Every finding on record at St Agatha Comfort Care, LLC

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. 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. This standard was not met as evidenced by document review and interview. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the emergency preparedness plan was tested annually as required. The agency did not participate in a full-scale exercise that was community-based exercise or conduct a mock drill of the organization's emergency plan. DOCUMENT 1: The agency's policy 4-001, titled Emergency Plan, dated July 2024, stated in part, "The hospice will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise." An interview with the Regional VP of Clinical Operations was conducted on January 29, 2026, and the information was reviewed. The agency lacked documentation demonstrating that the emergency plan had been tested. She contacted others within the corporation to determine whether any documentation supported the agency's annual testing of the emergency preparedness plan. She was unable to provide documentation and agreed with the findings. The standard was not met, as evidenced by the document review and interview. The agency did not ensure the emergency preparedness plan was tested annually as required. The agency did not participate in a full-scale exercise that was community-based exercise or conduct a mock drill of the organization's emergency plan.

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 the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure completion of the initial comprehensive assessments within five calendar days after the election of hospice care. DOCUMENT 2: The agency's policy 1-014, titled Comprehensive Assessment, dated May 2020, stated in part, "a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care." CLINICAL RECORD 4: The patient elected the hospice benefit on October 17, 2025. The initial comprehensive nursing assessment was completed on October 17, 2025. The initial psychosocial assessment was completed on November 7, 2025 (21 calendar days from the initial nursing comprehensive assessment). During the review of the clinical record, no documentation was found to determine the reason for the delayed psychosocial assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on January 9, 2026. The initial comprehensive nursing assessment was completed on January 9, 2026. The initial spiritual care assessment was completed on January 16, 2026 (8 calendar days from the initial nursing comprehensive assessment). During the review of the clinical record, no documentation was found to explain the delayed spiritual care assessment. An interview was conducted with the Regional VP of Clinical Operations on January 28, 2026, related to the clinical review and the delayed assessments. She stated that the issue was identified in August 2025, and a performance improvement project (PIP) has been developed to address the delayed assessment.

It is required that the hospice obtains 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 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure a criminal background check was obtained for a contracted employee DOCUMENT 3: The agency policy 1-005-HR, titled Selection/Hiring of Personnel, dated December 2024, stated in part, "a criminal background check will be obtained for all positions." PERSONNEL 9: The personal record revealed the contracted employee signed a contract on June 1, 2025. The record showed that a criminal background check was not conducted for the contracted employee. An interview was conducted with the Regional VP of Clinical Services on January 29, 2026. A review of the personnel record found no criminal background check before access to patient records. The personnel had provided physician orders and certification of terminal illness, and had participated in interdisciplinary group meetings over the prior seven months. She stated the background check was requested during the site visit, but agreed it was not performed prior to access to patient records.

Observed in Record Review. In 5 of 5 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific to the intervention and care needs of the patient and also did not provide timeframes and measures for goals. For example, in HSHV/RR #1, the patient was receiving treatment for constipation but there were no goals or interventions for that. During review of HSHV/RR #2 the patient is bedbound and also incontinent but no goals or interventions to reflect that issue. On review of HSRR #4, patient assessment showed moderate pain level and also had order for sleeping medications but no goals for pain management or sleep on the plan of care. On review of HSRR #5, the patient was receiving a stool softener but no goals or interventions for care related to that on the care plan. In addition during review of all five records goals for care had no time frame or element for measure, examples include: patient will have optimal level of oxygen, Pain will remain in comfortable level during care, Prevent discomfort due to increasing edema, Pain will remain in comfortable level during care.. This was reviewed with the administrator.

Observed in Record Review. in 1 of 5 records reviewed the ordered discipline and frequencies for the discipline were not on the plan of care. On review of HSRR #4, there was no ordered disciplines and visit frequencies specified on the plan of care. This was discussed with the Administrator and the agency leadership.

Observed in Patient Home. In 1 of 5 records reviewed, orders were not specific to the care provided. On review of HSHV/RR #1, it was noted that patient had oxygen and other DME that was not ordered and signed by the physician. This was discussed and reviewed with the administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, standard precautions were not used to reduce the risk of infections. Organizational policy (9-009.1) states, hand hygiene is indicated before contact with the patient. During HSHV/RR #1 the chaplain did not perform hand hygiene prior to patient contact. This was discussed with the Administrator and DPCS who were both present during the visit.

Observed in Patient Home. In 1 of 2 patients receiving aide services the hospice aide did not provide services in accordance with the aide plan of care. On review of the aide care plan for HSHV/RR #2, the surveyor noted during the home visit that the aide checked the patient's blood pressure however this task was not delegated on the aide plan of care. This was reviewed with the administrator.

Observed in HR File Review. In 1 of 6 HR files reviewed, the nurse surveyor noted that the organization had not documented an orientation with the medical director regarding policy and procedures for the organization. This was reviewed with the administrator and assistant administrator.

Observed in HR File Review. On review of the HR files, the nurse surveyor noted that the organization did not conduct an inital competency for the hospice medical director. Observed in HR File Review. The hospice agency was not able to provide documentation of a defined list of competencies it requires for the hospice physicians. On review of the medical directors HR file, the hospice was not able to provide a list of competencies required for this role. This was reviewed and validated with the administrator and assistant administrator..

Observed in Record Review. In 5 of 5 patient records reviewed, entries in the medical record were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Agency policy (5-006.2) states that documentation will be completed and turned in by end of the day and will include signature of clinician. In all five charts reviewed the surveyor noted the social work, chaplain and nursing notes were not authenticated with a signature for the document. This was reviewed and confirmed with the administrator and DPCS who were unaware this was not being done in program and were actively working with the EMR vendor while surveyor still on site to resolve the issue.

Observed in HR File Review. On review of the medical director's personnel file, there was no documentation that criminal background check was performed. Observed in Tracer Activities. On review of the agency contracts, it was noted there was no provision in the Home Medical Equipment and Therapy contracts that the contracted entity obtain criminal background checks. This was reviewed and confirmed with the Administrator.