Every finding on record at Trinity Hospice, LLC

Based on personnel file review and staff interview, the agency failed to implement an Emergency Preparedness (EP) training program for new employee orientation for two of two Volunteer’s (Volunteer #1 and #2), out of a total of 7 personnel files reviewed. Findings include: --- Review of the personnel files indicated the following:1.  Volunteer #1 had a hire date of 3/27/2025.  Review of the Volunteer Orientation Checklist indicated that Emergency Preparedness was not included in the orientation.2.   Volunteer #2 had a hire date of 5/5/2025.  Review of the Volunteer Orientation Checklist indicated that Emergency Preparedness was not included in the orientation.During an interview on 11/12/2025 at 1:00 P.M. the Director of Volunteer Services said she was unaware that the EP training was to be included as a topic for new volunteer orientation.During an interview on 11/12/2025 at 2:00 P.M. the Administrator and the Director of Volunteer Services said the new volunteer orientation should include Emergency Preparedness training but did not.

Based on record review and interview, the agency staff failed to conduct an initial Bereavement Assessment of the needs of the patient's family that may potentially impact their ability to cope with the patient's death for 3 patients (#10, #16, and #19), out of a total sample of 19 patients.Findings include: --- Review of the agency policy entitled, Bereavement Services, revised November 2024, indicated the following:*A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.*After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed. 1. Patient #10 was admitted to the agency in September 2025 with a diagnosis of Alzheimer’s disease.Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.2. Patient #16 was admitted to the agency in July 2025 with a diagnosis of moderate protein-calorie malnutrition.Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.3. Patient #19 was admitted to the agency in October 2025 with a diagnosis of cerebrovascular disease (variety of medical conditions that affect the blood vessels of the brain and cerebral circulation).Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 4:17 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.

Based on record review, policy review and interview, the agency failed to ensure all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 5 patients (#2, #10, #1, #4, and #9), out of a total sample of 19 patients.Findings include: --- 3.Patient #1 was admitted to the agency in August 2025 with a diagnosis of End Stage Renal Disease and required hospice services.Review of the clinical record included a physician ordered Hospice POC, dated 8/15/25 through 11/11/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.4.Patient #4 was admitted to the agency in August 2025 with a diagnosis of Parkinson’s Disease without Dyskinesia and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care POC, dated 8/15/25 through 11/12/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.5.Patient #9 was admitted to the agency in August 2025 with a diagnosis of Malignant Neoplasm of Prostate and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care POC, dated 8/11/25 through 11/8/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director said the POC should have been signed by the physician within the required timeframe of 30 days for Patients #2, #10, #1, #4, and #9.    Review of the agency's policy entitled Verification of Physician Orders, revised November 2024, indicated but was not limited to the following:-Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.1.Patient #2 was admitted to the agency in August 2025 with a diagnosis of Alzheimer’s disease and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care (POC), dated 8/15/25 through 11/12/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.2.Patient #10 was transferred/admitted to the agency in September 2025 with a diagnosis of Alzheimer’s disease and required hospice services.Review of the clinical record included a physician ordered Hospice POC, dated 8/1/25 through 9/29/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.

Based on document review and interview, the Agency failed to ensure initial training in Emergency Preparedness (EP) policies and procedures was provided to all new staff. Findings include: --- Review of the Agency's Emergency Operations Plan (EOP) Training Program policy, updated 1/18/23, indicated, but not limited to, the following: -Hospice will provide initial training in EP policies and procedures to all new and existing staff. Review of the Agency's list of new hires since the date of the last recertification survey (10/14/20) and the online in-service training program, indicated that 14 of the 14 employees did not receive EP training during their orientation. During an interview on 5/30/23 at 11:15 A.M., the Chief Executive Officer (CEO) said the Agency identified that new employees had not been provided education and training on the EP policies and procedures during orientation, as required.

Based on record review and interview, the Agency failed to ensure its staff completed an initial Bereavement Assessment upon admission for one Patient (#8), out of a total sample of 13 Patients. Findings include: --- Review of the Bereavement-Risk Assessment Policy, dated 6/1/16, included, but not limited to: -During the comprehensive assessment of the patient, information is obtained related to anticipated bereavement needs of the patient's family, caregivers and significant others. Patient #8 was admitted to the Agency in November 2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of a Start of Care Visit Note, dated 11/15/22, indicated for Bereavement-Bereavement Status, a Risk Assessment was not completed. During an interview on 6/2/23 at 1:15 P.M. after reviewing the clinical record, the Clinical Director said an initial Bereavement Risk Assessment was not completed, as required.

