Ardent Hospice of Fresno

“Based on interviews and record review the Hospice agency ((a specialized form of health care focused on comfort, dignity, and quality of life for individuals with a terminal illness who have a life expectancy of six months or less) failed to ensure the five day comprehensive assessment was done in time for one of three sampled patients (Pt 1) when the Chaplain (CH) made the first initial assessment on 6/22/26 which was 12 days later after the start of care 6/10/26.This failure had the potential to placed the CH at risk of non‑compliance and could have caused a delay in identifying Pt 1’s needs. Findings:During a review of Pt 1’ plan of care (POC) titled, Hospice POC Report, undated, the POC indicated Pt 1 start of care date was on 6/10/26.During a review of Pt 1’s nursing clinical documentation note titled, “Visit Note Report,” dated 6/10/26, the clinical documentation note indicated, “Visit date 6/10/2026…[line] indicate support services needed/referrals required: Chaplain/Spiritual Support…Is patient agreeable to receiving a Chaplain visit within 5 days of admission: YES…”During a review of Pt 1’s CH clinical documentation note titled, “Visit Note Report” dated, 8/6/2026, the CH clinical documentation note indicated, “Visit Date: 6/22/26…Visit Type: Chaplain Hospice Evaluation…”During a concurrent interview and record review with the DPCS, Pt 1’s clinical notes titled “Visit Note Report,” dated 6/10/26, were reviewed. The DPCS stated Pt 1 was admitted on 6/10/26 with the diagnosis of severe protein‑caloric malnutrition (a serious medical condition caused by a major lack of food, protein, and energy). The DPCS stated Pt 1 agreed to a CH visit within the first five days after the start of care. The DPCS stated the first CH visit occurred on 6/22/26, which was 12 days after the start of care. The DPCS stated the CH should have seen Pt 1 within five days. The DPCS stated, “There was nothing to explain why the CH visit was not done within five days.” The DPCS stated the CH did not describe in her interdisciplinary group (IDG—a team of people with training in different fields) note the reason she did not visit within five days. The DPCS stated, “We do not have anything mentioned in the IDG about the reason why, and I can’t tell you why it was late.” The DPCS stated the CH should have gone out to see Pt 1 to ensure a comprehensive assessment and establish spiritual needs in developing the plan of care. The DPCS stated that not going out within five days after the start of care placed the CH at risk of non‑compliance and could have caused a delay in identifying Pt 1’s needs.During a concurrent interview and record review on 8/7/26 at 9:42 a.m. with the Registered Nurse (RN), RN 1 stated she admitted Pt 1 on 6/10/26 and Pt 1 agreed to have the CH visit within five days. RN 1 stated the CH should have made the initial visit within five days after admission. RN 1 stated the team explains chaplain services, and the patient can decide. RN 1 stated the CH should complete the comprehensive assessment, address the patient’s needs, and initiate the individualized plan of care promptly. RN 1 stated patients could miss important information gathering for themselves and their families. RN 1 stated hospice patients have a short time frame and some remain on service for only a brief period. RN 1 stated the CH should make a visit to support patients and families during this critical time. RN 1 stated the patient and family could not receive support for their spiritual needs if the CH did not make a timely visit.During an interview on 8/7/26 at 10:48 a.m. with the CH, the CH stated they are part‑time per diem (on call). The CH stated, “The office does my schedule.” The CH stated, “We have five days to see the patients.” The CH stated, “I went to see the patient 10–15 days later.” The CH stated, “During this period I was having issues.” The CH stated, “I know I have five days to see the patient. If I can’t get a hold of the patient or family, I do not just show up.” The CH stated they need to see the patient and family within five days to complete the initial assessment, address spiritual needs, and share that information with the team. The CH stated they should document attempts. The CH stated they develop a care plan, identify religious beliefs, and support the patient through the process. The CH stated the patient and family could not receive the spiritual support they needed. The CH stated the patient and family might be in spiritual distress; an earlier visit builds trust, eases fear of the unknown and helps the patient find peace during the final stage of life. The CH stated, “It will fall through the “cracks” and they could not receive the care they need.”During an interview on 8/7/26 at 1:58 p.m. with the Executive Director (ED), the ED stated the CH should have completed the visit within five days, and she did not. The ED stated, “The policy was not followed, and she should have gone out within five days.” The ED stated the CH should have completed the visit within five days to develop an individualized and comprehensive plan of care. The ED stated, “Care could have been missed, and completing the visit within five days allows the disciplines to identify needs early in hospice services.”During a record review of the hospice agency’s policy and procedure (P&P), titled “Admission Criteria and Process” dated 5/2024 the P&P indicated, “…If the patient is accepted for hospice care, a comprehensives assessment of the patient will be preformed no later than 5 calendar days after the election of hospice care…””

