Every finding on record at St. Margaret's Home Health and Hospice, LLC

Based on record review and interview, it was determined the agency failed to ensure the interdisciplinary group completed all initial assessments no later than 5 calendar days after the election of hospice care for 4 (Patient #1, Patient #3, Patient #7, and Patient #12) of 14 sampled patients reviewed for timely initial assessments. Findings included: --- Patient #1 Review of Patient #1s Election of Hospice Services revealed Patient #1 elected hospice services on 10/25/2024. Review of Patient #1s Initial Spiritual Assessment revealed the initial spiritual assessment was not completed until 10/31/2024, which was 6 days after Patient #1s election of hospice services. In an interview on 12/20/2024 at 1:28 PM, S1Administrator indicated the agency did have any documented evidence S22Chaplain had completed a spiritual assessment within 5 days of Patient #1s election of hospice services, or a reason as to why the assessment could not be completed timely. Patient #3 Review of Patient #3s Election of Hospice Services revealed Patient #3 elected hospice services on 10/06/2023. Review of Patient #3s Initial Psychosocial Assessment revealed the initial psychosocial assessment was not completed until 10/13/2023, which was 7 days after Patient #3s election of hospice services. In an interview on 12/20/2024 at 1:38 PM, S1Administrator indicated the agency did not have any documented evidence the social worker had completed a psychosocial assessment within 5 days of Patient #3s election of hospice services, or a reason as to why the assessment could not be completed timely. Patient #7 Review of Patient #7s Election of Hospice Services revealed Patient #7 elected hospice services on 03/08/2023. Review of Patient #7s Initial Spiritual Assessment revealed the initial spiritual assessment was not completed until 07/19/2023, which was 132 days after Patient #7s election of hospice services. In an interview on 12/20/2024 at 1:46 PM, S1Administrator indicated the agency did not have any documented evidence the chaplain had completed a spiritual assessment within 5 days of Patient #7s election of hospice services, or a reason as to why the assessment could not be completed timely. Patient #12 Review of Patient #12s Election of Hospice Services revealed Patient #12 elected hospice services on 08/02/2023. Review of Patient #12s Initial Spiritual Assessment revealed the initial spiritual assessment was not completed until 09/15/2023, which was 44 days after Patient #12 election of hospice services. Review of Patient #12s Initial Psychosocial Assessment revealed the initial psychosocial assessment was not completed until 09/21/2023, which was 50 days after Patient #12s election of hospice services. In an interview on 12/20/2024 at 2:12 PM, S1Administrator indicated the agency did not have any documented evidence the chaplain and social worker had completed a spiritual assessment and psychosocial assessment within 5 days of Patient #12s election of hospice services, or a reason as to why the assessment could not be completed timely.