Based on record review and interview, the Agency failed to ensure the required staff members attended two Interdisciplinary Group (IDG-a chance for an interdisciplinary group to meet and discuss a patient's plan of care and properly negotiate involvement from the patient themselves, their family and various caregivers) meetings for one Patient (#9), out of a total sample of 14 Patients. Findings include: --- Review of the Interdisciplinary Group Policy, dated 6/1/16, included, but not limited to: -The IDG at Trinity Hospice includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy b. a registered nurse c. a Social Worker d. a pastoral or other counselor Patient #9 was admitted to the Agency in January 2022 with a diagnosis of Malnutrition. Review of the clinical record indicated an IDG meeting was held on 5/25/22. Review of the attendance sheet indicated no signature for the Chaplain and Medical Social Worker (MSW). Review of the clinical record indicated an IDG meeting was held on 6/8/22. Review of the attendance sheet indicated no signature for the Chaplain. During an interview on 6/2/23 at 1:10 P.M. after reviewing the clinical record, the Clinical Director said there was no documentation found to indicate the Chaplain and the MSW attended the 6/8/22 IDG meeting, as required. She further siad there was no documentation found to indicate the Chaplain attended the 6/10/22 IDG meeting, as required.

Based on record review and interview, the Agency failed to ensure its staff provided the care and services in accordance with the plan of care for 11 Patients (#5, #8, #9, #11, #13, #1, #2, #3, #7, #10, and #12), out of a total sample of 14 Patients. Findings include: --- ***Patient #1 was admitted in April 2023 with a terminal diagnosis of Severe Protein and Calorie Malnutrition (refers to deficiencies, excesses or imbalance in a person's intake of nutrients). Review of the Physician's orders for certification period 4/11/23 through 6/9/23, indicated the following: -Home Health Aide Visit (HHAV) five times a week for eight weeks. -Volunteer Visit (VV) two to four times a month for two months. Review of the clinical record indicated the Patient was provided only two HHAVs during the week of 4/16/23 to 4/22/23. Further review of the record indicated Missed HHAV notes on 4/20/23, 4/21/23 and 4/22/23. The notes did not indicate an alternate Home Health Aide (HHA) was offered or provided for the Patient. Review of a Missed VV note dated 4/17/23, indicated the Patient did not receive the VV, and did not indicate an alternate Volunteer was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 4/24/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or Review of a Missed VV note dated 4/26/23, indicated the Patient did not receive a VV, and did not indicate an alternate Volunteer was offered or provided for the Patient. provided for the Patient. Review of a Missed VV note dated 4/26/23, indicated the Patient did not receive the VV, and did not indicate an alternate Volunteer was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 5/29/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. ****Patient #2 was admitted to the Agency in March 2022 with a diagnosis of Malignant Neoplasm (cancer) of the Head, Face and Neck. Review of the Physician's orders for certification period 5/7/23 through 7/5/23, indicated the following: -VV two to four times a month for two months. Review of a Missed VV note dated 5/9/23, indicated the Patient did not receive the VV, and did not indicate an alternate Volunteer was offered or provided for the Patient. Review of a Missed VV note dated 5/26/23, indicated the Patient did not receive the VV, and did not indicate an alternate Volunteer was offered or provided for the Patient. ****Patient #3 was admitted to the Agency in February 2023 with a diagnosis of Hemiplegia (paralysis of one side of the body) Following A Cerebral Infarction (stroke). a. Review of the Physician's orders for certification period 2/11/23 through 5/11/23, indicated the following: -HHAV five times a week for 13 weeks. Review of a HHA Missed Visit note, dated 3/9/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of the clinical record indicated the Patient received three HHAVs during the week of 3/12/23 to 3/18/23. Further review of the record indicated HHA Missed Visit notes, dated 3/17/23 and 3/18/23, indicated the Patient did not receive the HHAVs and did not indicate an alternate HHA was offered or provided for the Patient on either day. Review of record indicated the Patient received two HHAVs during the week of 4/16/23 to 4/22/23. Further review of the record indicated HHA Missed Visit notes, dated 4/20/23, 4/21/23 and 4/22/23, indicated the Patient did not receive the HHAVs and did not indicate an alternate HHA was offered or provided for the Patient on any of the three days. b. Review of the Physician's orders for certification period 5/12/23 through 8/9/23, indicated the following: -Effective 5/12/23 to 7/1/23, HHAV five times a week for eight weeks. Review of a HHA Missed Visit note, dated 