“Based on interview and record review, the hospice agency (a specialized form of health care focused on comfort, dignity, and quality of life for individuals with a terminal illness who have a life expectancy of six months or less) failed to follow professional standards of practice for three of three sampled patients (Pt 1, Pt 2, and Pt 3) when the Chaplain did not complete clinical documentation for the interdisciplinary group (IDG—a team of professionals with training in different fields) and left blank templates in the IDG notes.This failure had the potential to result in inaccurate spiritual information being discussed and the spiritual needs of Pt 1, Pt 2, and Pt 3 not being met. Findings:During a record review of Pt 1’s IDG note titled “Hospice IDG Comprehensive Assessment and Plan of Care Updated Report,” dated 8/7/26, the IDG note indicated,“[Start of Care]: 6/10/26… This IDG meeting date: 6/24/26… [Chaplain section]: Name/Age/Where does the patient reside: [blank]… Does patient/caregiver have religious preferences: [blank]… Chaplain plan of care: [blank]… Spiritual risk assessment complete: [blank]… Goal of spiritual support: [blank]… Visit frequency: [blank]…”During a record review of Pt 1’s IDG note dated 8/7/26, the IDG note indicated, “[Start of Care]: 6/10/26… This IDG meeting date: 7/8/26… [Chaplain section]: Any changes in the last two weeks to the spiritual POC/Visit Frequency: [blank]… Progress toward goals: [blank]…”During a record review of Pt 1’s IDG note dated 8/7/26, the IDG note indicated, “[Start of Care]: 6/10/26… This IDG meeting date: 7/11/26… [Chaplain section]: Intervention: [blank]… Goal: [blank]… Progress toward goals: [blank]… Immediate needs: [blank]…”During a concurrent interview and record review on 8/6/26 at 2:00 p.m. with the Director of Patient Care Services (DPCS), Pt 1’s IDG notes were reviewed. The IDG notes dated 6/24/26, 7/8/26, and 7/11/26 were not complete. The DPCS stated that the 7/8/26 IDG note contained only a template. The DPCS stated that on 7/11/26 the Chaplain (CH) entered a note, but it was only a template and was not filled out. The DPCS stated all clinical documentation, including IDG notes, should have been complete. The DPCS stated the IDG notes should have shown that each patient’s unique issues were identified and discussed during the meeting. The DPCS stated absent or incomplete documentation shows the team did not discuss the patients’ spiritual issues. The DPCS stated, “Complete IDG notes would have shown the disciplines were involved in the discussion regarding the patient, and without it, could have shown the discipline was not participating in the IDG.” The DPCS stated, “We could have risked non-compliance, and there could have been a delay in identifying the patients’ needs.” The DPCS stated the CH should have documented “no changes” in the IDG note when there were no changes for the last two weeks.During a record review of Pt 2’s IDG note, dated 8/7/26, the IDG note indicated, “…[Start of Care]: 7/3/26…This IDG meeting date: 7/8/26…[Chaplain section]: Name/Age/Where does the Patient Reside: [blank]…Does Patient/Caregiver have religious Preference: [blank] Chaplain [Plan of care]-interventions: [blank]…Spiritual risk Assessment Complete? [blank]…Goal of Spiritual Support: [Blank]…Visit Frequency: [blank]…”During a record review of Pt 2’s IDG note, dated 8/7/26, the IDG note indicated, “…[Start of Care]: 7/13/26…This IDG meeting date: 7/22/26…[Chaplain section]…Any changes in the last 2 weeks to Spiritual [plan of Care]/Visit Frequency: [blank]…progress towards goals: [blank]…”During a concurrent interview and record review 8/6/26 at 2:50 p.m. with the DPCS, Pt’s 2 IDG dated 7/8/26 and 7/22/26 were reviewed. The DPCS stated the CH input an IDG clinical note on 7/8/26 but it was incomplete and there was a template for the portion of the CH. The DPC stated the CH input a template for the IDG note on 7/22/26 and it was not complete.During a record review of Pt 3’s IDG note, dated 8/7/26, the IDG note indicated, “…[Start of Care]: 7/13/26…This IDG meeting date: 7/14/26…[Chaplain section]: Name/Age/Where does the Patient Reside: [blank]…Does Patient/Caregiver have religious Preference: [blank] Chaplain [Plan of care]-interventions: [blank]…Spiritual risk Assessment Complete? [blank]…Goal of Spiritual Support: [Blank]…Visit Frequency: [blank]…”During a record review of Pt 3’s IDG note, dated 8/7/26, the IDG note indicated, “…[Start of Care]: 7/13/26…This IDG meeting date: 7/28/26…[Chaplain section] …Any changes in the last 2 weeks to Spiritual [plan of Care]/Visit Frequency: [blank]…progress towards goals: [blank]…”During a concurrent interview and record review on 8/6/26 at 3:00 p.m. with the DPCS, Pt 3’s IDG clinical notes were reviewed. The IDG clinical notes indicated the CH did not complete the clinical documentation and left templates blank for 7/14/26 and 7/28/26. The DPCS stated the documentation should have been completed, and it was not.During an interview on 8/7/26 at 9:42 a.m. with the Registered Nurse (RN), the RN stated, “We should make sure it is individualized and not leave just the template for the IDG notes.” The RN stated the IDG notes should have contained any changes for the patients within the last two weeks. The RN stated it was not acceptable to leave the template blank and not filled out. The RN stated failing to complete the template resulted in incorrect information being entered into the IDG note. The RN stated not inputting the information would prevent the team from knowing what was happening with the patients. The RN stated incomplete and inaccurate documentation can be a liability for the disciplines. The RN stated the CH was not entering accurate information when documentation was left blank. The RN stated incomplete IDG notes did not address spiritual needs, were not comprehensive, and could cause the team to miss important information regarding care if the disciplines were not coordinating.During an interview on 8/7/26 at 11:10 a.m. with the CH, the CH stated the IDG note contained an incomplete template and should have been completed. The CH stated it was important to fill out the IDG note so everyone was aware of what was going on and the team could see what was happening. The CH stated, “We should come together as a team and discuss the patient’s individual care plan.” The CH stated the IDG note should reflect the issues being discussed. The CH stated, “The patient could not get the provided care because the whole care team is not aware of what is going on at the end of life.” The CH stated the patient’s spiritual needs may not be met when documentation is incomplete.During the agency’s job description titled, Spiritual Care Counseling Services, dated 5/2024, the job description indicated, “To provide guidelines for the appropriate assessment and provision of service to meet the spiritual needs of patients and families/caregivers…The chaplain will be a member of the interdisciplinary group and will participate in the development…spiritual support person will be encourage to participate as an interdisciplinary group member…to document his/her intervention…all clinical notes…will be documented…, The Hospice Chaplain will provide staff, including IDG, support by:…participate in development…During a review of the agency’s policy and procedures (P&P) titled, Comprehensive assessment” dated 5/2024, the P&P indicated, “…The comprehensive assessment is updated by the interdisciplinary group as frequent as the patient’s condition requires…The interdisciplinary group is required to only update those sections that requires updating…If no changes are needed, then that must be documented…””

“Based on interview and record review, the Condition of Participation (COP) for Core Services (§418.64) was determined to not be NOT MET, for three of three sampled patients (Patient 1, 2 and 3) when the hospice (a specialized end of life care for individuals with a terminal illness) agency failed to provide chaplain documentation in the clinical note to assessed spiritual needs during the start of care and interdisciplinary group meeting (IDG- collaborative hospice team care consistent of medical director, registered nurse, social worker and chaplain meeting at least every 15 days to review patient care plans).This failure had the potential for spiritual needs to not be met which could have negatively affected and prolonged the grieving process for Patient 1, 2, and 3 and their families. This cumulative systemic failure resulted in the Hospice Agency’s substantial non-compliance in the provision of care in a quality and safe setting.”