Based on record review and interview, it was determined the agency failed to ensure pre-bereavement assessments were completed upon admission for 12 (Patient #1, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #11, Patient #12, Patient #13, and Patient#14) of 14 sampled patients reviewed for bereavement. Findings included: --- Review of the agencys Hospice Bereavement Services policy and procedure, with a reviewed date of 12/11/2024, revealed, in part, bereavement services included an initial bereavement assessment which began at admission. Patient #1 Review of Patient #1s record revealed Patient #1 was admitted to the agency on 10/25/2024. Further review of Patient #1s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #1 and Patient #1s caregivers upon admission. Patient #3 Review of Patient #3s record revealed Patient #3 was admitted to the agency on 10/06/2023. Further review of Patient #3s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #3 and Patient #3s caregivers upon admission. Patient #4 Review of Patient #4s record revealed Patient #4 was admitted to the agency on 11/26/2024. Further review of Patient #4s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #4 and Patient #4s caregivers upon admission. Patient #5 Review of Patient #5s record revealed Patient #5 was admitted to the agency on 04/11/2024. Further review of Patient #5s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #5 and Patient #5s caregivers upon admission. Patient #6 Review of Patient #6s record revealed Patient #6 was admitted to the agency on 11/26/2024. Further review of Patient #6s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #6 and Patient #6s caregivers upon admission. Patient #7 Review of Patient #7s record revealed Patient #7 was admitted to the agency on 03/08/2023. Further review of Patient #7s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #7 and Patient #7s caregivers upon admission. Patient #8 Review of Patient #8s record revealed Patient #8 was admitted to the agency on 06/23/2023. Further review of Patient #8s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #8 and Patient #8s caregivers upon admission. Patient #9 Review of Patient #9s record revealed Patient #9 was admitted to the agency on 11/26/2024. Further review of Patient #9s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #9 and Patient #9s caregivers upon admission. Patient #11 Review of Patient #11s record revealed Patient #11 was admitted to the agency on 05/20/2023. Further review of Patient #11s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #11 and Patient #11s caregivers upon admission. Patient #12 Review of Patient #12s record revealed Patient #12 was admitted to the agency on 08/02/2023. Further review of Patient #12s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #12 and Patient #12s caregivers upon admission. Patient #13 Review of Patient #13s record revealed Patient #13 was admitted to the agency on 01/17/2024. Further review of Patient #13s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #13 and Patient #13s caregivers upon admission. Patient #14 Review of Patient #14s record revealed Patient #14 was admitted to the agency on 11/14/2023. Further review of Patient #14s record revealed no documented evidence, and the agency presented no documented evidence, a pre-bereavement assessment was completed with Patient #14 and Patient #14s caregivers upon admission. In an interview on 12/20/2024 at 2:34 PM, S1Administrator indicated the agency had no documented evidence the above mentioned patients had initial bereavement assessments completed with the patients and caregivers upon admission to the agency as required.

Based on record reviews and interview, it was determined the agency failed to have evidence of following-up on a patients increased agitation for 1 (Patient #9) of 14 sampled patients reviewed for the coordination of services. Findings included: --- Review of Patient #9s Hospice Plan of Care for the certification period of 11/26/2024 through 02/23/2025 revealed, Patient #9 was admitted for a diagnosis of, in part, Malignant Neoplasm of the Colon (colon cancer). Review of Patient #9s Social Worker Visit note dated 12/14/2024 revealed, in part, S3Medical Social Worker (MSW) observed agitated behavior as evidenced by Patient #9 pulling at his feeding tube, his clothing, and was removing his gown. Further review of Patient #9s Social Worker Visit note revealed S3MSW notified S2Director of Nursing (DON). In an interview on 12/20/2024 at 1:57 PM, S2DON indicated she had received the phone call from S3MSW regarding Patient #9 being irritable, and the facility nurse had administered medication. S2DON further indicated the agency had no documented evidence that the agency had ensured the medication was effective, and/or that a nurse had followed-up since 12/14/2024, to determine if Patient #9s agitation had been resolved or required further intervention.

Based on record review and interview, it was determined the agency failed to ensure patients received hospice aide services in accordance with the plan of care for 2 (Patient #10 and Patient #12) of 14 sampled patients reviewed for care and services per the plan of care. Findings included: --- Patient #10 Review of Patient #10s Hospice Plan of Care for the certification period of 09/11/2024 through 12/09/2024 revealed Patient #10 was to receive hospice aide services three times a week. Review of Patient #10s record revealed the only hospice aide visits completed the week of 11/24/2024 through 11/30/2024 were completed on 11/27/2024 and 11/29/2024. In an interview on 12/202/2024 at 2:06 PM, S1Administrator indicated the agency had no documented evidence Patient #10 had a third hospice aide visit completed the week of 11/24/2024 through 11/30/2024 as required. Patient #12 Review of Patient #12s Hospice Plan of Care for the certification period of 03/29/2024 through 05/27/2024 revealed Patient #12 was to receive hospice aide services two times a week. Review of Patient #12s record revealed the only hospice aide visit completed the week of 05/19/2024 through 05/25/2024 was completed on 05/21/2024. In an interview on 12/202/2024 at 2:12 PM, S1Administrator indicated the agency had no documented evidence Patient #12 had a second hospice aide visit completed the week of 05/19/2024 through 05/25/2024 as required.

