Dignity Hospice

“Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to ensure patients are informed of all their rights, and the hospice must protect and promote the exercise of these rights. This deficient practice prevents patients from making informed decisions regarding their care. Findings include:Facility policy and procedure titled, “PATIENT RIGHTS AND RESPONSIBILITIES POLICY NUMBER: AD.P15 “, revealed: “...POLICY: Dignity Hospice informs patients of their rights, and protects and promotes the exercise of these rights. PROCEDURES: Patients and/or their representatives are provided with verbal and written notice of patient’s rights and responsibilities in advance of furnishing care. 2. The notice of the patients’ rights and responsibilities are provided in a language and a manner that the patient understands prior to furnishing care....”Review of Policy titled “Policy Number:AD.C20 COMPLIANCE WITH REGULATIONS” revealed: “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients...5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”A tour of the facility on 09/03/2025, revealed an Arizona Department of Health Services state license mounted on the wall next to the agency entrance door expired on 02/28/2025.Employee #1 confirmed in an interview on 09/03/2025, the agency does not currently hold an Arizona Department of Health Services state license. Review of the “Patient Rights and Responsibilities” document in the agency’s patient admission handbook presented on 9/3/2025 revealed: “ As a Dignity Hospice patient, you have the right to: Exercise his or her rights as a patient of the hospice...Appropriate or Compassionate Care regardless of race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis or ability to pay for services rendered...Free from mistreatment, neglect or verbal, mental, sexual, and physical abuse including injuries of an unknown source and misappropriation of patient’s property, coercion, manipulation, or seclusion....”Employee #1 acknowledged in an interview on 09/03/2025, the “Patient Rights and Responsibilities” document in the agency’s patient admission handbook did not contain exploitation or sexual assault.”

