patient events and implemented preventive action and mechanisms that include feedback and learning throughout the hospice. DOCUMENT 6: The QAPI Binder revealed a QAPI Committee Meeting on 07/09/2025, which documented 3 infections and 2 falls for the quarter. A QAPI Committee Meeting on 10/15/2025 documented 10 infections and 6 falls for the quarter. A QAPI Committee Meeting on 01/14/2026 documented 17 infections and 27 falls for the quarter. There was no documented evidence that the agency analyzed the data to determine the cause of increasing infections and falls. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the data for increasing infections and falls were analyzed to determine the cause. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats." A review of the QAPI Binder revealed that the agency did not ensure to analyze the causes of adverse patient events and implement preventive action and mechanisms that include feedback and learning throughout the hospice.

It is required that licensed professionals participate in hospice-sponsored in-service training. This standard was not met as evidenced by document review, interview, and personnel record review. In 10 of 10 (100%) personnel records reviewed, the agency did not ensure that the employees completed the required annual in-services as required by agency policy. DOCUMENT 4: Agency Policy, Staff Education, HR.S55, stated in part, "Non-direct personnel have a minimum of 8 hours of ongoing education per year. Direct Care Personnel must have a minimum of 12 hours of ongoing education during each 12-month period. Yearly in-service requirements include, but are not limited to: Infection Control, HIPAA, Medical Device Act/Reporting, Emergency Management/Disaster Training, Ethics, Methods for coping with work-related issues of grief, loss, and change, Compliance Plan, Patient Rights and Responsibilities, Communication Barriers and Cultural Diversity, and How to handle complaints/grievances. The Director of Nursing maintains a written description of in-service training provided during the previous 12 months." PERSONNEL RECORD 1: The Administrator/Director of Nursing/Registered Nurse/Volunteer Coordinator was hired on 05/24/2022 and completed in-service education in November 2022. There was no documented evidence that the required in-services were completed annually in 2023, 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 2: The Alternate Administrator/Alternate Director of Nursing/Registered Nurse was hired on 05/24/2022. There was no documented evidence that the required in-services were completed annually in 2023, 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 3: The Hospice Medical Director was hired on 01/03/2024. There was no documented evidence that the required in-services were completed annually in 2025 through 03/16/2026. PERSONNEL RECORD 4: The Alternate Medical Director was hired on 11/02/2022. There was no documented evidence that the required in-services were completed annually in 2023, 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 5: The Hospice Aide (CNA) was hired on 12/21/2022. There was no documented evidence that the required in-services were completed annually in 2023, 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 6: The Chaplain was hired on 07/21/2023. There was no documented evidence that the required in-services were completed annually in 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 7: The Master Social Worker/Bereavement Coordinator was hired on 05/30/2023. There was no documented evidence that the required in-services were completed annually in 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 8: The Nurse Practitioner was hired on 10/07/2024. There was no documented evidence that the required in-services were completed annually in 2025, and through 03/16/2026. PERSONNEL RECORD 9: The Registered Nurse was hired on 01/30/2023. There was no documented evidence that the required in-services were completed annually in 2024, 2025, and through 03/16/2026. PERSONNEL RECORD 10: The Volunteer was hired on 10/03/2023. There was no documented evidence that the required in-services were completed annually in 2024, 2025, and through 03/16/2026. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the employees completed the required annual in-services as required by agency policy. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats."

It is required that all hospice aides provided services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical records review, interview, document review, and observation, which revealed the hospice: Failed to ensure the agency provided at least 12 hours of in-service training during each 12-month period {HSRM.18.I/L620/ 418.76(d)}; Failed to ensure that the Hospice Aide (HA) followed the plan of care as ordered{HCDT.16.I/L626 /418.76(g)(2)(i)}; Failed to ensure that a Registered Nurse made an annual on-site visit to observe and assess the care provided by the aide{HSRM.27.D/L632 / 418.76(h)(2)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that a hospice aide receive at least 12 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. In-service training may be offered by any organization and is supervised by a registered nurse. The hospice maintains documentation that demonstrates that requirements 1 and 2, above, have been met for each aide. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel records of hospice aides reviewed revealed that the agency did not ensure to provide at least 12 hours of in-service training during each 12-month period. DOCUMENT 4: Agency Policy, Staff Education, HR.S55, stated in part, "All Hospice Aides must have a total of twelve (12) in-services annually." PERSONNEL RECORD 5: The Hospice Aide (CNA) was hired on 12/21/2022. There was no documented evidence of in-service training between 06/01/2023-03/16/2026. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the hospice aide received 12 hours of in-service training between June 2023-March 16, 2026. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats."

