Trifinity Hospice Inc.

“Upon patient record review, 12 of 14 (Patient #1,2,3,4,5,6,7,9,10,11,13,14) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient’s attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient #1 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #2 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 07/25/25. Patient #3 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #4 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #5 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #6 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #7 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 08/20/25. Patient #9 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 07/17/25. Patient #10 - There is no evidence of an updated plan of care and signatures of attendance by the IDG since 06/13/25. Patient #11 - There was no evidence of an updated plan of care and signatures of attendance by the IDG from 04/04/25 to date of death 05/04/25. Patient #13 - There was no evidence of an updated plan of care and signatures of attendance by the members of the IDG from 05/02/25 to date of discharge 07/13/25. Patient #14 - There was no evidence of an updated plan of care and signatures of attendance by the IDG during patient’s hospice stay from 09/25/24 to 01/20/25.”

“Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice’s management and administration of its resources to provide hospice services to patients and families. Based on contract review, the hospice agency failed to ensure that the necessary contractual arrangements were in place to provide General Inpatient (GIP) care and Respite care as required. The agency did not maintain executed agreements with appropriately licensed facilities to deliver these levels of care, and no evidence was provided to demonstrate that patients had access to GIP or Respite services if needed. There was not evidence the hospice agency was able to ensure the full scope of hospice services to meet the patient needs.”

“Upon personnel record review, 14 of 14 (Personnel #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 1-14 records showed no evidence of emergency procedures training either initially or annually for all personnel and contracted staff.”

“Upon patient record review 6 of 14 (Patient #1,5,9,12,13,14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1 - Patient was admitted on 07/18/24. The psychosocial comprehensive assessment was dated 09/06/24. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive. Patient #5 - Patient was admitted on 08/30/24. The psychosocial comprehensive assessment was completed on 09/14/24. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive or anytime prior to 09/14/24. Patient #9 - Patient was admitted on 04/01/24. The medical record showed the psychosocial comprehensive assessment was completed on 04/07/24. The nursing comprehensive showed no evidence that the elements of the psychosocial components assessed on admission. Patient #12 -The patient was admitted on 09/27/24. The record showed that the psychosocial assessment was not completed until 12/11/24. The nursing comprehensive did not include the elements of the psychosocial assessment. Patient #13, 14: The psychosocial and spiritual comprehensive assessments were not completed within 5 days of SOC.”

“Upon patient record review 7 of 14 (Patient #3,4,6,7,9,10,11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #3 - Patient was admitted on 09/12/24. The medical record showed no evidence that an psychosocial comprehensive assessment was completed. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive. Patient #4 - Patient was admitted on 12/13/24. The medical record showed no evidence that an psychosocial comprehensive assessment was completed. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive. Patient #6 - Patient was admitted on 08/01/24. The medical record showed no evidence that an psychosocial comprehensive assessment was completed. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive. Patient #7 - Patient was admitted on 06/01/24. The medical record showed no evidence that a spiritual care comprehensive assessment was completed. The medical record showed no evidence that the elements of the psychosocial comprehensive was assessed in the nursing comprehensive. Patient #9 - Patient was admitted on 04/01/24. There was no evidence that a spiritual care assessment was completed. The nursing comprehensive showed no evidence that the elements of the spiritual components assessed on admission. Patient #10 - Patient was admitted on 06/06/24. There was no evidence that a psychosocial or spiritual assessment was completed by either the psychosocial or spiritual care coordinator. The nursing comprehensive showed no evidence that the elements of the psychosocial or spiritual needs were assessed. Patient #11 - The patient was admitted on 08/26/24. There was no evidence in the patient record that the psychosocial completed a psychosocial assessment. The elements of the psychosocial assessment were not captured in the nursing comprehensive assessment.”

“Upon patient record review, 10 of 14 (Patient #3,4,5,6,8,9,10,11,12,14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients 3,4,5,6,8,9,10,11,12,14 did not have evidence in the medical record that an initial bereavement assessment was completed within the first 5 days. There was also no evidence of the name and relationship of the primary bereaved. These components of the bereavement assessment were not included in the nursing comprehensive assessment.”

“Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,7,9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1 - There is no evidence in the medical record that the RN has completed an assessment since 08/18/25. Patient #2 - There is no evidence in the medical record that the RN has completed an assessment since 08/19/25. Patient #3 - There is no evidence in the medical record that the RN has completed an assessment since 09/12/24. Patient #4 - There is no evidence in the medical record that the RN has completed an assessment since 05/02/25. Patient #5 - There is no evidence in the medical record that the RN has completed an assessment since 08/30/24. Patient #6 - There is no evidence in the medical record that the RN has completed an assessment since 08/02/25. Patient #7 - There is no evidence in the medical record that the RN has completed an assessment since 06/01/24. Patient #9 - There is no evidence in the medical record that the RN has completed an assessment since 08/04/25.”

“Upon patient record review, 10 of 14 (Patient #1,4,5,6,7,9,10,11,12,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,7,11 - The nursing comprehensive documented that patient required a mechanical soft diet. There was no problems, goals, or interventions related to dysphagia. Patient #4 - The medical record showed patient is undecided on code status. There was no problems, goals, or interventions related to this code status. The record also showed no active or current problems, goals, or interventions as all the initial goals were marked “resolved” on 06/19/25. Patient #5,6,10 - Patient’s advanced directives show patient wishes to remain a full code. There were no problems, goals or interventions related to this code status. Patient #9 - The medication profile contained ASA daily as a blood thinner. There was no bleeding risk problems, goals, or interventions. Patient #12 - Patient’s admitting diagnosis is end stage cardiac disease. There were no problems, goals, or interventions related to the cardiac disease. The medication profile consisted of ASA daily as a blood thinner. There were no problems, goals, or interventions related to the bleeding risk of this medication. Patient #14 - The nursing comprehensive was completed on 09/25/24. The plan of care had no problems, goals, or interventions listed.”

“Upon patient record review, 6 of 14 (Patient #1,2,7,9,10,14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1 - The nursing comprehensive dated 07/08/24 noted patient is incontinent of bowel and bladder. The incontinent supplies were not listed on the plan of care. Patient #2 - The nursing comprehensive dated 03/24/23 and subsequent nursing notes, documented that patient is incontinent of bowel and bladder. The incontinent supplies were not listed on the plan of care. Patient #7 - The nursing comprehensive dated 06/01/24 noted patient is incontinent of bowel and bladder. The incontinent supplies were not listed on the plan of care. Patient #9 - The medication profile showed patient was utilizing Albuterol - nebulized every 6 hours as needed. The nebulizer machine was not listed as a DME item on the patient’s plan of care. Patient #10 - The nursing comprehensive dated 06/06/24 and subsequent nursing notes, documented patient is incontinent of bowel and bladder. The incontinent supplies were not listed on the plan of care. Patient #14 - The medication profile showed patient was utilizing Albuterol - nebulized every 6 hours as needed. The nebulizer machine was not listed as a DME item on the patient’s plan of care.”

“Upon patient record review, 12 of 14 (Patient #1,2,3,4,5,6,7,9,10,11,13,14) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient #1,3,4,5,6,10 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG since 06/13/25. Patient #2 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG since 07/25/25. Patient #7 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG since 08/20/25. Patient #9 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG since 07/17/25. Patient #11 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG from 04/04/25 to date of death 05/04/25. Patient #13 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG from 05/02/25 to date of discharge 07/13/25. Patient #14 - There is no evidence the IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care, no signatures of attendance by the IDG throughout the patient’s hospice stay from 9/25/24 to 1/20/25.”

“Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - The initial plan of care order dated 07/18/24, had an MSW frequency order for 1 visit per month. There is no evidence showing any MSW visit since 09/06/24. There was no evidence of an MSW discontinuation order. Patient #2 - The medical record contained an order dated 07/25/25 that spiritual care had been declined. There was evidence that spiritual care visits were completed on 09/26/25 and 10/31/25 without an order.”

“Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #11,12 - The medical record did not contain evidence that a post death bereavement plan of care was initiated.”

“Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #7 - There was no evidence that a competency evaluation was completed with the aide. ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1 - The aide care plan showed an order dated 06/13/25 for “aide 2 times per week - one extra visit”. The aide cannot be assigned a frequency of PRN.”