“Based on record review and staff interview, it was determined that the hospice failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. This deficient practice has the potential that personnel, patients, and patient caregivers are not being educated on infection prevention and control issues, including their role in preventing the spread of infections and communicable diseases through daily activities, posing the risk for negative outcomes. Findings include:A review of the Dignity Hospice patient admission folder provided did not have documentation of patient and caregiver infection control education.A request was made for the staff infection control tracking. No documentation could be provided.A review of patient infection control logs revealed that infections are not being followed up after antibiotics are prescribed.A review of the emergency preparedness plan and policies did not include planning for new and emerging infectious diseases.A review of Policy PC.I40 titled” Infection Control-Program” revealed:”...Dignity Hospice maintains and documents an effective,organization-wide infection control program that includes active monitoring, surveillance, identification, prevention and control of known or suspected infections among the hospice’s patients and employees...The hospice’s infection control program includes, but is not limited to the following components: a. education and training for staff, volunteers, patients and their families, and visitors on the principles of infection identification, prevention and control, including the use of standard and transmission-based precautions;...e. a written plan for dealing with epidemics as a component of the hospice’s emergency/disaster management plan...2. As an integral component of the hospice’s quality assessment and performance improvement program, infection control data is collected and analyzed to determine trends and areas in need of improvement to minimize the risk of infections. Data collected may include, but not be limited to:...c. monitoring staff compliance with infection control policies and procedures; and d. reportable employee or patient illnesses and infections...e a written plan for dealing with epidemics as a component of the hospice’s emergency/disaster management plan 4. The hospice’s written infection control plan and its infection control practices are monitored, reviewed, evaluated and updated on an annual basis and as needed.....”A review of facility policy titled “Policy: HR.H10 Health/Physical Requirements” revealed: “…6. All employees and volunteers are required to have documented evidence of a tuberculin screening prior to patient contact. All employees and volunteers are required to complete the two-step PPD test if it has been more than a year since their last test was given…”.A review of facility policy titled “Policy: Hiring New Staff” revealed: “...6. During the hiring process, applicants are informed of necessary requirements for employment, including but not limited to: ...d. proof of TB test within last 12 months for all direct patient care staff....”A review of facility policy titled, “Policy Number AD.C20 Compliance with Regulations” revealed: “…POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients…5. The hospice’s compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medical conditions of participation and other Federal, State and local laws and regulations….”A review of Employee #1’s personnel file revealed a hire date of 07/01/24. No documentation was present in the personnel file of tuberculosis testing completed upon hire.A review of Employee #2’s personnel file revealed a hire date of 04/07/2025. No documentation was present in the personnel file of tuberculosis testing completed upon hire. Tuberculosis screening questionnaire not completed. Tuberculosis testing conducted on 04/29/25 invalid because there was no read time documented. Tuberculosis test performed on 04/29/25 was not a two-step test per facility policy.A review of Employee #3’s personnel file revealed a business agreement dated March 2021, and executed on 01/22/2025. No documentation was present in the personnel file of the tuberculosis risk assessment/screening questionnaire. completed upon hire or annually. A review of Employee #4’s personnel file revealed a hire date of 12/01/2022. No documentation was present in the personnel file of tuberculosis testing completed upon hire or an initial tuberculosis questionnaire. TB questionnaires for the subsequent years, 2023 and 2024, were also not documented or present. A review of Employee #5’s personnel file revealed a hire date of 09/03/24. No documentation was present in the personnel file of tuberculosis testing completed upon hire.A review of Employee #6’s personnel file revealed a hire date of 06/14/2023. No documentation was present in the personnel file of tuberculosis testing completed upon hire.TB screeing questionnaire upon hire wis as incomplete. No annual screening present for 2024, 2025. TB skin test conducted on 06/05/2025 not valid per agency policy.A review of Employee #7’s personnel file revealed a hire date of 09/07/2023. No documentation was present in the personnel file of tuberculosis screening was performed upon hire or 2024.A review of Employee #8’s personnel file revealed a hire date of 04/04/2019. No documentation was present in the personnel file of tuberculosis testing completed upon hire.No documentation of tuberculosis screening questionnaire on hire, or for years 2020, 2021, 2022, 2023, and 2024. The tuberculosis screening questionnaire for 2025 is incomplete. No documentation was present for tuberculosis testing upon hire, or for the years 2020, 2021, 2022, 2023, and 2024. The tuberculosis testing conducted on 05/05/25 was invalid as the time read was not completed and per agancy policy a two-step TB test is required. A review of Employee #9’s personnel file revealed a hire date of 12/02/24. No documentation was present in the personnel file of a valid tuberculosis test being completed upon hire.A review of Employee #10’s personnel file revealed a hire date of 02/27/2025. No documentation was present in the personnel file of a tuberculosis screening questionnaire, or a TB test was documented upon hire.A review of Employee #11’s personnel file revealed a hire date of 10/10/24. No documentation was present in the personnel file of a tuberculosis screening questionnaire, nor was a TB test documented upon hire.A review of Employee #12’s personnel file revealed a hire date of 01/07/2025. No documentation was present in the personnel file of a valid tuberculosis screening questionnaire, nor was a TB test documented upon hire.A review of Employee #13’s personnel file revealed a hire date of 04/03/2025. No documentation was present in the personnel file of a valid uberculosis screening questionnaire, nor was a two-step TB test documented upon hire.A review of Employee #14’s personnel file revealed a hire date of 04/30/2025. No documentation was present in the personnel file of a tuberculosis screening questionnaire was completed upon hire.A review of Employee #15’s personnel file revealed a hire date of 08/04/2025. No documentation was present in the personnel file of a tuberculosis screening questionnaire completed upon hire. The TB skin test was not valid as it was read out of range within 48-72 hours. It was read before 48 hours, making the results invalid/inaccurate.A review of Employee #16’s personnel file revealed a hire date of 07/31/2025. No documentation was present in the personnel file of a valid tuberculosis screening questionnaire, nor was a two-step TB test documented upon hire. Furher, the tuberculosis test conducted on 06/20/25 was invalid as there was no time documented as to when it was read.In an interview conducted on September 03, 2025, with Employee #1, they confirmed that no documentation of the Clinical Director is accountable for the infection control program in collaboration with the hospice’s QAPI committee, including the collection and analysis of surveillance data related to infections among staff, volunteers, and hospice patients. No additional information could be provided.In an interview conducted on September 04, 2025, with Employee #3, they confirmed the personnel files contained all available documentation.”

“Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to ensure that the services described in §418.72 through §418.78 are provided directly by the hospice or under arrangements made by the hospice as specified in §418.100. These services must be provided in a manner consistent with current standards of practice. This deficient practice has the potential to result in patients not receiving necessary services. Findings include:Review of agency policy and procedure titled, “Policy Number: PC.P25 PHYSICIAL, OCCUPATIONAL, SPEECH AND OTHER THERAPIES” revealed: “...Physical therapy, occupational therapy, speech-language pathology services and other therapies are provided in a manner consistent with accepted standards of practice, when necessary, for the management of symptoms related to the terminal illness...2. When these services are needed for palliation or to help the patient reach optimal functioning a physician’s order is obtained and services to be provide are included in the patient’s care plan. 3. When appropriate, referrals are made for these services and are provided by qualified individuals with whom the hospice has a written agreement. 4. The RN Case Manager coordinates and supervises the services provided to the patient to ensure they are in accordance with the patient’s plan of care....”Review of Policy titled “Policy Number: AD.C20 COMPLIANCE WITH REGULATIONS” revealed, “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients...5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”Review of agency contract binder presented on 09/04/2025 lacked a contract for registered dietician services. Employee #1 confirmed in an interview on 09/04/2025, there was no current contract for dietician services. Findings include:A contract for therapy services was presented on September 02, 2025, for Assisiteo Health. The contract was not fully executed. Missing signature from the contracting agency, Assisteo was not present. The contract was also not written fro Dignity Hospice. It was for the previous owner(s) with a name other than Dignity Hospice and an incorrect address. for the hospice.On September 03, 2025, Employee #2 presented a fully executed therpay contract backdated to the original date. They stated they had contacted the therapy company, and they were able to send a copy. The contract had not been corrected to reflect the correct name of Dignity Hospice, and the address was not updated. Employee #2 confirmed the information was incorrect and the contract was not accepted. A call was placed to the aforementioned home health agency to verify the therapy services contract. At the time of this writing, no phone call has been returned.”