5/12/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 5/16/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 5/26/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. ****Patient #7 was admitted to the Agency in January 2023 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and Congestive Heart Failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). Review of the Physician's orders for certification period 1/16/23 through 4/15/23, indicated the following: -Effective 1/23/23 to 4/15/23, HHAV three times a week for 12 weeks. Review of a HHA Missed Visit note, dated 1/27/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 4//3/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. *****Patient #10 was admitted to the Agency in August 2022 with a diagnosis of Chronic Systolic Heart Failure (a problem with how the left ventricle pumps blood to the rest of the body). a. Review of the Physician's order for certification period 11/3/22 through 1/31/23, indicated the following: -Skilled Nursing Visit (SNV) once a week for 13 weeks. -Three As Needed (PRN) SNVs. -Effective 11/6/22 to 1/28/23, HHAV five times a week. Review of a HHA Missed Visit note, dated 11/24/22, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a SNV Missed Visit note, dated 11/25/22, indicated the Patient did not receive the SNV and did not indicate an alternate Skilled Nurse (SN) was offered or provided for the Patient. Review of a SNV Missed Visit note, dated 12/22/22, indicated the Patient did not receive the SNV and did not indicate an alternate SN was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 12/26/22, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 1/2/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 1/3/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. b. Review of the Physician's order for certification period 2/1/23 through 4/1/23, indicated the following: -Skilled Nursing Visit (SNV) once a week for nine weeks. -Three PRN SNVs. -Effective 2/5/23 to 4/1/23, HHAV five times a week. Review of a HHA Missed Visit note, dated 2/7/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 2/23/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 2/28/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 3/14/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 3/17/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. *****Patient #12 was admitted to the Agency in August 2022 with diagnoses of Alzheimer's Disease (senile dementia) and Abnormal Weight Loss. a. Review of the Physician's orders for certification period 2/10/23 through 4/10/23, indicated the following: -SNV once a week for 9 weeks. -Three PRN SNVs. -Effective 2/10/23 to 2/11/23, one HHAV for one week. Review of a HHA Missed Visit note, dated 2/10/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a SNV Missed Visit note, dated 2/10/23, indicated the Patient did not receive the SNV and did not indicate an alternate SN was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 3/5/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. b. Review of the Physician's orders for certification period 4/11/23 to 6/9/23, indicated the following: -SNV once a week for nine weeks. -Three PRN SNVs. -HHAV five times a week for nine weeks. Review of a HHA Missed Visit note, dated 4/11/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 4/14/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 4/20/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. Review of a HHA Missed Visit note, dated 5/16/23, indicated the Patient did not receive the HHAV and did not indicate an alternate HHA was offered or provided for the Patient. During an interview on 6/6/23 at 3:45 P.M., after reviewing the clinical records of Patients #1, #2, #3, #7, #10 and #12, the Chief Executive Officer (CEO) and Clinical Manager said the visits (SNVs, HHAVs, VVs) had not been followed and services provided as ordered. The Clinical Manager said that other staff could have provided the visits, but the documentation did not indicate why it was not offered as an option. Review of the facility Policy titled, Plan of Care, dated 6/1/16, incuded, but not limited to: -Hospice care and services provided to patients and their familiies are in accordance with an individualized, written plan of care established by the hospice Interdisciplinary Group (IDG) in collaborationn with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver. 1. Patient #5 was admitted to the Agency in July 2022 with a diagnosis of Cerebral Atherosclerosis (a build up of plague in the blood vessels in the brain). Review of the Physician order for the certification period 3/12/23 through 5/10/23 indicated the following: -Home Health Aide Visit (HHAV), three times a week for eight weeks, beginning 3/13/23. Review of the clinical record indicated a HHAV was missed on 3/13/23. Further review of the clinical record indicated only two HHAVs occurred for the week of 3/12/23 to 3/18/23. There was no evidence an alternate HHAV was offered or provided to the Patient. Review of the clinical record indicated a HHAV was missed on 4/27/23 due to the HHA being ill. Further review of the clinical record indicated only two HHAVs occurred for the week of 4/23/23 to 4/29/23. There was no evidence an alternate HHAV was offered or provided to the Patient. 