Based on record review and interview, it was determined the agency failed to ensure the skilled nurse measured the patients wounds weekly to monitor wound healing for 1 (Patient #12) of 4 sampled patients with wounds reviewed for weekly wound care measurements. Findings included: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; and, evidence of infection in surrounding tissues. Further review revealed when recorded over time this information could be used to track the progress of wound healing. Review of Patient #12s Updated Comprehensive Patient Plan of Care for the certification period of 03/29/2024 through 05/27/2024 revealed, in part, Patient #12 had a stage I pressure ulcer (wound characterized by the skin being red and does not turn white when compressed, caused by prolonged pressure) of the sacrum with a start date of 11/09/2023. Review of Patient #12s record revealed no documented evidence, and the agency presented no documented evidence, the skilled nurse had assessed the measurements of Patient #12s stage I sacral wound for the weeks of, in part: 03/24/2024 through 03/30/2024; 03/31/2024 through 04/06/2024; 04/07/2024 through 04/13/2024; and, 04/14/2024 through 04/20/2024. In an interview on 12/20/2024 at 2:12 PM, S1Administator indicated the agency was not aware the skilled nurses were required to measure stage I pressure ulcers.

Based on record review and interview, it was determined the agency failed to ensure an on-site visit was conducted by a registered nurse (RN) no less frequently than every 14 days to assess the hospice aide for 5 (Patient #1, Patient #10, Patient #11, Patient #12, Patient #14) of 11 sampled patients with hospice aide services reviewed for supervisory visits. Findings included: --- Review of the agencys policy and procedure on Supervision of Hospice Aide and Licensed Practical Nurse, with a review date of 12/11/2024, revealed, in part, a supervisory visit was to be conducted every fourteen days with or without the aide being present in the home. Patient #1 Review of Patient #1s Hospice Plan of Care for the certification period of 10/25/2024 through 01/22/2025 revealed, in part, Patient #1 was to receive hospice aide services twice a week. Review of Patient #1s record revealed Patient #1 had a registered nurse hospice aide supervisory completed, in part: -10/30/2024 and 11/24/2024, which was 15 days after the last supervisory visit; and, -11/26/2024 and 12/12/2024, which was 16 days after the last supervisory visit. In an interview on 12/20/2024 at 1:28PM, S1Administrator indicated the agency had no documented evidence of hospice aide supervisory visits conducted by the registered nurse for the above mentioned timeframes as required. Patient #10 Review of Patient #10s Hospice Plan of Care for the certification period of 09/11/2024 through 12/09/2024 revealed, in part, Patient #10 was to receive hospice aide services three times a week. Review of Patient #10s record revealed Patient #10 had a registered nurse hospice aide supervisory visit completed on 09/16/2024 and 10/02/2024, which was 16 days after the last supervisory visit. In an interview on 12/20/2024 at 2:06 PM, S1Administrator indicated the agency had no documented evidence the hospice aide supervisory visit was conducted by the registered nurse for the above mentioned timeframe as required. Patient #11 Review of Patient #11s Hospice Plan of Care for the certification period of 03/15/2024 through 04/23/2024 revealed, in part, Patient #11 was to receive hospice aide services two times a week. Review of Patient #11s record revealed Patient #11 had a registered nurse hospice aide supervisory visit completed on 03/18/2024 and 04/03/2024, which was 16 days after the last supervisory visit. In an interview on 12/20/2024 at 2:11 PM, S1Administrator indicated the agency had no documented evidence the hospice aide supervisory visit was conducted by the registered nurse for the above mentioned timeframe as required. Patient #12 Review of Patient #12s Hospice Plan of Care for the certification period of 03/29/2024 through 05/27/2024 revealed, in part, Patient #12 was to receive hospice aide services two times a week. Review of Patient #12s record revealed Patient #12 had a registered nurse hospice aide supervisory visit completed on 04/30/2024. Further review revealed no documented evidence, and the agency presented no documented evidence, a registered nurse hospice aide supervisory visit was completed from 04/30/2024 through 05/27/2024, which was 27 days after the last supervisory visit, when Patient #12 revoked hospice services. In an interview on 12/20/2024 at 2:12 PM, S1Administrator indicated the agency had no documented evidence the hospice aide supervisory visit was conducted by the registered nurse for the above mentioned timeframe as required. Patient #14 Review of Patient #14s Hospice Plan of Care for the certification period of 11/14/2023 through 02/07/2024 revealed, in part, Patient #14 was to receive hospice aide services two times a week. Review of Patient #14s record revealed Patient #14 had a registered nurse hospice aide supervisory visit completed on 12/11/2023 and 12/27/2023, which was 16 days after the last hospice aide supervisory visit. In an interview on 12/20/2024 at 2:34 PM, S1Administrator indicated the agency had no documented evidence the hospice aide supervisory visit was conducted by the registered nurse for the above mentioned timeframe as required.