“Based on interview and record review, the hospice (a specialized end-of-life care for individuals with a terminal illness) agency failed to provide three of three sampled patients (Patient 1, 2 and 3) chaplain documentation in the clinical note to assessed spiritual needs during the start of care and interdisciplinary group meeting (IDG- collaborative hospice team care consistent of medical director, registered nurse, social worker and chaplain meeting at least every 15 days to review patient care plans).This failure had the potential for spiritual needs to not be met which could have negatively affected and prolonged the grieving process for Patient 1, 2, and 3 and their families. Findings:During an interview on 5/19/26 at 1:30 p.m. with the Executive Director (ED), the ED stated the hospice agency had two Chaplains: Chaplain 1 and Chaplain 2. The ED stated Chaplain 1 was on leave as of 2/13/26 and was projected to return on 3/12/26. The ED stated the agency provided chaplain services through a sister company while chaplain 1 was on leave. The ED stated Chaplain 2 was hired on 4/1/26. The ED stated no chaplain services were needed from 2/13/26-4/1/26.During an interview on 5/20/26 at 9:48 a.m. Patient 3’s Family Member (FM) was called. FM 1 stated Patient 3 was located at assistance living facility. FM 1 stated he did not recall if chaplain services were offered. FM 1 stated the agency communicated with him when they visited Patient 1. FM 1 stated he did not get any calls from the chaplain at start of care.During a concurrent interview and record review on 5/20/26 at 10:20 a.m. with the Director of Patient Care Services (DPCS – a clinical manager of the hospice agency), Patient 1’s “Hospice Certification and Plan of Care (HCPC – a documentation which outlines the specific medical, physical, emotional, and spiritual services a patient and their family will receive)”, “undated” was reviewed. The “HCPC” indicated, “… Start of Care Date: 3/14/2026…Frequency/Duration of Visits… [Chaplain 1 month 1 time] … Orders of Discipline and Treatments…CHAPLAIN TO EVALUATE PATIENT AND DEVELOP PLAN OF CARE…” The DPCS stated the chaplain did not make a visit for Patient 1. The DPCS stated there was no documentation by the chaplain at start of care During a concurrent interview and record review on 5/20/26 at 10:25 a.m. with the DPCS, Patient 1’s “Visit Note Report (VNR),” dated 3/17/26 was reviewed. The “VNR” indicated, “… Religious and cultural status no religious affiliation was reported. No specific cultural or spiritual needs were identified at this time…” The DPCS stated “We did not send out the chaplain because the MSW identified there were no need for the visit.During a concurrent interview and record review on 5/20/26 at 10:40 a.m. with the DPCS, Patient 2’s HCPC, “undated” was reviewed. The HCPC indicated, “…Frequency/Duration of Visits… [Chaplain 1 month 1 time] … Orders of Discipline and Treatments… CHAPLAIN TO EVALUATE PATIENT AND DEVELOP PLAN OF CARE…” The DPCS stated the chaplain did not make a visit. The DPCS stated there was no documentation by the chaplain at start of careDuring a concurrent interview and record review on 5/20/26 at 10:45 a.m. with the DPCS, Patient 2’s “VNR,” dated 3/17/26 was reviewed. The “VNR” indicated, “…Religious and cultural status the patient identifies as Christian. The family reports strong support from their church community and declined chaplain services at this time…” The DPCS stated “We did not send out the Chaplain because the MSW identified there were no need for the chaplain visit.”During a concurrent interview and record review on 5/20/26 at 10:50 a.m. with the DPCS, Patient 3’s “Patient Information Report (PIR - a document that summarizes a patient’s health status, medical history, medications, and treatments)”, undated was reviewed. The “PIR” indicated no visit frequency for chaplain. The DPCS stated, “The chaplain did not go out per RN initial assessment.” The DPCS stated chaplain were needed to provide spiritual support for patients and families at end of life. During an interview on 5/21/26 at 2:52 p.m. with the RN, the RN stated the chaplain should have completed the initial spiritual assessment for all hospice patients to be compliant with regulations. The RN stated the chaplain should have gone out to address spiritual issues and concerns. The RN was asked if MSW can assess the spiritual needs of the patient and family. The RN stated, “The MSW would not be able to address spiritual related issues or concerns”. The RN stated each hospice patient has a designated visit frequency that should be followed to meet the patients’ needs and remain compliant with the plan of care. The RN stated the care plan should be updated for any changes to guide care and treat the patient accordingly. The RN stated, without the Chaplain visit, the spiritual needs of the patient and family would not be met.During an interview on 5/21/26 at 3:21 p.m. with Chaplain 2, Chaplain 2 stated the initial spiritual assessment should have been completed by the chaplain within five days of hospice admission and documented. Chaplain 2 stated it was important to complete the spiritual assessment to determine the patient’s and family’s religious beliefs and identify the type of spiritual counselling needed. Chaplain 2 stated the initial visit would have help determine whether patient and families would like to connect with a priest or another spiritual advisor of their choice. Chaplain 2 stated chaplains provided spiritual support and addressed the spiritual needs of patients and families as a comprehensive part of patient care. Chaplain 2 stated the spiritual care plan should have been updated for any changes in interventions by the DPCS. Chaplain 2 stated the MSW could not assess the spiritual needs of the patient and family. Chaplain 2 stated the spiritual needs of the patients and families would not be met when the initial visit assessment was not done.During an interview on 5/21/26 at 3:37 p.m. with MSW, the MSW stated, “ I do not do the spiritual counseling.” The MSW stated, “ I do bereavement and address the psychosocial aspect for the patient and families” The MSW stated she does not provide spiritual support. The MSW stated. “I give the family a call and introduce myself and tell them about my work and do my psychosocial assessment.” The MSW stated she attended IDG meetings. The MSW stated during her initial assessment she would have identified what kind of church the patients were affiliated with. The MSW stated she would document that on her clinical note. The MSW stated it was part of her initial assessment to ask the questions. The MSW stated her documentation does not mean the family or patient does not need spiritual needs. The MSW stated she would not recommend the chaplain to not make a visit. The MSW stated it was important for the chaplain to do their own assessment. The MSW stated the chaplain should have gone out within 5 days to do their own spiritual assessment. The MSW stated it was important for the chaplain to do the assessment to address the spiritual needs and should have been documented. The MSW the spiritual needs for patients and family would have not been met when it was not done. The MSW stated she would not be able to play the role of the chaplain because she was not a chaplain. During an interview on 5/21/26 at 3:37 p.m. with the ED, the ED stated we have an agreement with their sister hospice facility in Sacramento to provide MSW and chaplain services. The ED stated there were no documentation done by the chaplain due to the assessment of the MSW for the patients. The ED stated no chaplain visit and no documentation was done for Patient 2 due to MSW document note. The ED was able to provide the name of the chaplain who filled in for Chaplain 1. The ED stated he would provide the phone number for the chaplain who filled in for Chaplain 1 on 5/22/26. During an interview on 5/22/26 at 8:30 a.m. with the ED, the ED was asked to provide the contact information for the chaplain who covered Chaplain 1 while on leave. The ED was unable to provide contact information. The ED stated both ED and DPCS were responsible for finding the coverage for Chaplain 1’s absenceDuring an interview on 5/22/26 at 8:59 a.m. with DPCS, the DPCS stated the initial spiritual assessment was an individualized care plan and was needed to address the spiritual needs of the patient and family. The DPCS stated the importance of chaplain assessment is to provide spiritual health for the patients and families. The DPCS stated the failure to complete a chaplain assessment will result in increased grieving, and the emotional and spiritual needs of the patient and family may go unmet. The DPCS stated his role, and responsibilities were to provide general oversight and ensure all disciplines attend IDG meetings. The DPCS stated he was responsible for ensuring all staff follow policies and procedures.During an interview on 5/27/26 at 3:35 p.m. with the DPCS, the DPCS stated the plan of care which addresses the patients’ need were discussed during the IDG meeting. The DPCS stated the Medical Director (a licensed physician responsible for clinical oversight, strategic leadership, and regulatory compliance within a healthcare facility) RN, MSW and chaplain should have attended all IDG meetings. The DPCS stated the chaplain services were not needed for Patient 1, 2 and 3. The DPCS stated there were no documentations in the IDG meeting from the chaplain. The DPCS, stated “I do not recall if there was a discussion about the spiritual needs.” The DPCS was asked to provide documentation to show the chaplain was part of the IDG meeting. The DPCS stated the chaplain was not needed during the periods of 2/13/26-4/1/26. The DPCS stated we do not have the phone number for the chaplain who filled in for Chaplain 1. The DPCS stated we communicated with the chaplain who filled in for Chaplain 1 communicate application and email. The DPCS stated, “ We did not use his services at that time” The DPCS stated he did not have the information for the chaplain who filled in for Chaplain 1.During a review of the agency’s job description (j/d) titled, Medical Social Worker/social work Associate, dated 2018, the J/D indicated, “Essential job functions/responsibilities” assess the psychosocial status…assess for and educate IDG group on special needs related to culture…assist family and patient in planning for funeral arrangements…” The job description did not specify any spiritual assessment responsibilities.During a review of the agency’s “J/D” titled, “Hospice Chaplain” dated 2018, the “J/D” indicated, “The Hospice Chaplain is responsible for the provision of spiritual care services to patients and families/caregivers….7. attends patient care conference and interdisciplinary group meetings as a member of the interdisciplinary group….8. Provide consultation, education, and support to the interdisciplinary group on spiritual care…”During a review of the agency’s policy and procedure (P&P) titled, “SPIRITUAL ASSESSMENT,” dated May 2024, the P&P indicated, “…A spiritual assessment will be completed for each patient/family by the Hospice Chaplain. The assessment will include, but not limited to, evaluation of the following… Coping with and adjusting to the patient’s terminal illness… if the patient and/or family/caregiver refuse these services, the refusal will be documented. The interdisciplinary group members will continue to assess spiritual needs and offer appropriate services to the patients and or family/caregiverDuring a review of the agency policy and procedures (P&P) titled, Interdisciplinary Group Membership and Responsibilities, dated 2018, the “P&P” indicated, “…The hospice interdisciplinary group member includes at minimum: A, Physician, B. Registered nurse, C. Social worker/marriage and Family counselor, D. Pastoral [chaplain]…”During a review of a professional article title, “Spiritual Care Guide in Hospice-Palliative Care” dated 12/1/2023, retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10703561/, the professional article indicated, “… The purpose of hospice and palliative care is to relieve the physical, psychological, social, and spiritual distress of patients who are approaching the end of their lives, as well as that of their families, ultimately enhancing their quality of life. Specifically, providing spiritual support to patients during end-of-life care has been shown to have markedly positive effects on a range of health outcomes. These include spiritual well-being, overall quality of life, adaptability, physical health, and reductions in depression and anxiety. Additionally, it contributes to increased satisfaction with care, improved social connections, and more informed end-of-life decision making. Therefore, spiritual care is a vital element of hospice and palliative care, significantly influencing the quality of the care provided…””

