Self-Help Home Care & Hospice

“It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment of 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. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/06/2025 with a diagnosis of general atherosclerosis. The initial comprehensive nursing assessment dated 12/06/2025 did not include an initial bereavement assessment of the needs of the patient’s family or other individuals. The social worker evaluation dated 12/07/2025 did not include an initial bereavement assessment of the needs of family and other individuals. During an interview with the administrator on 03/03/2026, she reviewed the record and agreed that the initial bereavement assessment was not documented. She stated, “This is usually completed by the social worker or the nurse during the admission assessment. The Social worker documented on the evaluation form rather than initial assessment form and the initial bereavement assessment was not included. There is a separate bereavement assessment form that should have been used.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) bereavement records reviewed of patients who expired, the agency did not ensure that bereavement services were available to the family and other individuals up to one (1) year following the death of the patient, or that the bereavement services reflected the needs of the bereaved per a bereavement plan of care that included: the types of bereavement services to be offered; the frequency of service delivery. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/11/2025 with a diagnosis of Alzheimer’s dementia and expired on 03/22/2025. The bereavement record included documentation that mailings were provided on 03/27/2025 and 04/30/2025. There was no evidence of a post death bereavement risk assessment or a bereavement plan of care. The bereavement coordinator documented a phone call on 03/25/2025 which stated, “She might not need follow up. I will find out from her whether she would like to receive any brochures or supportive flyers from us per month.” There was no further evidence of follow-up with the bereaved to determine her need for bereavement services or her desire to receive mailings. During an interview with the administrator on 03/04/2026, she reviewed the record and agreed that the bereavement follow up was not evident in the documentation. She stated, “The bereavement coordinator during that time is no longer employed.” She stated she will be sure the current bereavement coordinator documents all follow up going forward.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) hospice aide personnel files reviewed the agency did not ensure an annual on-site visit to the location where a patient is receiving care was completed. PERSONNEL RECORD 7: The hospice aide was hired on 12/10/2019. An annual on-site review was documented on 06/23/2025. There was no evidence of an annual on-site review for 2023 and 2024. During an interview with the administrator on 03/04/2026, she stated, “I was unable to find documentation from the previous administrator and completed an on-site hospice aide review in June 2025.””

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 14 (14%) personnel records reviewed, the agency did not ensure that an initial orientation was provided for each employee. DOCUMENT 1: ORIENTATION Policy No. 1-027 stated in relevant parts: “All personnel and volunteers will be required to attend an orientation program upon employment and at the time of reassignment. The goal of orientation will be to inform and instruct new personnel regarding (agency name) mission, policies and procedures, benefits (if applicable), the performance appraisal process, competency testing, as well as individual responsibilities and relationships to other personnel. All personnel will demonstrate knowledge and proficiency in skills appropriate to their assigned responsibilities during the orientation period. All clinical personnel prior to being assigned to care must present documentation of current CPR certification. CPR certification must be renewed per American Heart Association guidelines. 4. The orientation process for contract personnel will consist of the following: A. For contract personnel, the contracted organization will have one (1) member of the organization that has been oriented to (agency name) policies, procedures, and information presented during orientation. That individual will be responsible for orienting other contract personnel from that organization to (agency name). B. For personnel the organization individually contracts with, a preceptor will be assigned during the orientation process. 8. A Personnel Orientation Checklist (see “Personnel Orientation Checklist” Addendum 1- 027.A) will be completed for all new personnel. New personnel will sign and date when their orientation has been completed. 9. The supervisor will sign and date the checklist when new personnel have completed all the required activities. PERSONNEL RECORD 9: The hospice medical director was contracted on 10/20/2024. The personnel record did not contain evidence that a personnel orientation checklist was completed and signed. PERSONNEL RECORD 10: The hospice associate medical director was contracted on 03/17/2025. The personnel record did not contain evidence that a personnel orientation checklist was completed and signed. During an interview with the administrator on 03/04/2026, she stated, “I was not aware that contracted physicians were required to receive orientation.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 8 (50%) personnel records reviewed of personnel requiring an annual competency evaluation, the agency did not ensure all individuals were assessed for competencies annually according to agency policy. DOCUMENT 2: Policy No. 1-026 PERFORMANCE EVALUATIONS Stated in relevant parts: “All organization personnel will be evaluated at periodic intervals by their supervisor based on the appropriate job description to determine strengths and areas requiring performance improvement. PROCEDURE 1. Performance evaluations will be completed (and dated) on all personnel as follows: B. Annually, based on personnel’s annual evaluation date At least annually, clinical personnel must demonstrate proficiencies in the appropriate core competency.” PERSONNEL RECORD 1: The registered nurse, administrator, was hired on 06/19/2023. The personnel record contained one annual competency assessment dated 08/15/2024. There was no evidence that an annual competency assessment was completed for the year 2025. PERSONNEL RECORD 2: The registered nurse, director of patient care services, was hired on 07/16/2008. The personnel record contained one competency assessment dated 06/17/2025. There was no evidence that an annual competency assessment was completed for the years 2009-2024. PERSONNEL RECORD 6: The registered nurse was hired on 12/22/2008. The personnel record contained one annual competency assessment dated 06/25/2025. There was no evidence that an annual competency assessment was completed for any subsequent years following 2008-2024. PERSONNEL RECORD 7: The hospice aide was hired on 12/10/2019. The personnel record contained one competency assessment dated 06/23/2025. There was no evidence that an annual competency assessment was completed for any subsequent years following 2019-2024. During an interview with the administrator on 03/04/2026, she stated, “I was unable to find documentation from the previous administrator and completed competency assessments for all clinical staff during the month of June 2025. I will be sure that competencies are completed annually for all clinical staff annually.””