Based on record review and interview, it was determined the agency failed to provide volunteer orientation for 16 (S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer) of 17 volunteers reviewed for orientation. Findings included: --- Review of the agencys volunteer documentation for January 2023 through December 2024 revealed S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer had provided direct patient care and/or had access to patient records for the above mentioned time period. There was no documented evidence, and the agency presented no documented evidence, S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer had orientation completed prior to direct patient care and/or access to patient records. In an interview on 12/20/2024 at 1:06 PM, S1Administrator indicated the agency did not have documented orientation for the above mentioned volunteers as required.

Based on record review and interview, it was determined the agency failed to documented efforts to recruit and retain volunteers. Findings included: --- There was no documented evidence, and the agency presented no documented evidence, that the agency documented efforts to recruit and retain volunteers. In an interview on 12/20/2024 at 1:06 PM, S1Administrator indicated the agency did not have evidence of recruitment and retention of volunteers as required.

Based on record review and interview, it was determined the agency failed to ensure the agency volunteers provided day-to-day administrative and/or direct patient care services that, at a minimum, equaled five percent of the total patient care hours of all paid hospice employees. Findings included: --- Review of the agencys Volunteer Recap for 2023 revealed no documented evidence, and the agency presented no documented evidence, any volunteer hours were provided January 2023 through May 2023. Further review revealed no documented evidence, and the agency presented no documented evidence, the amount of paid patient care hours had been calculated to determine the level of activity from January 2023 through December 2023. Review of the agencys Volunteer Recap for 2024 revealed no documented evidence, and the agency presented no documented evidence, any volunteer hours were provided May 2024 through September 2024, nor any documented evidence the amount of paid patient care hours for May 2024 through September 2024 had been calculated to determine if the level of activity was five percent or greater. In an interview on 12/20/2024 at 1:06 PM, S1Administrator indicated the agency had no documented evidence of the above mentioned findings, therefore the agency had no evidence the amount of administrative and/or direct patient care services provided by volunteers was, at a minimum, equal to five percent of the total patient care hours of all paid hospice employees.

Based on record review and interview, it was determined the agency failed to ensure supervised volunteers who had direct patient contact and access to patient records had a criminal background check completed for 16 (S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer) of 17 sampled volunteers reviewed for criminal background checks. Findings included: --- Review of the agencys supervised volunteer documentation for January 2023 through December 2024 revealed S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer had either provided direct patient care or access to patient records for the above mentioned time period. There was no documented evidence, and the agency presented no documented evidence, S5Volunteer, S6Volunteer, S7Volunteer, S8Volunteer, S9Volunteer, S10Volunteer, S11Volunteer, S12Volunteer, S13Volunteer, S14Volunteer, S15Volunteer, S16Volunteer, S17Volunteer, S18Volunteer, S19Volunteer, and S20Volunteer had criminal background checks completed prior to direct patient care or access to patient records. In an interview on 12/20/2024 at 1:06 PM, S1Administrator indicated the agency did not have criminal background checks for the above mentioned supervised volunteers as required.