“Based on interview and record review, the agency did not have a volunteer program from August 2022 until present since the change of the ownership. This failure placed the agency out of compliance for CFR (code of federal regulation) 418.78 Conditions of participation: Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects. One of two projects was hiring a volunteer coordinator to establish the volunteer program. The DPCS stated she found a good candidate to hire to designate the position as volunteer coordinator. The DPCS presented a paper with handwritten projects with priorities she had been working on for the past few months. The DPCS admitted the agency had been out of compliance with the conditions of participations for Volunteers. During a phone interview on 10/15/24 at 1:36 p.m., with the Administrator (ADM), the ADM stated he was just appointed as the new administrator a month ago and the agency was in process of correcting many issues. The ADM stated since the change of ownership occurred in August 2022 the agency decided to withdraw from being deemed. The ADM stated since the change of ownership, the agency had been out of compliance for Volunteers program. The ADM stated he was working on hiring a candidate for the position for Volunteer Coordinator with the DPCS to start the program. During an interview on 10/22/24 at 2:30 p.m., with the DPCS and the candidate for volunteer coordinator, the DPCS was reminded the required components of the volunteer programs including training, role, recruiting and retraining, cost saving and level of activity. The DPCS understood the requirements to meet the condition of participation upon re-visit. During a review of the agencys policy and procedure (P&P) titled “;Volunteers” dated 5/22, the P&P indicated, “;[the agency] will provide volunteer services under the direction of a Volunteer Coordinator and the assistance of trained hospice volunteers.””

“Based on interview and record review, the agency failed to ensure the governing body oversees the management, operations and services provided to patients when the agency did not have a volunteer program since 8/2022. This failure placed patients and their families at risk for not receiving the physical and emotional assistance needed during end of life. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanent as of 8/15/24 after serving as an interim by cooperate office. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a phone interview on 10/15/24 at 1:36 p.m., with the Administrator (Adm), the Adm stated he was just appointed as the new administrator a month ago. The Adm stated since the change of ownership on 8/2022, the agency had been out of compliance for Volunteers program. During a review of the agencys policy and procedure (P&P) titled “;Governing Body” dated 5/24, the P&P indicated, “;The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resources management, review of the organizations budget and operational plans, and its quality assessments and performance improvement (QAPI) program.””