2. Patient #8 was admitted to the Agency in November 2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow amd make it difficult to breathe). a. Review of the Physician's orders for certification period 11/15/22 through 2/12/23 indicated the following; -SNV, two times a week for 14 weeks. -SNV, four times, PRN. -HHAV, one time a week for 13 weeks. Review of a missed HHAV note on 11/23/22 indicated a visit was declined by the Patient. There was no evidence an alternate HHAV was offered or provided to the Patient. Review of a missed SNV note on 11/25/22 indicated a visit was declined by the Patient. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed SNV note on 12/2/22 indicated only a phone call was made to the Patient. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed HHA note on 12/7/22 indicated a visit was declined by the Patient. There was no evidence an alternate HHA was offered or provided to the Patient. Review of a missed SNV note on 12/9/22 indicated the visit was not made due to all needs met. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed SNV note on 12/22/22 indicated the Patient declined a visit. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed SNV note on 12/30/22 indicated the visit was declined by the Patient. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed SNV note on 1/5/23 indicated the visit was declined by the Patient. There was no evidence an alternate SNV was offered or provided to the Patient. Review of a missed SNV note on 2/12/23 indicated a visit was not made. There was no evidence an alternate SNV was offered or provided to the Patient. b. Review of the Physician's orders for the certification period 2/13/23 through 5/13/23 indicated the following: -SNV, once a week for 13 weeks. -SNV, three times PRN. Review of a missed SNV note on 2/23/23 indicated a visit was refused by the Patient. There was no evidence an alternate SNV was offered or provided to the Patient. 3. Patient #9 was admitted to the Agency in January 2022 with a diagnosis of Malnutrition. Review of the Physician's orders for certification period 5/19/22 through 7/17/22 indicated the following: -HHAV, two times a week for one week. -HHAV, three to five times a week for eight weeks. Review of the clinical record indicated missed HHAVs for 5/30/22, 6/15/22, 7/1/22 and 7/9/22. There was no evidence alternate HHAVs were offered or provided to the Patient. 4. Patient #11 was admitted to the Agency in May 2022 with a diagnosis of Malignant Neoplasm (Cancer) of the Vulva (outer part of the female reproductive system). Review of the Physician's orders for certification period 5/2/22 through 7/30/22 indicated the following: -SNV, one to two times a week for 12 weeks. -SNV, six times PRN. -HHAV, three to five times a week for 12 weeks. -MSW, two visits a month for one month. Review of the clinical record indicated a missed MSW visit on 5/6/22. There was only one MSW visit for May and not the two, as ordered. There was no evidence an alternate MSW visit was offered or provided to the Patient. Review of the clinical record indicated a missed HHAV on 5/27/22. There was no evidence an alternate HHA was offered or provided to the Patient. Review of the clinical record indicated a missed SNV on 5/27/22 due to all needs met, no visit needed. There was no evidence an alternate SNV was offered or provided to the Patient. Review of the clinical record indicated a missed HHAV on 5/30/33, 6/18/22 and 7/4/22. There was no evidence an alternate HHAV was offered or provided to the Patient for the missed HHAVs. Review of the clinical record indicated a missed SNV on 6/23/22. There was no evidence an alternate SNV was offered or provided to the Patient. Review of the clinical record indicated a missed SNV on 7/8/22 due to current Plan of Care being effective. There was no evidence an alternate SNV was offered or provided to the Patient. During an interview on 6/6/23 at 2:10 P.M., the Clinical Manager said for the listed missed visits for Patients #5, #8, #9 and #11, there was no evidence found that an alternate visit was offered or provided, as required. 5. Patient #13 was admitted to the Agency in April 2023 with a diagnosis of Cerebral Atherosclerosis. Review of a Physician order for certification period 5/1/23 through 6/29/23 indicated for Oxygen via nasal cannula (a device used to deliver supplemental oxygen), administer at 2 liters per minute (LPM-the flow rate of oxygen), inhaled continous flow. During an observation of a home visit with a Skilled Nurse (SN) on 6/2/23 at 9:00 A.M., Patient #13 was sitting upright in a chair and had an oxygen concentrator set at 0.5 liters via a nasal cannula. The SN did not check or verify the oxygen setting during the home visit. During an interview on 6/2/23 at 9:45 A.M., the SN said he never verified the oxygen setting on the concentrator as per Plan of Care, as required.