Based on record review and interview, it was determined the agency failed to obtain a criminal background check for all states a licensed person had lived or worked in the last three years for 2 (S3Medical Social Worker [MSW] and S4Medical Director) of 6 licensed personnel reviewed for criminal background check requirements. Findings included: --- Review of S3MSWs personnel file revealed a hire date of 09/03/2023. Review of S3MSWs Criminal Background Search Authorization Form dated 08/29/2023 revealed S3MSW lived in Georgia from July 2018 through May 2022, and lived in South Carolina from May 2022 through June 2023. Review of S3MSWs Criminal Background Check and National Sexual Offender Public Registry Check completed on 09/22/2023 revealed, in part, the criminal background check was only completed for Louisiana State Police records. There was no documented evidence, and the agency presented no documented evidence, a criminal background check for S3MSW had been completed for Georgia and South Carolina. Review of S4Medical Directors personnel file revealed a hire date of 05/05/2022. Further review revealed no documented evidence, and the agency presented no documented evidence, a criminal background check was completed on S4Medical Director. In an interview on 12/19/2024 at 3:15 PM, S1Administrator indicated a criminal background check was not completed for S3MSW for the states of Georgia and South Carolina, and the agency did not have documented evidence a criminal background check was completed for S4Medical Director. Review of S3MSWs personnel file revealed a hire date of 09/03/2023. Review of S3MSWs Criminal Background Search Authorization Form dated 08/29/2023 revealed S3MSW lived in Georgia from July 2018 through May 2022, and lived in South Carolina from May 2022 through June 2023. Review of S3MSWs Criminal Background Check and National Sexual Offender Public Registry Check completed on 09/22/2023 revealed, in part, the criminal background check was only completed for Louisiana State Police records. There was no documented evidence, and the agency presented no documented evidence, a criminal background check for S3MSW had been completed for Georgia and South Carolina. Review of S4Medical Directors personnel file revealed a hire date of 05/05/2022. Further review revealed no documented evidence, and the agency presented no documented evidence, a criminal background check was completed on S4Medical Director. In an interview on 12/19/2024 at 3:15 PM, S1Administrator indicated a criminal background check was not completed for S3MSW for the states of Georgia and South Carolina, and the agency did not have documented evidence a criminal background check was completed for S4Medical Director.

Based on record review and interview the agency failed to have an emergency preparedness plan which included policy and procedures which included the process for use of volunteers and State and Federally designated health care professional to address surge needs during an emergency. Findings: Review of the agency's Emergency Preparedness Plan revealed no documented evidence of a policy and procedure which addressed the use of volunteers and/or State and Federal designated staff to address surge needs during an emergency. In an interview on 04/14/2022 at 4:15pm, S2Alterante Administrator/Alternate DON (Director of Nursing) and S3Office Manager stated the agency did not have an emergency policy and procedure which included the use of volunteers and/or State and Federal designated staff to address surges during an emergency.

Based on record review and interview the agency failed to ensure all members of the interdisciplinary group completed the assessments within 5 calendar days of election of services for 3 of 13 sampled patients (Patient #6, Patient #10, and Patient #12) reviewed for assessments within 5 days of election of services. Findings: Patient #6 Review of Patient #6's Comprehensive Patient Plan of Care revealed Patient #6 was admitted to the agency and elected services on 02/13/2022. Review of Patient #6's record revealed the chaplain did not assess Patient #6 until 02/23/2022, which was 10 calendar days after the election of services. In an interview on 04/14/2022 at 3:35pm, S3Office Manager stated the agency did not have any documented evidence for the reason why the chaplain had not performed the spiritual assessment within 5 calendar days of election of services. Patient #10 Review of Patient #10's Comprehensive Patient Plan of Care revealed Patient #10 was admitted to the agency and elected services on 01/14/2022. Review of Patient #10's record revealed the chaplain did not assess Patient #10 until 02/03/2022, which was 20 calendar days after the election of services. In an interview on 04/14/2022 at 3:49pm, S1Administrator/DON (Director of Nursing) and S3Office Manager stated the agency had no documented evidence as to the reason why the chaplain did not provide services within 5 calendar days of the election of services. Patient #12 Review of Patient #12's Comprehensive Patient Plan of Care revealed Patient #12 admitted to the agency and elected services on 03/29/2021. Review of Patient #12's record revealed no documented evidence of the registered nurse's admission assessment within 5 days of election of services. In an interview on 04/14/2022 at 4:05pm, S1Administrator/DON and S3Office Manager stated the agency had no documented evidence of a registered nurse upon admission or within 5 days of election of services.