“Based on record review and staff interviews, it was determined that the hospice failed to use volunteers and track cost savings. This deficient practice has the potential that volunteers are not being used to the full extent, posing the risk for poor patient outcomes and all aspects of hospice services not being provided. Findings include:A review of Policy Number PC.V20 titled”VOLUNTEERS - SERVICES” revealed:”...The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients...2. Recruitment efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations...10. The Volunteer Coordinator maintains records of volunteer activity and records levels of volunteer participation and cost savings on a monthly and annual basis....” A review of Policy Number: HR.V25, titled”VOLUNTEERS-RECORDKEEPING”, revealed:” POLICY: Volunteer hours of service and cost savings are recorded monthly toensure compliance with Federal regulations...3. The Volunteer Coordinator summarizes the volunteer activity that has occurred each month and estimates the total cost savings achieved through the use of donated volunteer hours.4. Data from the monthly volunteer activity summaries is compiled annually to document and demonstrate that the services provided by hospice volunteers equals or exceeds five (5) percent of the total patient care hours of all paid hospice employees and contract staff.5. The Volunteer Coordinator compiles the monthly data and submits the information to the President.6. The annual volunteer data is tabulated by January 30ᵗʰ of the followingyear and is submitted to the President....” A review of Policy Number Policy Number: HR.V30, titled” Volunteers-recruitment”, revealed:”...Dignity Hospice makes a consistent and concerted effort to recruit qualified, appropriate and competent men and women willing to volunteer their services to the hospice program....Procedure: 1. A mailing list is updated on a regular basis to include names of potential sources of volunteers...2. One (1) month prior to a scheduled volunteer training program, a mailing is sent to the above resources announcing the program and requesting assistance with posting announcements of the training. In addition, press releases are sent to various area publications either by mail or facsimile...5. All efforts to recruit hospice volunteers are documented and maintained by the Volunteer Coordinator....”A review of Policy Number: HR.V35, titled”VOLUNTEERS - RETENTION, SUPPORT AND EDUCATION”, revealed:”...POLICY: Dignity Hospice documents and demonstrates viable and ongoing efforts to retain, support and provide continuing education opportunities...1. Efforts ate made to retain and support hospice volunteers through: a a formal Volunteer Recognition event held annually during National Volunteer Month; b. regular and consistent contact with the Volunteer Coordinator and other members of the hospice’s IDG....”A review of Policy Number: PC.V20, titled”VOLUNTEERS-SERVICES”, revealed:”POLICY: The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients...PROCEDURES:...2. Recruitment efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations...10. The Volunteer Coordinator maintains records of volunteer activity and records levels of volunteer participation and cost savings on a monthly and annual basis....”Facility policy and procedure presented on 9/4/2025 titled, “Policy Number: HR.V10 Volunteers - Orientation and Training” revealed: “...POLICY: An initial orientation and training program is provided to all volunteers that is consistent with hospice industry standards...4. Documentation of the volunteer’s successful completion of orientation as well as on-going in-services is retained in the volunteer’s file....”A review of documents titled”Volunteer Coordinator’s Monthly Report” revealed:”...Month Reporting Aug 24...Report completed by[name redacted]... Date:...Reviewed by Administrator or designee on______________ (Date) _________________....” The report was not dated by the person completing the form nor signed and dated by the administrator or designee. A second “Volunteer Coordinator’s Monthly Report” revealed:”....Month Reporting June...Report completed by[____________... Date:...Reviewed by Administrator or designee on______________ (Date) _________________....” The report was not dated by the person completing the form, nor signed and dated by the administrator or designee. A third document titled “Volunteer Coordinator’s Monthly Report” revealed:”...Month Reporting July 24...Report completed by[name redacted]... Date:...Reviewed by Administrator or designee on______________ (Date) _________________....” The report was not dated by the person completing the form nor signed and dated by the administrator or designee. No further documentation of the monthly and annual volunteer savings program could be provided.A review of a volunteer personnel record revealed that no documentation of orientation was present in the personnel file for Employee #12. In an interview conducted on September 04, 2025, with Employee #2, they confirmed that no documentation of mailings, recruitment, further monthly reports, or the annual report presented to the President could be provided. No additional documentation could be provided.In an interview conducted on September 04, 2025, with Employee #3, the personnel file for Employee #12 was complete, no additional information was available for review, and no documentation of volunteer orientation was present.”

“Based on record review and staff interview, it was detrermined that the hospice is operating and furnishing services without a current State license. This deficient practice has the potential to compromise the health and safety of patients, posing the risk for negative outcomes. Findings include:A review of the document, titled,”... PROPERTY OF THE ARIZONA DEPARTMENT OF HEALTH SERVICES...”, revealed:”....This facility is licensed to operate as a(n) Hospice Agency...Effective: August 1, 2022...HSPC9475....” The license was voided by the Arizona Department of Health Services for non-payment. The license expired 02/28/2025 and at the time of this writing there is no state license for this hospice.A review of Dignity Hospice Policy Number: AD.C20, titled,”COMPLIANCE WITH REGULATIONS” revealed:”...Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients...5. The hospice’s compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of The participation and other Federal, State and local laws and regulations....”.A review of the patient census presented on August 29, 2025, revealed 91 current/active patients.In an interview conducted on August 29, 2025, with Employee #1, they confirmed they were aware they had no state license. They became aware the beginning of August and continued to operate and take new admissions.In an interview conducted on September 02, 2025, with Employee #2, they confirmed that the license had expired. A new application has been placed with the State, and it has not been approved for licensure.At the time of this writing, no state license has been issued to the hospice.”