“Based on interview and record review, the agency failed to conduct the initial assessment within 48 hours for one of 14 sampled patients (Patient 6). This failure placed Patient 6 at risk for not receiving palliative care and for the family members and caregivers to not receive support as soon as possible. During a concurrent interview and record review, on 10/21/24 at 10:25 a.m., with the Director of Patient Care Services (DPCS), Patient 6s clinical record was reviewed. The referral was on 10/31/23 but the start of care (SOC) was on 11/6/23. The DPCS could not locate the reason for the delay of service. The DPCS stated the current electronic medical record (EMR) did not show the coordination note justifying the reason for the delay. The DPCS stated she was new to the agency, and she deferred the question to the Intake personal who was familiar with the record keeping. During an interview with the intake personal at 10:30 a.m., the Intake Personal stated, “;If there was a delay in the coordination, a note should be generated.” The DPCS confirmed the delay of the service without justification. The DPCS stated it was very important to provide service within 48 hours from the referral for the agency to provide the necessary palliative measure to the patient and the bereavement service to the family members and caregivers. During a review of the agencys policy and procedure (P&P) titled, “;Admission Criteria and Process” dated 5/22, the P&P indicated, “;...Once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission , and applicable law and regulations...In the event that time frame for assessment cannot be met, the patients physician and the referral source, as well as the patient , will be notified for approval of the delay. Such notification and approval will be documented.””

“Based on interview and record review, the agency failed to provide initial bereavement assessment for three of 14 sampled patients (Patients, 1. 3 and 8). These failures placed patients, their family members, and caregivers at risk for not receiving necessary bereavement support identified from the beginning of the service. 1.During a concurrent interview and record review on 10/17/24 at 10:40 a.m., with the Director of Patient Care Services (DPCS), Patient 1s initial bereavement assessment record was reviewed. The initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop a bereavement plan of care. The start of care (SOC) was on 9/28/23. The coordination note indicated Patient 1 refused Master Social Work (MSW) 2s visit on 9/29/23. Chaplain 1 tried to contact Patient 1 on 10/3/23 and 10/30/23 but unsuccessful. 2.During a concurrent interview and record review on 10/17/24 at 11:30 a.m., Patient 3s initial bereavement assessment record was reviewed. DPCS stated the initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop bereavement plan of care. The SOC was on 5/22/24. Chaplain 1 made a home visit on 5/23/24 and MSW 2 made a visit on 5/24/24. Three disciplines (Registered Nurse/Case Manager, MSW and Chaplain) made home visits within 5 days of the SOC but did not conduct the bereavement assessment to develop a bereavement plan of care. 3.During a concurrent interview and record review on 10/17/24 at 4 pm, with the DPCS, Patient 8s initial bereavement assessment record was requested to be reviewed. The initial bereavement assessment was not conducted. The DPCS stated she could not locate the documented evidence that the agency identified the bereaved and the level of crisis to develop bereavement plan of care. The SOC was on 9/30/24. MSW 1 made a home visit on 10/3/24 and Chaplain 1 made visit on 10/4/24. Three disciplines made home visits within 5 days since the SOC but did not conduct the initial bereavement assessment to develop a bereavement plan of care. During an interview on 10/16/24 at 9:40 a.m., with Chaplain 1, Chaplain 1 stated his responsibility was to ensure make calls to schedule visits. Chaplain 1 stated once the visit was made, he follows up on the concerns. Chaplain 1 stated currently most of patients were at low risk and no counselling was provided. MSW 2 was no longer employed by the agency and was unable to conduct an interview. During an interview on 10/17/24 at 10:40 a.m., with the DPCS, the DPCS stated, “;Initial bereavement assessment should be done within 5 days from start of care. If death is imminent, I expect the registered nurse case manager (RN/CM) should conduct bereavement assessment on start of care. Currently Chaplain 1 oversees the agencys bereavement program.” During a review of the agencys policy and procedure (P&P) titled “;Bereavement Services” date 5/24, the P&P indicated, “;[the agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator...A bereavement risk assessment will be completed by the hospice social worker at the time of admission of 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.””

“Based on observation, interview, and record review, the agency failed to educate primary caregivers the importance of reporting patient care and safety needs during home visits for one of three sampled patients (Pt 2) when board and care staff was unaware to report Pt 2s fall incidents and need for a podiatry consult for overgrown toenails to the agency. This failure placed Pt 2 at risk for serious injury from possible entrapment during a fall from a bed with side rails and experienced pain and discomfort from an overgrown toenail. During a concurrent observation and interview, on 10/15/24 at 11:30 a.m., with the Master Social Work (MSW) 1, in Patient 2s boarding care facility, Patient 2 was observed sleeping in her bed. One side of the bed was observed against the wall and the other side was observed with a metal side rail up. The side rail was equipped with padding which was secured by Velcro at several points. Patient 2 was observed small in size in her bed. Patient 2s caregiver stated Patient 2 had a fall on 10/12/24 at 6:10 p.m. causing her bruises but no other injuries. Patient 2s caregiver stated Patient 1 had torn the padding from the side rail and slipped through the side rail and fell. Pt 2s caregiver stated she was unaware the expectation was to call the agency after each fall, regardless if there are no injuries. During a concurrent observation and interview on 10/15/24 at 12 p.m., with the Registered Nurse/Support Clinical Staff (RN/SCS) who accompanied the home visit, Patient 2s feet were observed. Patient 2s right and left big toenails were too thick and long to check the cleanliness of the nail bed. Patient 2s left middle toenail was observed long and curved and Patient 2s right 4th toenail and pinky toenail were observed long and curved. The RN/SCS stated Patient 2s nail care should have been done either by the agencys aide or the facilitys caregiver before it came to this situation requiring a podiatrist. During a review of Patient 2s plan of care (POC) dated from 9/30/24 to 11/28/24, the POC indicated, “;Goals: Patient will have safety needs met...Patient will receive personal care and hygiene other activities of daily living to their optimal level...” During an interview on 10/23/24 at 10 a.m., with Registered Nurse/Case Manager (RN/CM) 1, the RN/CM 1 stated she expected Pt 2s board and care staff to notify the agency of any concerns regarding safety and personal care. The RN/CM 1 stated it was the agencys responsibility to ensure the board and care staff know what to report by ongoing communication. The RN/CM 1 stated Patient 2 was assigned to RN/CM 2 recently. The DPCS stated RN/CM 2 was not available for an interview due to a family emergency. During a review of the document titled “;Important Reasons to Call Hospice” undated, indicated, “;...Has fallen -even if he/she can get up and denies injury...” During a review of the document titled “;Facility & Hospice Coordination of Care” customized for Patient 2, dated 10/14/24, indicated, “;Hospice will provide ...Aide will provide personal care to resident 2 time/week...” During a review of Patient 2s “;Aide Care Plan Report” dated 10/11/24, the Aide Care Plan Report indicated nail care was to be provided once a week. During a review of the agencys policy and procedure (P&P) titled “;Interdisciplinary Group Coordination of Care” dated 5/22, the P&P indicated, “;It will be the responsibility of the Clinical Supervisor to assign a Case Manager who is a registered nurse. The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge...It will be the responsibility of the case manager to facilitate communication about changes in the patients status...””