It is required that a hospice aide provide services ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met, as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records of patients who received Hospice Aide services reviewed revealed that the agency did not ensure that the Hospice Aide (HA) followed the plan of care as ordered. CLINICAL RECORD 2: The hospice aide plan of care dated 07/25/2024 ordered hospice aide services twice weekly with instructions to shower twice weekly. For the week of 01/21/2026-01/27/2026, two visits were completed by the hospice aide. The second visit of the week on 01/22/2026 documented that a bed bath was given. For the week of 03/08/2026-03/14/2026, two visits were completed by the hospice aide. The second visit of the week on 03/12/2026 documented that a bed bath was given. The hospice aide's plan of care did not include a bed bath as an ordered task. CLINICAL RECORD 3/HOME VISIT 2: The hospice aide plan of care dated 02/04/2025 ordered hospice aide services twice weekly with instructions to shower twice weekly. For the week of 01/04/2026-01/10/2026, two visits were completed by the hospice aide. The visits on 01/05/2026 and 01/08/2026 documented that a bed bath was given. For the week of 03/08/2026-03/14/2026, two visits were completed by the hospice aide. The visits on 03/09/2026 and 03/12/2026 documented that a bed bath was given. The hospice aide's plan of care did not include a bed bath as an ordered task. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that the hospice aide did not follow the plan of care as ordered. Additionally, the Administrator stated, "Both patients should be getting showers since that is what is ordered."

It is required that a registered nurse make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of hospice aides reviewed revealed that the agency did not ensure that a Registered Nurse made an annual on-site visit to observe and assess the care provided by the aide. PERSONNEL RECORD 5: The Hospice Aide (CNA) was hired on 12/21/2022. There was no documented evidence that a Registered Nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care in 2024, 2025, and through 03/16/2026. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that a Registered Nurse made an annual on-site visit to observe and assess the care by the hospice aide. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 7 of 10 (70%) personnel records reviewed revealed that the agency did not ensure that the competencies of all staff providing care. DOCUMENT 7: Agency Policy, Personnel Records, HR.P25, stated in part, "For direct care staff, skills competencies checklist (if 2 job descriptions signed, need competency checklist for both) upon hire and annually. PERSONNEL RECORD 1: The Administrator/Director of Nursing/Registered Nurse/Volunteer Coordinator was hired on 05/24/2022. The last Registered Nurse competency was documented on 05/24/2023. The last Volunteer Coordinator competency was documented on 05/31/2022. There was no documented evidence that competencies were completed annually. PERSONNEL RECORD 2: The Alternate Administrator/Alternate Director of Nursing/Registered Nurse was hired on 05/24/2022. The staff was hired as a Licensed Practical Nurse and completed a competency on 05/24/2022. The staff became licensed as a Registered Nurse on 08/14/2023 and signed a job description the same day. The Registered Nurse visits started on 10/25/2023. There was no documented evidence of a Registered Nurse competency assessment. PERSONNEL RECORD 3: The Hospice Medical Director was hired on 01/03/2024. There was no documented evidence of a Hospice Medical Director competency assessment. PERSONNEL RECORD 5: The Hospice Aide (CNA) was hired on 12/21/2022. The last hospice aide competency was completed on 12/23/2022. There was no documented evidence that competencies were completed annually. PERSONNEL RECORD 6: The Chaplain was hired on 07/21/2023. The last Chaplain competency was completed on 07/21/2023. There was no documented evidence that competencies were completed annually. PERSONNEL RECORD 7: The Master Social Worker/Bereavement Coordinator was hired on 05/30/2023. The last Bereavement Coordinator competency was completed on 08/30/2023. There was no documented evidence of a Social Worker competency. There was no documented evidence that competencies were completed annually. PERSONNEL RECORD 10: The Volunteer was hired on 10/03/2023. The last Volunteer competency was completed on 10/03/2023. There was no documented evidence that competencies were completed annually. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence that the competencies were completed as required by agency policy. Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats." agree

It is required that a patient's clinical record, containing past and current findings, be maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met, as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records of patients that had a live discharge revealed that the agency did not ensure that a physician's order was obtained for the discharges. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/21/2025 and was discharged due to revocation on 04/19/2025. There was no documented evidence of a physician's order to discharge the patient. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/13/2025 and was discharged due to no longer being terminally ill on 07/12/2025. There was no documented evidence of a physician's order to discharge the patient. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence of a physician's order to discharge the patients. Additionally, the Administrator stated, "We didn't put the order in, we missed it."

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 2 of 2 (100%) clinical records of patients that had a live discharge reviewed revealed that the hospice did not ensure that the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/21/2025 and was discharged due to revocation on 04/19/2025. There was no documented evidence of a discharge summary. There was no documented evidence that a discharge summary was sent to the patient's attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 02/13/2025 and was discharged due to no longer being terminally ill on 07/12/2025. There was no documented evidence of a discharge summary. There was no documented evidence that a discharge summary was sent to the patient's attending physician. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence of a discharge summary or that the discharge summaries were sent to the patient's attending physician. Additionally, the Administrator stated, "We missed these. I'm sure we notified the doctor, but nothing is documented."

