Newport Hospice Care

“Based on interview and record review, the hospice (medical care for people who are expected to live six months or less) agency failed to ensure an initial bereavement assessment (an evaluation of the patient’s family and caregivers to identify bereavement needs and factors that may affect their ability to cope with the patient’s death) was completed for one of 14 sampled patients (Patient 13).This failure had the potential to negatively impact Patient 13’s family and caregivers due to the hospice agency not being able to identify bereavement needs and provide appropriate support to Patient 13’s family and caregivers before and following the patient’s death. A review of Patient 13’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of March 29, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of March 29, 2026, to June 26, 2026. Patient 13 had primary diagnoses that included frontal lobe and executive function deficit following a nontraumatic intracerebral hemorrhage (a lasting brain condition where a spontaneous, non-injury brain bleed damages the front part of the brain, causing trouble with high-level thinking, planning, and self-control).During a concurrent record review and interview on September 2, 2026, at 10:00 AM with the Bereavement Coordinator (BC), the BC reviewed Patient 13’s electronic clinical records and was unable to locate an initial bereavement assessment in Patient 13’s electronic clinical records. The BC acknowledged she did not complete the initial bereavement assessment for Patient 13 and stated the initial bereavement assessment should have been initiated during the admission process and completed no later than 5 calendar days after the admission date.During an interview on September 2, 2026, at 10:10 AM, with the BC, the BC stated that completing the initial bereavement assessment was crucial because it identifies the bereavement needs of the patient’s family and caregivers, including factors that could affect their ability to cope with the patient’s death. The BC further stated the assessment was important to identify the appropriate bereavement support and services needed by the family and caregivers before and following the patient’s death.During a concurrent interview and record review on September 2, 2026, at 3:00 PM, the BC reviewed the agency’s policy and procedure (P&P) titled “Bereavement Assessment,” revised October 2026, which indicated, “Purpose. To provide guidance for the assessment and reassessment of the bereavement needs of family/caregivers. POLICY. [Name of the Hospice Agency] will provide bereavement services for up to one year after the patient’s death to surviving family/caregiver members. PROCEDURE. 1. On admission, the social worker, hospice registered nurse, chaplain or bereavement coordinator will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. 2. The Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors. 3. Bereavement needs will be reassessed during each contact…” The BC stated the agency did not follow the policy.”

“Based on observation, interview and record review, the hospice agency failed to ensure two of 14 sampled patients’ (Patients 2 and 6) comprehensive assessment (a patient-specific evaluation that identifies the patient’s need for hospice) included reassessment of the patient’s response to care when the interdisciplinary group (IDG-a team of hospice professionals responsible for reviewing the patient’s condition, needs, response to care, and continued appropriateness for hospice services) did not address Patients 2 and 6’s continued hospice eligibility, potential discharge, and barriers to discharge during their IDG meeting.This failure had the potential for changes affecting the continued hospice eligibility of Patients 2 and 6 go unnoticed and unidentified, delaying appropriate discharge planning. A review of Patient 2’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of August 8, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of July 12, 2026, to September 9, 2026. Patient 2 had primary diagnoses which included senile degeneration of brain (a decline in an individual’s memory, behavior, and cognitive abilities).A review of Patient 6’s face sheet indicated a start of care date of March 19, 2025, with a certification period of August 3, 2026, to October 01, 2026. Patient 6 had primary diagnoses which included senile degeneration of brain, congested heart failure (CHF - a chronic condition where the heart muscle becomes too weak or stiff to pump blood effectively through the body) and contractures (a permanent or chronic tightening of muscles, tendons, skin, and connective tissues that cause joints to stiffen and shorten, preventing normal movement).During a review of the interdisciplinary group (IDG) meeting on September 2, 2026, at 11:00 AM, it indicated Patients 2 and 6’s plan of care were discussed. Both patients had received hospice services for more than six months. Further review indicated the IDG did not discuss continued hospice eligibility, whether the patients continued to benefit from hospice services, potential discharge, or barriers to discharge for Patients 2 and 6.During an interview on September 2, 2026, at 4:00 PM, with the Director of Operations (DO), who moderated the IDG meeting, the DO acknowledged that he did not discuss potential discharge or barriers to discharge for Patients 2 and 6. The DO stated that potential discharge, barriers to discharge, continued hospice qualification, and benefit from hospice services should have been discussed during every IDG meeting, even when the patients continued to qualify for hospice services and recertification had been completed.During an interview on September 2, 2026, at 4:30 PM, with the Administrator (Admin), the Admin stated that the IDG meeting was important because it allowed the interdisciplinary team to evaluate each patient as a whole, including the patient’s current condition, needs, response to care, continued qualification for hospice services, and whether the patient continued to benefit from hospice services. The Admin, further stated that potential discharge and barriers to discharge should be discussed during the IDG meeting even when a patient continued to qualify for hospice services during recertification, because the discussion ensured ongoing evaluation of the patient’s overall status, hospice eligibility, benefit from services, and any factors that could affect future discharge planning. Furthermore, the Admin stated that discharge planning should have started through the IDG process in accordance with the hospice’s policy.During a concurrent interview and record review on September 2, 2026, at 4:30 PM, the Admin and the DO reviewed the agency’s policy and procedure (P&P) titled “Interdisciplinary Group Coordination and Care”, revised October 2016, which indicated, “Purpose. To ensure the coordination of services for each patient. POLICY [Name of the Hospice Agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. …”. The Admin and the DO stated the agency did not follow the policy. During a concurrent interview and record review on September 2, 2026, at 4:35 PM, the Admin and the DO reviewed the agency’s policy and procedure (P&P) titled “Interdisciplinary Group Meeting”, revised October 2016, which indicated, “Purpose. To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY. The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment… Procedure… 7. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness…” The Admin and the DO stated the agency did not follow the policy.During a concurrent interview and record review on September 2, 2026, at 4:40 PM, the Admin and the DO reviewed the agency’s policy and procedure (P&P) titled “Discharge From Hospice Program ”, revised October 2016, which indicated, “PURPOSE. To establish standards and a process by which patients are discharged from the hospice program. POLICY. [Name of the Hospice Agency] will provide service to a patient and family/caregiver as long as the patient is certified as terminally ill with a prognosis of six months or less, lives in the designated service area, and care can be provided safely and appropriately… PROCEDURE. 1. The hospice interdisciplinary group will develop a discharge plan which includes the possibility that a patient’s condition might stabilize or change such that the patient cannot be certified as terminally ill. The discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge…” The Admin and the DO stated the agency did not follow the policy.”