“Upon patient record review, 3 of 14 (Patient #6,10,11) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient #6 - The medical record showed an order for the patient to receive 2 aide visits per week. The week of 09/28/25 showed the patient received visit on 09/30/25, 10/03/25, and 10/04/25. There was no evidence of an order for the visit on 10/04/25. The record also showed no evidence of aide visits for the week of 10/12/25 and no evidence of a change in frequency or missed visits notes. Patient #10 - The medical record shows evidence of a physician order for aide frequency to be two times per week. There is no evidence of aide visits since 08/02/25 - no evidence of an order to discontinue aide visits. Patient #11 - The medical record showed evidence of a physician order for aide frequency to be two visits per week. The week of 04/14/25 and 04/21/25 there was evidence of 1 visit. The record also showed no visits from 04/21/25 until date of death on 05/04/25. There was no missed visit note and no order to change the frequency of visits.”

“Upon patient record review 3 of 14 (Patient #1,6,7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #1 - The medical record shows that aide visits were completed twice per week. There is no evidence of a supervisory visit by an RN since 08/18/25 to time of survey. Patient #6 - The medical record shows that aide visits were completed twice per week. There is no evidence of a supervisory visit completed by an RN since 08/02/25 to time of survey. Patient #7 - The medical record shows that aide visits were completed twice per week. There is no evidence of a supervisory visit by an RN since 06/01/24 to time of survey.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Based on review of personnel records and patient record reviews, the hospice’s Governing Body failed to provide effective oversight of key operational, clinical, and administrative functions. Personnel files lacked required elements, including evidence of completed orientation, annual competencies, and performance evaluations, and the agency did not ensure appropriate supervision of the LPN and hospice aides by a registered nurse. Clinical documentation was incomplete and inconsistent, including recertification of Terminal Illness (CTI) forms missing required signatures, insufficient documentation to support eligibility, with invalid face-to-face encounters, and recertification CTIs not completed in accordance with regulatory requirements. Additionally, the emergency preparedness plan had not been updated since 2019, demonstrating a failure to maintain current and comprehensive emergency procedures. IDG oversight was insufficient, with many patients lacking evidence of IDG meetings, updated plans of care or confirmation that patients and families understood the plan of care. Collectively, these deficiencies reflect a lack of Governing Body oversight and responsibility for the operation of the hospice.”

“Upon observation and contract review, 2 of 4 (Aegis Hospice, Life Care Center of Paradise) there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance There was no evidence of a contract for respite or general inpatient level of care. This was corrected onsite and contracts were initiated and dated 11/13/25.”

“Upon personnel record review, 8 of 14 (Personnel #3,4,5,6,8,9,10,11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 3 - Personnel record did not show evidence of an orientation checklist related to the Administrator role. Personnel 4 - Personnel record did not show evidence of an orientation checklist related to the Alt Administrator or DPCS role. Personnel 5 - Personnel record did not show evidence of an orientation checklist related to the Registered Nurse role. Personnel 6 - Personnel record did not show evidence of an orientation checklist related to the LPN role. Personnel 8 - Personnel record did not show evidence of an orientation checklist related to the MSW role. Personnel 9 - Personnel record did not show evidence of an orientation checklist related to the Spiritual Care role or the Bereavement Coordinator role. Personnel 10 - Personnel record did not show evidence of an orientation checklist related to the Volunteer Coordinator role. Personnel 11 - Personnel record did not show evidence of an orientation checklist related to the Volunteer role.”

“Upon patient record review, 7 of 14 (Patient #1,3,5,6,7,9,10) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #1 - There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for recertification period 09/11/25-11/09/25. Patient #3 - There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for the recertification period 09/03/25 - 11/01/25. Patient #5 - There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for recertification period 08/25/25-10/23/25. Patient #6 - There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for recertification period 09/25/25-11/23/25 and certification period 07/27/25 - 09/24/25. Patient #7 -There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for recertification period 07/26/25 - 09/23/25, or 09/24/25-11/22/25. Patient #9 - There was no evidence of a clinical review, documentation of eligibility, or signature on the Certification of Terminal Illness from the Medical Director for recertification period 07/25/25-09/22/25. Patient #10 - The physician recertification for benefit period 08/23/25-10/21/25 had no evidence of the hospice physician signature.”