It is required that the hospice obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 10 (20%) personnel records reviewed revealed that the agency did not ensure that criminal background checks were completed upon hire on all hospice employees, including contracted staff. CONTRACT 1: The Hospice Medical Director contract on 01/03/2024 required the hospice to complete a criminal background check upon hire. PERSONNEL RECORD 3: The Hospice Medical Director was hired on 01/03/2024. There was no documented evidence that hospice obtained a criminal background check prior to hire or between 01/03/2024-03/16/2026. PERSONNEL RECORD 6: The Chaplain was hired on 07/21/2023. There was no documented evidence that hospice obtained a criminal background check prior to hire or between 07/21/2023-03/16/2026. During a joint record review and interview on 03/18/2026, the Administrator (Personnel Record 1) agreed that there was no documented evidence of a criminal background check. Additionally, the Administrator stated, "We don't have one. We did one this morning, and it's pending." Additionally, the Administrator stated, "I was in the field a lot providing patient care until I hired another nurse. These administrative items fell to the wayside. I was busy with CMS audits, and a lot of paperwork didn't get done. I was wearing too many hats."

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. 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, document review and interview. 5 of 5 (100%) clinical records reviewed of patient's that died while receiving hospice services revealed the agency did not ensure the development of a bereavement plan of care (POC) that reflected the needs of the bereaved and included the types of bereavement services to be offered, and the frequency of service delivery. Agency Policy, #PC. B35, "Bereavement - Tracking and Evaluation (Dated: 2022)," stated in part, "Procedure: The Bereavement Coordinator documents the dates when each of the follow-up services, as specified in the bereaved person's plan of care, has been completed." Clinical Record 5: The patient elected the hospice benefit on 12/22/22. The patient died on 1/6/23. The clinical record did not include documented evidence of a bereavement POC for the bereaved. The clinical record did include evidence that supportive letter(s) were sent. Clinical Record 6: The patient elected the hospice benefit on 1/9/23. The patient died on 1/13/23. The clinical record did not include documented evidence of a bereavement POC for the bereaved. The clinical record did include evidence that supportive letter(s) were sent. Clinical Record 7: The patient elected the hospice benefit on 2/7/23. The patient died on 2/11/23. The clinical record did not include documented evidence of a bereavement POC for the bereaved. The clinical record did include evidence that supportive letter(s) were sent. Clinical Record 8: The patient elected the hospice benefit on 2/8/23. The patient died on 2/23/23. The clinical record did not include documented evidence of a bereavement POC for the bereaved. The clinical record did include evidence that supportive letter(s) were sent. Clinical Record 9: The patient elected the hospice benefit on 4/20/23. The patient died on 4/22/23. The clinical record did not include documented evidence of a bereavement POC for the bereaved. The clinical record did include evidence that supportive letter(s) were sent. In an interview on 5/24/23, the Administrator/Director of Nursing Services reviewed and agreed the agency did not ensure the development of a post-death bereavement POC for the bereaved.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview and observation. 2 of 2 (100%) clinical records reviewed for patients that received hospice services in a skilled nursing facility revealed the agency did not ensure that the plan of care (POC) identified which provider was responsible for performing functions agreed upon and identified in the plan of care. Agency Policy #PC.H55, "Hospice Care for Nursing Facility Residents - Plan of Care (Dated: 2022)," stated in part, "Procedure: 2. The plan of care for the facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care." Clinical Record 3: The patient elected the hospice benefit on 2/8/23. The patient was currently receiving routine hospice services in a Skilled Nursing Facility (SNF). The POC did not include documentation that specifically identified which provider was responsible for performing the functions that were agreed upon and included in the POC. Clinical Record 7: The patient elected the hospice benefit on 2/7/23. The patient had received routine hospice services in an SNF. The POC did not include documentation that specifically identified which provider was responsible for performing the functions that were agreed upon and included in the POC. Clinical Record 9: The patient elected the hospice benefit on 4/20/23. The patient received routine hospice services in an SNF. The POC did not include documentation that specifically identified which provider was responsible for performing the functions that were agreed upon and included in the POC. In an interview on 5/23/23, the Administrator/Director of Nursing Services reviewed and agreed the agency did not ensure the POC specifically identified which provider was responsible for performing the functions that were agreed upon and included in the POC.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review, interview and observation. 1 of 1 (100%) home visit of a patient currently receiving hospice services in a skilled nursing facility revealed the agency did not ensure the hospice binder included documentation of the physician certification and recertification of terminal illness. Agency Policy: #PC.H50, "Hospice Care for Nursing Facility Residents - Coordination of Services (Dated: 2022)," stated in part, "Procedure: 3. The hospice agency will provide the following information to the facility: c. Physician Certification and recertification of the terminal illness specific to each patient." Home Visit 3: The patient elected the hospice benefit on 2/8/23. The patient observation visit was completed on 5/23/23. Upon review of the hospice binder at the skilled nursing, the tab that was labeled, "CTI," did not include documented evidence of the initial Certification of Terminal Illness (CTI) and the Recertification of Terminal Illness. In an interview on 5/24/23, the Administrator/Director of Nursing Services reviewed the finding and agreed the hospice binder at the SNF for the patient above did not include a copy of the initial CTI and recertification of terminal illness.