“Based on review of facility policy, review of facility documentation and interview, it was determined the facility failed to include names and contact information for staff, patient physicians in the facility communications plan. Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients. Findings include:Review of agency document titled, “ ...Emergency Operations Plan....” in Emergency Preparedness binder revealed: “...B. General Protocol...all Dignity Health Hospice Field Staff and Managers Should Carry the Following During Working Hours: Cell Phone Current Employee phone list....”Review of Policy titled “Policy Number:AD.C20 COMPLIANCE WITH REGULATIONS” revealed: “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients... 5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”Review of agency Emergency Preparedness binder revealed no evidence of name and contact information for staff, patient physicians, or complete list of vendors.Employee #1 confirmed in an interview on 09/05/2025 staff phone list, patient list with physician name and contact number, and complete vendor list was not included in the emergency preparedness binder. No additional documentation was provided.”

“Based on interview, review of facility policies and procedures and documentation it has been determined the facility failed to ensure each personnel member has been trained at hire and at least every two (2) years in emergency preparedness policies and procedures. Emergency Preparedness training documentation must include the specific training completed as well as the methods used for demonstrating knowledge of the training program. Failure to ensure staff are trained both at hire and at least biennially on facility emergency preparedness policies and procedures can result in staff being unprepared in an emergency event, leading to increased likelihood of staff and patient injury or death. Findings include:Review of Policy titled “Policy Number AD.E13 EMERGENCY PREPAREDNESS PROGRAM - TRAINING AND TESTING” revealed: “...POLICY: Dignity Hospice maintains an emergency preparedness training and testing program that is based on its emergency plan, emergency preparedness polices and procedures and the emergency preparedness communication plan...Training program ...1. The hospice’s emergency preparedness training program provides for the following: a. initial training in emergency preparedness polices and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles: b. demonstration of staff knowledge of emergency procedures. c. emergency preparedness training at least every two years; ...e. documentation of all emergency preparedness training....”Review of Policy titled “Policy Number: AD.C20 COMPLIANCE WITH REGULATIONS” revealed: “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients... 5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”Review of agency Emergency Preparedness Binder presented on 09/03/2025 revealed no documentation to support initial emergency preparedness training for employees #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16Review of personnel records presented on 09/03/2025 revealed no documentation to support initial emergency preparedness training for employees #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16Review of agency Emergency Preparedness Binder presented on 09/03/2025 revealed no documentation to support emergency preparedness training every two years for employees #4,#6,#8Review of personnel records presented on 09/03/2025 revealed no documentation to support emergency preparedness training every two years for employees #4,#6,#8In an interview conducted on 09/04/2025, with employee #1, they acknowledged Emergency preparedness training should be documented per policies and procedures. No additional documentation was presented.”

