Every finding on record at Sap Palliative and Hospice Care Inc

Based on record review and interview, the agency failed to ensure all services were provided according to the plan of care for 1 of 1 patients ( Patient #1), in that: CH A failed to visit Patient #1 as ordered by the physician on Patient #1’s plan of care. This failure places the agency’s patients at risk of not receiving care ordered by the physician. --- Findings include: Review of agency policy titled “Plan of Care Process” dated 3/16/2026, read in part,, “…Information will be gathered from the initial assessment and be used by the Hospice to develop the Initial Plan of Care…Physician’s Orders and to provide care and services to treat a patient’s and patient’s family’s immediate care and support needs… Standing orders or routine orders must be individualized to address the specific patient’s needs and signed by the patient’s physician.” Record review of Patient  #1’s plan of care dated 11/24/2025, with a service period of 11/23/2025-12/4/2025, revealed a terminal diagnosis of liver cancer with hospice services ordered of skilled nursing ordered once weekly, social worker visits ordered once monthly, chaplain visits ordered once monthly, and hospice aide services ordered five visits weekly.   Further record review of Patient #1's  clinical records revealed no chaplain visits were performed during the dates of 11/23/2025-12/4/2025.  Further record review also revealed no documented evidence of Patient #1 declining chaplain services. During an interview with CH A on 4/27/2026 at 11:00 a.m., CH A stated that he didn’t remember due to his own personal issues, but stated that he understands the importance of physician ordered visits for chaplain services for spiritual support during  a hospice patient's end of life care. During an interview with the Admin on 4/27/2026 at 12:00 p.m., the Admin acknowledged the above findings and stated the importance of providing physician ordered services for the hospice patients.

Based on record review and interview, the agency failed to adopt and enforce written policies addressing infection control in that: 1)  The agency failed to produce documentation on individualized bloodborne pathogens training annually in 2 of 6 (Admin, CH A) employees. This failure places agency staff and patients at risk of harm from bloodborne illnesses. --- Findings Include: Record review on 4/26/2026   of the OSHA regulation on the website titled,”1910.1030 - Bloodborne pathogens. | Occupational Safety and Health Administration” revealed in part ,” Annual training for all employees shall be provided within one year of their previous training...The employer shall train each employee with occupational exposure in accordance with the requirement of this section...The employer shall institute a training program and ensure employee participation in the program... Training shall be provided at the time of initial assignment to tasks where occupational exposure may take place and at least annually thereafter.”. Record review of agency policy titled “Exposure Control Plan” dated 05/12/25, read in part…” hospice responsibilities: to provide training and information related to…bloodborne pathogens for all HCP upon hire and annually thereafter.”Record review of the training records of the Admin, revealed date of hire of 12/2/2025, revealed no initial or annual exposure control individualized training documented in the record. Record review of CH A, date of hire 4/25/2022, revealed no initial or annual exposure control individualized training was documented in the training record.During a joint interview with the Admin and Alt Admin on 4/26/2026 at 12:00 PM, the Alt Admin and Admin were informed of the above findings.  The Admin and Alt Admin confirmed the CHA and Admin’ job description confirms face-to-face contact with the agency’s patients. The Alt Admin also stated he is responsible for administrating the training and that the documents of CH A’s training record retrieved by the previous owners of the agency are complete.  The Alt Admin also stated that he acknowledged the importance of the training was to prevent infection.

Upon patient record review 1 of 7 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7: The patient was admitted for hospice services on 03.17.2023; however, the chaplain did not visit the patient until 03.24.2023 to complete the spiritual care assessment.

Upon patient record review and direct observation during the home visit, 1 of 7 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The patient was admitted for hospice services after falling seriously ill while visiting her daughter from her homeland in Africa; she is a native French speaker. The EMR does not indicate the patient speaks French, is not an English speaker, requires an interpreter for communication, etc. On review of documentation from all clinicians, there was no evidence of how information was collected from the patient, given the language barrier. There has been no care plan developed to address the patient's language barrier, and no interventions to address communication needs for the patient and her daughter (caregiver). During the home visit with the patient, the patient is alert and oriented and has a translation app on her phone and the chaplain and the surveyor were able to converse with the patient using the app. (corrected onsite by updating the plan of care with the patient's language barrier and communication needs)

Upon patient record review, 1 of 7 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The patient utilizes oxygen, a walker, wheelchair, and a nebulizer for management of the terminal illness; however this DME does not appear on the plan of care. (corrected onsite)