Based on record review and interview, the Agency failed to ensure its staff notified the Physician when there was a change in the plan of care for three Patients (#6, #11 and #3), out of a total sample of 14 Patients. Findings include: --- 3. Patient #3 was admitted to the Agency in February 2023 with a diagnosis of Hemiplegia (weakness in one side of the body) Following a Cerebral Infarction (stroke). Review of the Physician's orders for certification period 2/11/23 through 5/11/23, indicated the following: -Oxybutynin Chloride (to treat overactive bladder) 5 milligrams (mg), twice a day for bladder spasms. -Tramadol Hydrochloride (to treat moderate to severe pain) 50 mg, one tablet every six hours as needed (PRN) for pain. Review of the Start of Care (SOC) note, dated 2/11/23, indicated Nursing recommended to discontinue the Oxybutynin and Tramadol. Review of Interdisciplinary Group Meeting (IDG) notes, dated 2/11/23, 3/1/23, 5/10/23, indicated Oxybutynin and Tramadol remained on the Patient's active medication list. Review of the Physician's orders for certification period 5/12/23 through 8/9/23, indicated the following: -Oxybutynin Chloride (to treat overactive bladder) 5 milligrams (mg) twice a day for bladder spasms. -Tramadol Hydrochloride (to treat moderate to severe pain) 50 mg, one tablet every six hours as needed (PRN) for pain. Review of the clinical record indicated the Oxybutynin, and the Tramadol were discontinued by the Physician on 5/23/23. During an interview on 6/6/23 at 4:00 P.M., the Clinical Director said the two medications had not been discontinued as recommended by the Nurse on 2/11/23. She the recommendations did not get communicated to the IDG team and Physician, as required, until 5/23/23. 1. Patient #6 was admitted to the Agency in May 2022 with a diagnosis of Late Onset Alzheimer's Disease (people who experience memory loss and cognitive difficulties after age 65). Review of the Physician's orders for certification period 5/1/23/ through 6/29/23 indicated: -Home Health Aide Visit (HHAV); five times a week for eight weeks, four times a week for one week. Start Date: 5/1/23-End Date: 6/29/23. Review of the clinical record indicated a cancelled HHAV on 3/13/23. There was no documentation found to indicate the Physician had been notified of the missed HHAV. During an interview on 6/6/23 at 12:46 P.M. after reviewing the clinical record, the Clinical Director said there was no documentation found to indicate the Physician had been notified of the missed HHAV, as required. 2. Patient #11 was admitted to the Agency in May 2022 with a diagnosis of Malignant Neoplasm (Cancer) of the Vulva (outer part of the female reproductive system). Review of the Physician's orders for certification period 5/2/22 through 7/30/22 indicated the following: -Medical Social Worker (MSW), two visits a month for one month. -HHAV, three to five times a week for 12 weeks. -Skilled Nurse Visit (SNV), one to two times a week for 12 weeks. -SNV, six times, as needed (PRN). Review of the clinical record indicated the following missed visits: -MSW on 5/6/22, -HHA on 5/27/22, -SN on 5/27/22, -HHA on 5/3022, -HHA on 6/18/22, -SN on 6/23/22, -HHA on 7/4/22, -SN on 7/31/22. During an interview on 6/6/22 at 1:07 P.M. after reviewing the clinical record, the Clinical Director said the ordered visits were missed and the Physician was not notified of the missed visits, as required.