“Based on record review and staff interview, it was determined that the hospice agency failed to inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable State law. This deficient practice has the potential that patients and patient representatives are not being educated, posing the risk for patient rights violations and ill-informed decisions with negative outcomes. Findings include:A patient admission packet was requested on August 29, 2025. A review of the orange folder with “Dignity Hospice” titled on the front was conducted. A document titled” Patient Rights and Responsibilities,” dated at the bottom January 2023, revealed:”... Inform the hospice of any advance directives or any changes in advance directives and provide the hospice with a copy....” A review of all 42 pages did not provide documentation of advance directive information. Consent forms requiring patient or representative signature titled”AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION”,”Acknowledgment of Patient Rights and Responsibilities”,”DIGNITY HOSPICE SAFE USE AND DISPOSAL OF CONTROLLED SUBTANCES”, “Patient Evacuation Plan”, Dignity Hospice INFORMED CONSENT AND ELECTION OF HOSPICE BENEFIT”, “Dignity Hospice HIPAA Right of Access Form For Family Member/Friend”, and “Informed Consent for Psychotropic Medication Treatment...(March 2020),” did not have documentation that the patient acknowledged that they had received advanced directive information or the hospice’s policies on advance directives.A review of the Policy AD. ClO, titled” COMMUNITY EDUCATION AND REACH OUT “, revealed:”...Dignity Hospice provides education regarding hospice and palliative care to community groups and referral sources...Speakers are provided upon request from community groups or referral sources to provide information and targeted education on topics that may include, but are not limited to: a. advance care planning/advance directives;...4. Community education that has been provided and the identification of needs in the community are documented and reported to the Board of Directors for inclusion in the hospice’s strategic planning process....”A review of the in-service education was reviewed. No documentation was provided the education of staff concerning its policies and procedures on advance directives, and (6) Provide for community education regarding issues concerning advance directives that may include material required in paragraph (a)(1) of this section, either directly or in concert with other providers and organizations. Separate community education materials may be developed and used at the discretion of providers. The same written materials do not have to be provided in all settings, but the material should define what constitutes an advance directive, emphasizing that an advance directive is designed to enhance an incapacitated individual’s control over medical treatment, and describe applicable State law concerning advance directives. A provider must be able to document its community education efforts. No documentation of community education could be provided.A review of Policy AD.C20, titled “COMPLIANCE WITH REGULATIONS”, revealed:”...POLICY:...Dignity Hospice operates and furnishes services in compliance with allapplicable Federal, State, and local laws and regulations related to hospice care and the health and safety of patients....5.The hospice’s compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State, and local laws and regulations....”A review of Dignity Hospice Policy AD.P15 titled “PATIENT RIGHTS AND RESPONSIBILITIES”, revealed:”...Dignity Hospice informs patients of their rights, and protects and promotes the exercise of these rights.. 1. Patients and/or their representatives are provided with verbal and written notice of the patient’s rights and responsibilities in advance of furnishing care....”A review of the Governing Body minutes revealed no documentation of community education or a report to the Board of Directors..In an interview conducted on September 02, 2025, with Employee #1, they confirmed that the advanced directive information was not present in the patient admission folder provided.”

“Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to ensure the hospice does not hamper exercising the patient’s rights. The hospice must assure that its staff will protect patients’ rights. This deficient practice has the potential to lead to a failure in patient’s needs not being adequately addressed leading to poor patient outcomes. Facility policy and procedure titled, “PATIENT RIGHTS AND RESPONSIBILITIES POLICY NUMBER: AD.P15 “, revealed “...POLICY: Dignity Hospice informs patients of their rights, and protects and promotes the exercise of these rights. PROCEDURES: Patients and/or their representatives are provided with verbal and written notice of patient’s rights and responsibilities in advance of furnishing care. 2. The notice of the patients’ rights and responsibilities are provided in a language and a manner that the patient understands prior to furnishing care....”Review of Policy titled “COMPLIANCE WITH REGULATIONS” Policy Number:AD.C20” revealed, “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients... 5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”Review of document titled “Dignity Hospice INFORMED CONSENT AND ELECTION OF HOSPICE BENEFIT “ in the agency patient admission packet presented on 09/03/2025 revealed. “MEDICARE PATIENT RIGHTS AND RESPONSIBILITIES...Any complaints to the Agency should be made directly to...or the AZ Department of Health Service’s can be called at 602-542-0883.This surveyor called 602-542-0883 on 09/02/2025 at 3:30 pm. This number is a fax number. Employee #1 acknowledged in an interview on 09/03/2025, the “Dignity Hospice INFORMED CONSENT AND ELECTION OF HOSPICE BENEFIT” form should be updated to reflect correct complaint phone number for Arizona Department of Health compliant hotline.”