“It is required that a patient’s clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff including physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure written physician orders were obtained. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/06/2025 with a diagnosis of general atherosclerosis. On 01/01/2026 the RN documented “wound care provided with antibiotic ointment and bandage.” The physician’s order dated 01/01/2026 included orders to continue RN visits 2 times/week for 2 weeks for wound management starting on 01/04/2026. The written physician’s order did not specify the type of wound, the location of the wound, the application of an antibiotic ointment or the application of a bandage. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/11/2025 with a diagnosis of Alzheimer’s disease and expired on 03/22/29025. The RN (registered nurse) comprehensive assessment was dated 03/19/2025. The RN documented the wound was dressed with hydrogel. An RN comprehensive assessment was dated 03/20/2025. The RN documented wound care was provided to the sacral area, stage 2 pressure ulcer, cleansed with wound cleanser, covered with gauze/tape. There was no written physician’s order for wound care for the specific type of wound, the location of the wound, the application of neomycin or hydrogel, and how often to administer the wound care. The IDG meeting review dated 03/13/2025 indicated spiritual care services were declined. The initial plan of care dated 03/16/2025 did not include an order for a spiritual counselor initial assessment. There was a spiritual care visit dated 03/20/2025. There was no evidence of a written physician’s order to initiate spiritual counselor services. During an interview with the administrator on 03/03/2025, she reviewed the record and agreed there was no written physician’s order for wound care or for spiritual services to be initiated. She stated “This must have been an oversight. The nurse should have entered the orders. I will follow up with the nurse.””

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 6 (17%) contracts reviewed, the agency did not ensure the hospice contract contained language that required contracted employees who have direct patient contact or access to patient records obtain criminal background checks. CONTRACT 3: The durable medical equipment (DME) contract which was effective 11/07/2024 did not contain a statement that a criminal background check would be completed on all employees who have direct patient contact or access to patient records. During an interview with the administrator on 03/02/2026, she agreed that the DME contract did not state contain language that criminal background checks would be obtained for all employees who have direct patient contact or access to patient records. She stated, “The DME administrator is not currently available. I will obtain an amendment to the contract as soon as he returns.””

“Based on interview and EHR, the agency failed to ensure RN assessed status of dialysis fistula for one (Patient 2) of 13 patients. The deficient practice had the potential result for patient not getting the necessary treatment and care. During an observation on 9/17/2024, at 11:40 AM, in Patient 2s home, Patient 2 was in bed. RN 2 assessed Patient 2. During a concurrent observation and interview on 9/17/2024, at 12:06 PM, when asked, “;Are you done with Patient 2 assessment?” RN 2 stated, “;Im done.” RN 2 did not assess Patient 2s fistula. RN 2 stated the status of the fistula should be assessed during nurse visits. During EHR review with RN 2 on 7/19/2024, for Patient 2, indicated, “;Medical Diagnoses, End Stage Renal (kidney) Disease, included, Dependence on renal dialysis...” During EHR review with RN 2 of Plan of Care, dated 7/19/2024, for Patient 2, indicated, “;Dialysis (a treatment that removes water, salt, and waste from the blood when the kidneys are unable to do so naturally) fistula on left mid arm, Assess skin integrity, and dialysis fistula, start effective date 7/19/2024...” During EHR review with RN 2 of Comprehensive Assessment, dated 9/11/2024, for Patient 2, indicated, “;Integumentary (skin), wound #1, location left upper arm, type surgical wound, Dialysis fistula on left arm mid arm ... Instructed patients wife to manage patients dialysis fistula follow dialysis nurse instruction. Report on any pain or redness, bleeding on dialysis fistula...” During review of Agency document titled, “;Comprehensive Assessment,” revised May 2024, indicated, “;1. During the comprehensive patient assessment, all baseline date and other relevant information will be documented in the patient clinical record... B. An assessment of severity of secondary symptoms such as... 4. Skin Integrity ...” During EHR review with RN 2 on 7/19/2024 at 5:09 PM of Agency document titled,” Nursing Comprehensive Reassessment, dated 9/11/2024, for Patient 2, indicated, “;Caregiver (RN 1) (documented)... Diagnosis... Other... Chr(onic) kidney disease Stage 5... Start Effective Date: 7/19/2024... ESRD (end stage renal disease) ... Dependence on renal dialysis... Start Effective Date: 7/19/2024... Genitourinary (urinary function ability) incontinent... Dialysis (not marked or addressed) ... Integumentary... Dialysis fistula on left mid arm. Integumentary Interventions Skin integrity and dialysis fistula Effective 7/19/2024...” Condition/Status/Patency of dialysis fistula not addressed. During a concurrent interview with RN 2 on 7/19/2024, at 5:09 PM, RN 2 stated, For Patient 2, the Condition/Status/Patency of dialysis fistula should be assessed on nurse visits.”