“Based on interview and record review, the agency failed to provide and ensure the ongoing sharing of information between all disciplines providing care and services for one of 14 sampled patients (Patient [Pt]12) when Pt 12 refused three consecutive Aide service dates and the Aide did not communicate with the Registered Nurse/Case Manager (RN/CM). This failure resulted in not notifying the physician and possible altering the Aide visits to meet the needs of Patient 12. Patient 12 was discharged from the agencys service. During a concurrent interview and record review, on 10/15/24 at 3:30 p.m., with the Director of Patient Care Services (DPCS), Patient 12s clinical record was reviewed. Patient 12s Plan of Care (POC) dated from 6/26/24 to 8/24/24 was reviewed and the POC indicated the start of care (SOC) was 6/26/24. The physician ordered the hospice aide to provide visits twice a week. The coordination note indicated that hospice aide visit was missed three consecutive times, on 7/5/24, 7/9/24 and 7/11/24. The DPCS stated there was no evidence of communication between the aide and RN/CM 4 to notify the physician to discuss the situation. The DPCS stated Patient 2 wanted minimal visits from the necessary discipline and disliked busy scheduling. The DPCS stated Patient 2 could have benefited from discontinuing aide visits from physician from the beginning of the service if there were communication between disciplines to honor Patient 2s comfort level of visit frequency and type of service. During a review of Patient 12s “;Discharge Note” dated 7/15/24 and written by Registered Nurse/Case Manager (RN/CM) 4, the discharge note indicated, “;Patient has elected to revoke hospice services at this time...she likes to get out and waiting for visits causes her to alter her daily plans...” RN/CM 4 was no longer employed by the agency and was unavailable for an interview. During a review of the facilitys policy and procedure (P&P) titled “;Interdisciplinary Group Coordination of Care” dated 5/22, the P&P indicated, “;It will be the responsibility of the Case Manager to facilitate communication about changes in the patients status between interdisciplinary group members and the patients attending physician.””

“Based on interview and record review, the agency failed to document for the previous two-year period what performance improvement (PI) project(s) was being conducted, the reason for conducting these projects, and the measurable progress achieved on these projects. These failures resulted in the agency not evaluating the quality of services being provided to patients which could result in avoidable negative outcomes. These failures affected all patients provided services by the agency. During an entrance conference interview on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects by hiring volunteer coordinator to establish volunteer program and establishing hospice aide supervision and training program. The DPCS stated those two PI projects were chosen to meet the federal requirements. The DPCS presented a paper with handwritten projects. The DPCS admitted the agency had been out of compliance with two conditions of participations involving volunteers and hospice aide program. The DPCS stated the agency did not have any PI projects for past two years while the previous Administrator/DPCS was the designee for the PI projects. During a review of the agencys policy and procedure (P&P) titled “;Improving Organizational Performance” dated 5/22, the P&P indicated, “;1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity and past performance of the organizations services and operations. 2. The organization must document the quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress achieved on these projects.” During a review of the agencys P&P titled “;Governing Body” dated 5/24, the P&P indicated “;The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systemic communication between the two. Performance of the Executive Director/Administrator will be monitored annually through a procedure established by the Governing Body...Relevant findings of performance improvement activities are consistently provided to the Governing Body...””

“Based on interview and record review, the agencys Governing Body failed to ensure the QAPI (Quality Assessment Performance Improvement) meeting was held quarterly when the agency missed three quarterly meetings, one for the 4th quarter of 2023 and two for the second and third quarter of 2024. These failures placed patients at risk for not receiving quality patient care services in a safe setting. During a concurrent phone interview and record review on 10/15/24 at 7 a.m., with the corporate personnel, the corporate personnel explained the agencys poor performance from August 2022 till the current DPCS was designated in August 2024. The corporate personnel stated due to lack of leadership the agency did not have good record keeping for quarterly QAPI meetings. After the phone conversation with the corporate personnel, the agency presented past QAPI meeting minutes. Since the change of the ownership in August 2022 the QAPI meeting was held five times instead of eight times with no QAPI meeting being held for the 4th quarter of 2023 and the 2nd and 3rd quarter of 2024 During a review of the agencys policy and procedure (P&P) titled “;Governing Body” dated 5/24, the P&P indicated, “;The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide quality assessment and performance improvement program (QAPI). Information related to the performance improvement program will be provided to the Governing Body on a quarterly basis...The Governing Body will appoint a Corporate Compliance Committee (The Committee) ...the Committee will meet at least quarterly...””