“Based on record review and staff interviews, it was determined that the hospice failed to ensure that hospice aides receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This deficient practice has the potential that the personnel members are not being educated on the most current evidence-based practices that promote safe, effective patient care, posing the risk for injury to both the personnel member and patient. A review of agency policy titled “ Policy Number: PC.H22 Hospice Aide In-Service Training “ revealed: “...Policy: A hospice aide receives at least 12 hours of in-service training during each 12-month period...4. All in-service training provided to hospice aides is documented and a training file for each hospice aide is included with his/her personnel record...”Review of Policy titled “COMPLIANCE WITH REGULATIONS” Policy Number:AD.C20” revealed, “...POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients... 5. The hospice’s corporate compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medicare conditions of participation and other Federal, State and local laws and regulations....”Review of personnel records for employee #6 with hire date of 6/14/2023 presented on 09/03/2025 and in-service training documentation presented on 09/04/205 revealed, “Health Stream Student and Group Transcript Report... Total Completions:4 Estimated Time 4:25...Bloodborne Pathogens - 20-870515 Estimated Time: 1:30 Completion Date 05/30/2023, Hand Hygiene and Skin Care for Healthcare Assistants Estimated Time :30, HIPAA:A Guide for Healthcare Workers - 20-943604...Estimated Time:1:05, Safe Patient Handling: Lifting - 20-569145... Estimate Time...1:20...05/30/2023”. No documentation provided to support additional HHA in-service training hours for 2023. No documentation provide to support HHA in-service training for 2024 or 2025.In an interview with employee #2, they acknowledged no other documentation could be provided to support HHA in-service training hours. Findings include:Facility policy titled “Hospice Aide In-Service Training” states: “...a hospice aide receives at least 12 hours of in-service training during each 12-month period...”A review of personnel records revealed that employee #6 had evidence of one hospice aide training dated 2023.”

“Based on record review and staff interview, it was determined that the hospice failed to provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. This deficient practice has the potential that staff are not educated on the principles and have a basic understanding hospice posing the risk for patient care and services not being provided adequately in alignment with the hospice principles. Findings include:A review of facility policy titled “Policy Number: HR.O15 Orientation Program” revealed: “…1. All newly hired employees participate in an orientation program prior to providing patient care…2. All employees are oriented to: (a) the hospice philosophy of care…5. Documentation of the successful completion of the orientation program is retained in the employee’s personnel record…6. Contract personnel receive orientation to…the hospice philosophy of care….”A review of personnel records revealed no documentation of orientation to the facility’s hospice philosophy for employees: #3, #7, #9, #10, #11, #12, #14, and #16.In an interview conducted on September 04, 2025, with Employee #1, they confirmed all staff should be educated on the hospice philosophy during orientation and acknowledged the agency policy.In an interview conducted on September 04, 2025, with Employee #3, they confirmed the personnel files provided were complete, and no additional documentation was available.”

“Based on record review and staff interviews, it was determined that the hospice failed to provide an initial orientation for each employee that addresses the employee’s specific job duties. This deficient practice has the potential that employees are not being educated on their specific responsibilities and roles regarding patient care and services, posing the risk that patient and patient representatives are not receiving the appropriate care, leading to poor outcomes. Findings include:A review of facility policy titled Policy Number HR.015, titled” Orientation Program,” revealed: “…POLICY: Dignity Hospice provides an orientation program intended to ensure that all newly hired employees have the training and competency necessary to perform their jobs effectively…1. All employees are oriented to...f. job description and responsibilities; and g. policies and procedures as appropriate to the employee’s position…3. Patient care employees receive orientation appropriate to their job functions...5. Documentation of the successful completion of the orientation program is retained in the employee’s personnel record...6. Contract personnel receive orientation to the hospice’s policies regarding confidentiality, the hospice philosophy of care, and the contract personnel’s specific job duties....”A review of personnel records revealed no documentation of orientation-specific to job duties for Employees: #3, #7, #9, #10, #11, #12, #14, and #16.In an interview conducted on September 4, 2025, with Employee #3, they confirmed the aforementioned personnel files were complete, and no additional documentation was available.”