Based on observation, record review and interview, the Agency failed to ensure its staff maintained infection control practice during a home visit for one (#13) out of three Patients. Findings include: --- Review of the facility Policy titled, Infection Control-Bag Technique, dated 6/1/16, included, but not limited to: -Hospice nurses and home health aides are required to maintain their bags containing equipment and supplies in a clean environment at all times. -Upon arrival at the patient's home, the bag is placed on a clean surface utilizing newspaper, paper towels, and/or liner as a barrier. Alternatively, the bag may be hung on a doorknob if no liner is available. -The newspaper, paper towel, and/or liner are disposed of upon completion of the visit. Patient #13 was admitted to the Agency in April 2023 with a diagnosis of Cerebral Atherosclerosis (a buildup of plaque in the blood vessels of the brain). Review of a Physican's order, dated 5/1/23, indicated Skilled Nurse Visits two times a week for eight weeks and three visits, as needed (PRN). During an observation of a home visit on 6/2/23 at 9:00 A.M., Nurse #1 removed a crumbled blue liner from a side pocket of his/her bag and placed it on a table. Nurse #1 then placed his/her bag on the liner and began the home visit. After the completion of the home visit, Nurse #1 folded the liner and placed in a side pocket of his/her bag. During an interview on 6/2/23 at 9:45 A.M., Nurse #1 said he/she had placed his/her bag on a liner that had been used in other home visits and it was not a new liner, as required.

Based on record review and interview, the Agency failed to ensure its staff signed clinical notes by the end of the day, after providing a home visit for four Patients (#10, #6, #8, and #13), out of a total sample of 14 Patients. Findings include: --- Review of the Agency's Documentation Requirement Policy, dated 2/22/19, indicated, but not limited to, the following: -Documentation is completed by all hospice staff and volunteers whenever a patient/caregiver visit occurs. -All documentation is completed by the end of the work day. 1. Patient #10 was admitted to the Agency in August 2022 with a diagnosis of Systolic Heart Failure (a problem with how the left ventricle pumps blood to the rest of the body). a. Review of the Physician's order for certification period 11/3/22 through 1/31/23, indicated the following: -Skilled Nursing Visit (SNV) once a week for 13 weeks. -Three As Needed (PRN) SNVs. -Effective 11/6/22 to 1/28/23, HHAV five times a week. Review of the clinical record indicated the following: -A Home Health Aide Visit (HHAV) occurred on 11/4/22, and the clinical note was signed and closed on 11/6/22. -A Skilled Nurse Visit (SNV) occurred on 11/6/22, and the clinical note was signed and closed on 11/6/22. -A HHAV occurred on 11/10/22, and the clinical note was signed and closed on 11/12/22. -A SNV occurred on 11/17/22, and the clinical note was signed and closed on 11/27/22 -A HHAV occurred on 11/18/22, and the clinical note was signed and closed on 11/20/22. -A HHAV occurred on 11/25/22, and the clinical note was signed and closed on 11/27/22. -A HHAV occurred on 12/2/22, and the clinical note was signed and closed on 12/4/22. -A HHAV occurred on 12/8/22, and the clinical note was signed and closed on 12/11/22. -A HHAV occurred on 12/9/22, and the clinical note was signed and closed on 12/11/22. -A SNV occurred on 12/16/22, and the clinical note was signed and closed on 12/20/22. -A HHAV occurred on 12/16/22, and the clinical note was signed and closed on 12/18/22. -A HHAV occurred on 12/22/22, and the clinical note was signed and closed on 12/28/22. -A Missed HHAV visit note for 1/3/23 was signed and closed on 1/6/23. -A HHAV occurred on 1/5/23, and the clinical note was signed and closed on 1/9/23. -A HHAV occurred on 1/6/23, and the clinical note was signed and closed on 1/9/23. -A HHAV occurred on 1/9/23, and the clinical note was signed and closed on 1/11/23. b. Review of the Physician's order for certification period 2/1/23 through 4/1/23, indicated the following: -Skilled Nursing Visit (SNV) once a week for nine weeks. -Three PRN SNVs. -Effective 2/5/23 to 4/1/23, HHAV five times a week. -A SNV occurred on 2/9/23, and the clinical note was signed and closed on 2/11/23. -A HHAV occurred on 2/10/23, and the clinical note was signed and closed on 2/13/23. -A HHAV occurred on 2/17/23, and the clinical note was signed and closed on 2/19/23. -A HHAV