Based on record review and interview the agency failed to ensure the hospice aide and chaplain provided services per the frequencies on the plans of care for 4 of 11 sampled patients (Patient #2, Patient #8, Patient #9, and Patient #11) reviewed for care and services in a total sample of 13. Findings: Patient #2 Review of Patient #2's Updated Comprehensive Patient Plan of Care for certification period of 02/14/2022 to 04/14/2022 revealed Patient #2 was to receive hospice aide services twice a week. Review of Patient #2's record revealed on the week of 02/27/2022 to 03/05/2022 Patient #2 only received hospice aide services on 03/04/2022; and on the week of 03/27/2022 to 04/02/2022 Patient #2 only received hospice aide services on 03/27/2022. In an interview on 04/14/2022 at 3:25pm, S1Administator/DON (Director of Nursing) and S3Office Manager stated the agency had no documented evidence of a second hospice aide visit having been conducted the weeks of 02/27/2022 to 03/05/2022 and 03/27/2022 to 04/02/2022. Patient #8 Review of Patient #8's Updated Comprehensive Patient Plan of Care for certification period of 02/24/2022 to 05/24/2022 revealed Patient #8 was to receive chaplain services once a month. Review of Patient #8's record revealed no documented evidence and the agency presented no documented evidence of the chaplain having provided services for the month of March 2022. In an interview on 04/14/2022 at 3:40pm, S1Administrator/DON and S3Office Manager stated the agency had no documented evidence of chaplain services for March 2022. Patient #9 Review of Patient #9's Updated Comprehensive Patient Plan of Care for certification period of 01/16/2022 to 04/15/2022 revealed Patient #9 was to receive chaplain services once a month. Review of Patient #9's record revealed no documented evidence and the agency presented no documented evidence of the chaplain having provided services for the month of January 2022. In an interview on 04/14/2022 at 3:48pm, S1Administrator/DON and S3Office Manager stated the agency had no documented evidence of chaplain services for January 2022. Patient #11 Review of Patient #11's Updated Comprehensive Patient Plan of Care for certification period of 01/31/2022 to 03/31/2022 revealed Patient #11 was to receive chaplain services once a month. Review of Patient #11's record revealed no documented evidence and the agency presented no documented evidence of the chaplain having provided services for the month of January 2022. In an interview on 04/14/2022 at 3:56pm, S1Administrator/DON and S3Office Manager stated the agency had no documented evidence of chaplain services for January 2022.

Based on record review and interview the agency failed to ensure a patient had an initial Certification of Terminal Illness (CTI) prior to receiving services for 1 of 13 sampled patients (Patient #13) reviewed for Certifications of Terminal Illness. Findings: Review of Patient #13's record revealed Patient #13 was admitted to the agency on 04/20/2021. Further review revealed no documented evidence, and the agency was unable to present any documented evidence of Patient #13 having had the attending physician and/or the medical director complete a CTI, which was a certification of a terminal diagnosis with a life expectancy of six months or less. In an interview on 04/14/2022 at 4:02pm, S1Administrator/DON (Director of Nursing) and S3Office Manager stated the agency was unable to provide any documented evidence of Patient #13's CTI having been completed.