“Based on interview and record review, the agency failed to demonstrate an organized bereavement program for one of two expired patients (Patient 13) when the bereavement care plan for Patient 13 was not updated after Patient 13s death to support the bereaved according to bereavement activity records. This failure placed the bereaved not receiving needed grief and loss counselling. During a review of Patient 13s “;Bereavement Activity Report (BAR)” dated from 12/26/23 to 3/8/24 indicated Patient 13s date of death was 12/22/23. The BAR indicated Chaplain 1 made a phone visit to Patient 1s bereaved on 12/26/23. The “;Visit Note Report” dated 12/26/24 indicated, “;CP (chaplain) called granddaughter to offer condolences and bereavement support. Granddaughter reported that family has some challenges in adjusting to loss. Granddaughter and spouse are open to bereavement support. Bereavement Coordinator will follow up with family to schedule bereavement support after the holiday season. Granddaughter said that they will begin final arrangement plans today.” During a concurrent interview and Patient 13s clinical record review on 10/15/24 at 3:30 pm, with the Director of Patient Care Services (DPCS), Patient 13s Plan of Care (POC) dated from 10/3/23 to 12/31/23 was reviewed. The POC indicated the start of care was 10/3/23 and the Medical Social Work (MSW) 2 made a visit on 10/5/23. The DPCS confirmed the second visit by MSW 2 was 6 days prior to patients death on 12/22/23. The DPCS stated there was no evidence of MSW 2 or Chaplain 1 called or visited the Bereaved to support as death was imminent. The DPCS confirmed there was no follow up visit by either Chaplain 1 or MSW 2 to support Patient 13s granddaughter who expressed need for counselling service. The IDG (interdisciplinary Group) meeting note dated 12/27/23 written by MSW 2, the note indicated, “;Psychosocial status at time of death: Patient passed at home with family bedside. Family/caregiver coping/ support system: granddaughter has large family support system. Any need for counselling? Grief counselling offered.” The DPCS stated that time the Bereavement Coordinator was Chaplain 1. During a review of the agencys policy and procedure (P&P) titled “;Bereavement Services” dated 5/24, the P&P indicated, “;[the agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (10 year following the death of the patient. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice...Information generated 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...The bereavement counsellors may provide supportive counselling to the patient and family/caregiver prior to death...persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered as noted in the plan of care. Persons identified will be referred to the Bereavement Coordinator and intervention will be followed as follow: A. The Bereavement Coordinator will evaluate each bereaved on a case by case and evaluate the need for individual counselling...A bereavement file will be maintained...Each file will contain the following information...A bereavement plan of care that includes needs and goals for ongoing support...””

“Based on interview and record review, the agency failed to demonstrate evidence of annual 12 hours in-service requirement for three of six hospice aides (Hospice Aide 1, 2 and 3). These failures placed patients at risk for receiving personal care from personnel without updated skills and could possibly negatively affect patients. During a concurrent interview and record review on 10/21/24 at 2:30 p.m., with the Director of Patient Care Services (DPCS), hospice aide (HA)s annual in-service record was reviewed. The DPCS stated the agency did not have a readily available organized tracking system for review. The DPCS stated since she took over the position a few months ago she had been working on this project. The DPCS contacted each HA and provided copies of evidence of in-service. Three of six HAs had in-service hours that have been met. The following three HAs did not meet the annual 12 hours in-service requirements from their date of hire (DOH). HA 1 DOH 7/1/23 In-service hours completed 5.26 hours. HA 2 DOH 3/6/23 In-service hours completed 4.85 hours. HA 3 DOH 5/8/23 In service hours completed 0.00 hours. During a review of the agencys policy and procedure (P&P) titled “;Director of Patient Care Services-Hospice” undated, the P&P indicated, “;Plans and implements in-service and continuing education programs to meet education and training needs of organization personnel.””

“Based on observation, interview, and record review, the Registered Nurse/Case Manager (RN/CM) 2 who was responsible for the supervision of Hospice Aide (HA) 4 failed to provide written patient specific plan of care (POC) for one of three sampled patients with home visit (Patient 2) when instructions were not provided to perform both fingernail and toenail care. Toenail care was not done by HA 4 on Pt 2s toenails. These failures placed Patient 2 at risk to experience discomfort and pain while ambulating and worsened the condition of the toenails and required podiatrist consultation. During a concurrent observation and interview on 10/15/24 at 12 p.m., with Registered Nurse/Support Clinical Staff (RN/SCS) who accompanied the home visit, Patient 2s feet were observed. Patient 2s right and left big toenails were too thick and long to check the cleanliness of the nail bed. Patient 2s left middle toenail was observed flipped and Patient 2s right ring toenail and pinky toenail were observed long and curved. The RN/SCS stated Patient 2s nail care should have been done either by the agencys aide or the facilitys caregiver before the situation worsened requiring a podiatrist. During a phone interview on 10/21/24 at 4:10 p.m., with HA 4, HA 4 stated, “;...Nail care means file the nails and check the nail beds for cleanness. We are not allowed to cut the nails. I have been doing only fingernails...supposed to check toenails as well...” During an interview on 10/21/24 at 4:10 p.m., with the Director of the Patient Care Services (DPCS), the DPCS stated, “;I expect the case manager give the aides specific guidance about nailcare...its not clear to the aide assignment...should have better plan of care for aide to follow...” During a review of Patient 2s “;Aide Care Plan Report” dated 9/30/24, the Aide Care Plan Report indicated nail care was to be provided once a week. It did not indicate fingernails or toenails or what to do and what not to do. During a review of Patient 2s aide visit note dated 10/10/24, the aide visit note entered by HA 4 indicated, “;Service Nail Care Completed: Y {yes). “;No narrative documents were entered on this visit. During a review of Patient 2s “;Client Coordination Note Report” dated 10/20/24 and 10/22/24 entered by RN/CM 2, did not contain observation of Client 2s toenails requiring podiatrists intervention. During an interview on 10/22/24 at 9:15 a.m., with the RN/CM 3, RN/CM 3 stated she expected the aide to provide nailcare for both fingernails and toenails and for the aids to check the nails and if they were too brittle or unable to keep them clean for any reason to report to their case managers. The RN/CM 3 stated unless the aide care plan specified not to do toenail care due to diabetes, she expected the patients feet to be maintained clean and toenails to be filed. During an interview on 10/22/24 at 10 a.m., with RN/CM 1, RN/CM 1 stated she expected HA 4 to provide nail care. When asked about Patient 2s overgrown toenails RN/CM 1 stated Patient 2 was no longer her patient. RN/CM 1 stated Patient 2 was reassigned to RN/CM 2 recently. The DPCS stated RN/CM 2 coded her visits as supervisory visits, but she did not identify the issues with Patient 2s toenails. The DPCS stated RN/CM 2 was not available for an interview due to a family emergency. During a review of the agencys policy and procedure (P&P) titled “;Registered Nurse” dated 6/26/24, the P&P indicated, “;...Instructs, supervises and evaluates home health [hospice] aide care provided every (2) weeks...” During a review of the agencys P&P titled “;Responsibilities/Supervision of Clinical Services” dated 5/24, indicated, “;Nursing and hospice aide services will be under the supervision of a registered nurse who has at least two (2) years of hospice or community-based health care experience...Hospice aide supervisory visits will be conducted on site at least every two weeks by a hospice registered nurse. Supervisory visits can be made in conjunction with the hospice aide or in his/her absence. A direct observation supervisory visit will be made at least annually...””