occurred on 2/24/23, and the clinical note was signed and closed on 2/26/23. -A HHAV occurred on 3/2/23, and the clinical note was signed and closed on 3/5/23. -A HHAV occurred on 3/3/23, and the clinical note was signed and closed on 3/7/23. -A SNV occurred on 3/9/23, and the clinical note was signed and closed on 3/13/23. -A HHAV occurred on 3/10/23, and the clinical note was signed and closed on 3/13/23. -A HHAV occurred on 3/16/23, and the clinical note was signed and closed on 3/20/23. During an interview on 6/6/23 at 3:30 P.M., after reviewing the clinical record for Patient #10, The Chief Executive Office said documented visit notes were signed and closed later than required, per the Agency's policy. 2. Patient #6 was admitted to the Agency in May 2022 with a diagnosis of Late Onset Alzheimer's Disease (people who experience memory loss and cognitive difficulties after age 65). Review of the Physician order for certification period 5/1/23 through 6/29/23 indicated: -Aide; five times a week for eight weeks, and four times a week for one week. Start Date: 5/1/23-End Date: 6/29/23. Review of the clinical record indicated the following: A missed HHAV occurred on 3/31/23, and the note was signed and closed on 4/3/23. A missed HHAV occurred on 5/15/23, and the note was signed and closed on 4/3/23. 3. Patient #8 was admitted to the Agency in November 2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breath.) Review of the Physician's orders for certification period 11/15/22 through 2/12/23 indicted the following: -SN, twice a week for 14 weeks, and four visits as needed (PRN). Start: 11/16/22, End: 2/12/23. -HHA, once a week for 13 weeks. Start: 11/23/22, End:2/12/23. Review of the clinical record indicated the following: -A SNV occurred on 11/18/22, and the clinical note was signed and closed on 11/20/22. -A SNV occurred on 11/23/22, and the clinical note was signed and closed on 11/25/22. -A SNV occurred on 11/25/22, and the clinical note was signed and closed on 11/27/22. -A SNV did not occur on 12/2/22, and the clinical note was signed nd closed on 12/5/22. -A SNV occurred on 12/8/22, and the clinical note was signed and closed on 12/11/22. -A SNV was missed on 12/9/22, and the clinical note was signed and closed on 12/11/22. -A SNV was missed on 1/6/23, and the clinical note was signed and closed on 1/8/23. -A SNV was missed on 1/13/23, and the clinical note was signed and closed on 1/15/23. Review of a Physician order for certification period 2/13/23 through 5/13/23 indicated the following: -SN, once a week for 13 weeks, and three visits PRN. Start: 2/13/23, End: 5/13/23. Review of the clinical record indicated the following: -A SNV occurred 2/15/23, and the clinical note was signed and closed on 2/20/23. -ASNV was missed on 2/23/23, and the clinical note was signed and closed on 2/25/23. -A SNV occurred on 3/3/23, and the clinical note was signed and closed on 3/5/23. -A SNV occurred on 3/17/23, and the clinical note was signed and closed on 3/24/23. 4. Patient #13 was admitted to the Agency in April 2023 with a diagnosis of Cerebral Atherosclerosis (a build up of plague in the blood vessels of the brain). Review of the Physician order for certification period 3/2/23 through 4/30/23 indicated the following: -SN, twice a week for nine weeks, and five visits PRN. Review of the clinical record indicated a missed SNV on 4/16/23, and the clinical note was signed and closed on 4/19/23. During an interview on 6/6/23 at 2:00 P.M., the Clinical Director said all the clinical notes were signed and closed later than required, as per the Agency's policy.

Based on record review and interview, the Agency failed to ensure its staff completed a nursing license verification upon hire for one of six new employee records reviewed. Findings include: --- Review of the facility Policy titled, Hiring New Staff, dated 6/1/16, included, but not limited to: -During the hiring process, applicants are informed of necessary requirements for employment, including, but not limited to: *Copy of current license or certification if position requires license or certification.... Review of Employee #6 file indicated the date of hire was 2/20/23. The file contained documentation that a nursing license verification was completed on 6/1/23 and not upon hire. During an interview on 6/2/23 at 12:00 P.M., after reviewing Employee #6 file, the Executive Director said the nursing license verification was completed late and not upon hire, as required.