“Based on interview and EHR, the agency failed to notify the doctor regarding refusal of Hospice Aide visit for one (Patient 7) of 13 patients. The deficient practice resulted in coordination of patient care needs not maintained. During an interview on 9/16/24 at 9:27 AM, RN 2 stated hospice work week started on Sundays and ended on Saturdays. During EHR review with RN 2 on 7/19/2024, at 3:03 PM, for Patient 7, indicated, “;Hospice Plan of Care... Start of care Date 7/11/24... Musculoskeletal/Activities... Provide Hospice Aide Start Effective Date 7/11/2024, Provide Personal Care/ADL (Activities of Daily Living) instructions to caregiver Start Effective Date 7/11/2024... FREQUENCIES HHA (Home Hospice Aide)... 1 x (time every) week for 2 weeks starting 07/14/2024 (Week 2) End Date: 07/27/2024... “; During a concurrent interview on 7/19/2024, at 3:03 PM, RN 2 stated, no hospice aide home visit was done during Week 3 ( 7/21/24 to 7/27/24). During EHR review with RN 2 of Agency document titled, “;HHA Patient Missed Visit”, dated 7/25/2024, for Patient 7, indicated, “;Caregiver (Hospice Aide) (documented) Patient family said they will assist patient to do ADL...” During a concurrent EHR review and interview with RN 2 on 7/19/2024 of Agency document titled, “;Hospice Nursing Clinical Note”, 7/25/2024, for Patient 7, RN 2 confirmed/stated RN 1 did not address/document familys refusal for Hospice Aide visit (7/25/24). During a concurrent EHR review and interview with RN 2 on 7/19/2024 of Agency document titled, “;IDG (Interdisciplinary Group) Meeting Review”, dated 7/25/2024, for Patient 7, RN 2 stated familys refusal for Hospice Aide visit (7/25/24) was not addressed during the IDG meeting. The doctor needed to be notified of 7/25/24 hospice aide missed visit, and a Doctors Order for 7/25/24 hospice aide missed visit should have been obtained. During review of Agency document titled, “;Care Service Coordination “;, revised May 2024, indicated, “;Purpose To ensure the coordination of services for each patient and to minimize the potential for missed conflicting or duplicated services... Policy... It will be the responsibility of the Case Manager to facilitate communication about changes in the patient’s status among assigned personnel. Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided . The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel... Procedure... 4. Care coordination will include... C. Regularly occurring telephone or e-mail communication among team members... 5. It will be the responsibility of the primary clinician to facilitate communication about changes in the patient status among all assigned disciplines... 9... all personnel will be knowledgeable regarding patient needs goals of care and services...” During review of Agency document titled, “;Missed Visit “;, revised May 2024, indicated, “;Purpose To ensure that misfits are documented and does not affect the quality of patient care. Policy Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. Missed visits will be rescheduled the same week if possible. Missed visits will be documented in the clinical records. Procedure 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patients clinical record the following information... 6. Other person(s) that were notified of missed visit...””

“Based on observation, interview, and EHR, the agency failed to ensure Hospice Aide performed hand hygiene between gloves change. The deficient practice had a potential result for spread of infectious microorganisms. During an observation on 9/17/2024 at 9:43 AM, after Hospice Aide provided personal hygiene care to Patient 1, Hospice Aide 1 did not perform hand hygiene between gloves change. During an interview on 9/17/2024, at 10:05 AM, with RN 2 and Hospice Aide, RN 2 stated that hospice aide should have done hand hygiene between gloves change. Review of Agency document titled, “;Infection Control Guideline”, undated, indicated, “;Handwashing with hand sanitizer opportunities/principles for visiting clinicians... 6. Before donning gloves. 7. After doffing gloves. 8. After contact with body fluids/ excretions, mucous membranes non intact skin, wound dressing. 9. Before moving from dirty body site to a clean body site...””