“Based on interview and record review, the agency failed to conduct an annual on-site visit to evaluate hospice aide (HA) s performance for two of six hospice aide (HA 2 and HA 3). This failure placed the patients care needs to not be met. During a concurrent interview and record review on 10/21/24 at 2:30 p.m., with the Director of Patient Care Services (DPCS), hospice aides annual on-site performance evaluation record was reviewed. The DPCS stated two of six HAs did not have their annual evaluations. The following two HA did not have the annual on-site evaluation from their date of hire (DOH). HA 2 DOH 3/6/23 annual on-site evaluation due 3/6/24 (7 months overdue) HA 3 DOH 5/8/23 annual on-site evaluation due 5/8/24 (5 months overdue) During a review of the agencys policy and procedure (P&P) titled “;Responsibilities/Supervision of Clinical Services” dated 5/24, the P&P indicated, “;Nursing and hospice aide services will be under the supervision of a registered nurse who has at least two (2) years of hospice or community-based health... A direct observation supervisory visit will be made at least annually...””

“Based on interview and record review, the agency failed to maintain, document and provide volunteer orientation and training for two years (since August 2022 until present). This failure placed the agency unable to provide qualified volunteers to provide appropriate services in accordance with the plan of care and hospice program. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance Improvement) projects and one of them is to hire a qualified volunteer coordinator who can establish the volunteer training program. The DPCS stated the two PI projects were chosen to meet the federal requirements. The DPCS stated the agency had been out of compliance by not having a volunteer program. During a review of the agencys policy and procedure (P&P) titled “;Volunteer Services” dated 5/22, the P&P indicated, “;to ensure that qualified volunteers provide appropriate services...The Volunteer Coordinator will develop, implement, and evaluate the volunteer services program on an ongoing basis but at least annually...The Volunteer Coordinator will document ongoing efforts to...train...””

“Based on interview and record review, the agency failed to utilize volunteers in day to day administrative and/or direct patient care roles for 14 of 14 sampled patients. This failure placed the agency out of compliance for the condition of participation for Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI projects, one of them is to hire a volunteer coordinator to establish the volunteer program. The DPCS stated the agency did not utilize volunteers at all for past two years. During a review of the agencys policy and procedure (P&P) titled “;Volunteer Services” dated 5/22, indicated, “;...Volunteers may work in variety of capacities, including 1. Patient care volunteers 2. Bereavement volunteers 3. Errands and transportation volunteers 4. Office volunteers...””

“Based on observation, interview, and record review, the agency failed to demonstrate the effort to recruit and retain volunteers. This failure placed the agency being out of compliance with the condition of participation for Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position as permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. There was no brochure observed in the lobby area for a volunteer program. When asked to provide any brochure or advertisement to recruit volunteers, the DPCS stated the agency had none. The DPCS stated she would be hiring the volunteer coordinator and start the recruitment process and advertise for volunteers. During a review of the agencys policy and procedure (P&P) titled “;Volunteers Services” dated 5/22, the P&P indicated, “;The Volunteer Coordinator will document ongoing efforts to recruit, train and retain volunteers of all ages and ethnic backgrounds.””

“Based on interview and record review, the agency failed to document the cost savings achieved using volunteers. This failure placed the agency out of compliance for the condition of participation for Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled “;Volunteer Services” dated 5/22, the P&P indicated, “;Volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patients clinical record...the Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer service will exceed 5 % of the total patient care hours of paid and contracted hospice personnel.””

“Based on interview and record review, the agencys volunteers failed to provide day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 % of the total patient care hours for all paid hospice employees and contract staff and maintain records of hours and type of service. This failure placed the agency out of compliance for the condition of participation for Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled “;Volunteer Services” dated 5/22, the P&P indicated, “;the Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer service will exceed 5 % of the total patient care hours of paid and contracted hospice personnel.””

“Based on interview and record review the agency failed to provide Volunteer services for patients as a standard service when the agency did not have a designated volunteer coordinator to establish the program necessary for two years since the change of the ownership occurred in August 2022. This failure placed the agency out of compliance for the condition of participation for Volunteers. During an entrance conference on 10/14/24 at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she took the position permanently as of 8/15/24 after serving as an interim DPCS. The DPCS stated she had been working on two PI (performance improvement) projects and one of the projects was to hire a volunteer coordinator to establish a volunteer program. The DPCS stated the agency had been out of compliance for the condition of participation for Volunteers since the agency did not have an active volunteer program for two years (since 8/2022). During a review of the agencys policy and procedure (P&P) titled “;Governing Body” dated 5/24, the P&P indicated, “;The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resources management, review of the organizations budget and operational plans, and its quality assessments and performance improvement (QAPI) program.””

“Based on interview and record review, the agency failed to perform the annual evaluation for two of six Hospice Aides (HA 2 and HA 3) and one of four Registered Nurse/Case Managers (RN/CM 1). These failures placed patients care needs to not be met. During a concurrent interview and record review, on 10/23/24 at 9:50 a.m., with the Human Resources (HR), the agencys personnel files for competency evaluation were reviewed. The HR was not able to locate the annual competency evaluation for the following employees. The HR stated the annual competency date should have been done on or near the date of hire (DOH) every year. The following employees were found to not have a competency evaluation for 2024 in their files. HA 2 DOH 3/6/23 HA 3 DOH 5/8/23 RN CM2 DOH 8/16/22 During an interview on 10/23/24, at 10 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she performed annual competency evaluation for HA 2s on 10/14/24 (survey entrance date). The DPCS stated it was the DPCSs responsibility to evaluate clinicians and ensure RN/CMs evaluate their HAs competency annually. During a review of the agencys policy and procedure (P&P) titled “;Performance Evaluation” dated 5/24/24, the P&P indicated, “;Performance evaluations will be completed (and dated) on all personnel as follows...annually, based on personnels annual evaluation date...At least annually, clinical personnel must demonstrate proficiencies in the appropriate core competency...” During a review of the agencys job description titled “;Director of Patient Care Services-Hospice” undated, indicated, “;Conducts clinician performance evaluations annually, or more frequently if indicated...Evaluates performance of Clinical Supervisors [RN/CM] ...””