“Based on record review and staff interview, it was determined that the facility failed to assess the skills and competence of all individuals furnishing care, including volunteers. This deficient practice has the potential that personnel members’ knowledge and skills are not being assessed before providing care to a vulnerable population, posing the risk of negative patient outcomes Findings include:A review of Policy Number HR.C10, titled “Competency Assessment,” revealed:”...POLICY...The hospice implements a systematic competency assessment program to assure that all staff and volunteers are competent to perform their jobs effectively. PROCEDURES: 1. The hospice’s governing body is ultimately responsible for assuring the competency of all individuals who provide patient and family care and services on the hospice’s behalf.....3. As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing care or assuming administrative responsibilities...4. Competency evaluations are specific to the skills needed for each job category and specific competencies are delineated in job descriptions and performance evaluations....The competency of all staff and volunteers (including supervisors and management staff) is assessed through self-evaluations and checklists, supervised visits, interviews, simulated practice and/or written tests...Competency assessment occurs during the orientation period, annually....”A review of personnel records revealed that documentation of initial competency assessments was completed and documented for employees #1, 2, 3, 5, 7, 9, 10, 11, 12, 14, and 16.In an interview conducted on September 04, 2025, with Employee #1, they confirmed the competency assessments should have been present in the aforementioned personnel files.In an interview conducted on September 04, 2025, with Employee #3, they confirmed the competency assessments were not present in the personnel files for employees #1,2,3,5,7,9,10,11,12,14, 14, and 16. They also confirmed the personnel files were complete and no additional documentation was available.”

“Based on a review of policies and interviews, it was determined that the facility failed to provide orientation and training to any skilled nursing facility(ies) with whom they contract for in-patient respite care. This deficient practice has the potential for harm when there is no evidence of training staff on how to properly care for skilled nursing patients, posing a risk for negative outcomes. A review of facility policy titled, “Policy Number AD.C20 Compliance with Regulations” revealed: “…POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients…5. The hospice’s compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medical conditions of participation and other Federal, State and local laws and regulations….”Review of facility contacts did not support evidence of training to skilled nursing facilities with whom the hospice has contracted for in-patient care.In an interview with employee #1 on 09/04/2025 documentation of General Inpatient/Respite Care/Skilled Nursing facility training was requested. Not provided. A review of facility policy titled, “Policy Number AD.C20 Compliance with Regulations” revealed: “…POLICY: Dignity Hospice operates and furnishes services in compliance with all applicable Federal, State and local laws and regulations related to hospice care and the health and safety of patients…5. The hospice’s compliance program is intended to ensure that mechanisms are in place to audit and monitor compliance with the Medical conditions of participation and other Federal, State and local laws and regulations….”Documentation to support evidence of training to skilled nursing facilities with whom the hospice has contracted for in-patient care was requested. Not received.”

“Based on record review and staff interviews, it was determined that the facility failed to obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. This deficient practice poses risk when the hospice does not perform their diligence in checking employees for criminal background, which could result in patient harm. Findings include:A review of the facility’s policy titled, “Criminal Background Checks” HR.C25, revealed “...Diginity Hospice obtains a criminal background check as required by State laws and regulations. In the absence of State requirements for any individuals/disciplines that have contact with patients or access to patient records, Federal criminal background check requirements are followed. 1. Criminal background checks are required for all employees (including volunteers) and contracted staff who provide direct patient care or who have access to patient records....”A review of the facility’s policy titled “Policy Number HR.P25 Personnel Records” revealed: “…Regular audits of personnel records ensure that required information is current and available in individual files…”.A review of personnel records revealed that employees #3, #7, and #15 did not contain evidence of a background check. Employee #3 confirmed that employee #3, #7, and #15’s personnel files did not contain evidence of a background check.”