“The agency failed to ensure the standard precautions (minimum infection prevention and control practices used for all patient care, regardless of a patient’s suspected or confirmed infection status) on the individual Plan of Care (a written guide that lists the specific medical, physical, and supports services a patient needs) for 2 of 14 sampled patients, Patient 2 and 3 were followed when: The Social Worker (a licensed professional who supports terminally ill patients and their families by managing the emotional, social, and practical challenges of end-of-life care) (SW), did not follow clean bag technique (an infection-control method used by healthcare workers during home visits to safely deliver patient care while preventing the spread of germs between the patient’s environment) while providing care for Patient 2.The Spiritual Counselor (a trained professional on an end-of-life care team who supports the emotional and spiritual well-being of patients and their families) (SC) did not perform hand hygiene while providing care for Patient 3. This failure had the potential to place Patients 2 and 3 at risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of infectious microorganisms. 1. A review of Patient 2’s face sheet (contains demographic and medical information, undated, indicated Patient 2 had a start of care date of July 8, 2026, with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of July 8, 2026, to October 5, 2026. Patient 2 had diagnosis that included senile degeneration of brain (severe mental decline and brain cell loss in older adults). During a review of Patient 2’s individual plan of care dated July 27, 2026, with “6-Focus Area... Infection Prevention” was reviewed. During a home visit observation at Patient’s 2’s home on September1, 2026, at 10:00 AM, with the SW, and in the presence of Patient 2, the SW entered the patient’s room after performing hand hygiene. The SW then placed his computer bag directly on the patient’s bed. The computer bag was not protected by a clean barrier or on paper towel prior to being placed on the patient’s bed. The SW did not use clean bag procedure before and after giving care to Patient 3, to prevent cross examination. During an Interview on September 1, 2026, at 11:00 AM, SW stated he should have performed clean bag procedure, he should have used barrier/paper towel for bedside table to prevent cross contamination, The SW further stated he forgot to do that. During an Interview on September 2, 2026, at 11:30 AM, with the Director of Patient Care Services (DPCS), the DPCS stated staff were supposed to use a barrier for them to put their bag and belongings and/or equipment on when in the Patient’s home. The DPCS further stated the SW should not have placed his bag on patients’ bed without using protective barrier to prevent cross contamination. During a concurrent interview and record review with the DPCS on September 2, 2026, at 11:45 AM, the DPCS reviewed agency’s policy and procedure (P&P) titled, “BAG TECHNIQUE”, dated July 2009, which indicated, “PURPOSE- To describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination… PROCEDURE-Bag Technique-1. The bag will be placed on a clean surface (i.e. a surface that can be easily disinfected) in the car and in the home…5. When a visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solutions, hands will be washed, and equipment and supplies will be returned to the bag…7. If paper towels/newspapers have been used as protective barrier for bag placement in the Patients home, they will be discarded”. The DPCS stated the agency staff did not follow the infection prevention control policy. 2. A review of Patient 3’s face sheet, undated, indicated Patient 3 had a start of care date of July 6, 2026, with a certification period of July 6, 2026, to October 3, 2026. Patient 3 had diagnosis that included senile degeneration of brain. During a review of Patient 3’s individual plan of care dated July 6, 2026, with “6-Focus Area... Infection Prevention” was reviewed. During a home visit observation at Patient 3’s home on September 1, 2026, at 11:55 AM, with the SC, and in the presence of Patient 3, the SC provided spiritual counseling and prayer to the patient. The SC entered the patient’s room without performing hand hygiene (hand washing with soap and water or using alcohol rub) prior to entering patient care area. During the prayer, the SC held patients 3’s hand and maintained direct physical contact with the patient. The SC did not perform hand hygiene prior to or following the direct patient contact. During an Interview at Patient 3’s home on September 1, 2026, at 12:30 PM, the SC stated he should have performed hand hygiene by washing his hands with soap and water or alcohol rub before giving spiritual care to Patient 3 to prevent cross contamination, the SC further sated he forgot to do that. During a concurrent interview and review of September 2, 2026, at 12:05 PM with DPCS, the agency’s policy and procedure (P&P) titled, “STANDARD PRECAUTIONS”, dated November 2009, the policy indicated, “PURPOSE-To reduce the risk of exposure of infections when caring for patients…PROCEDURE-General Precautions- Hand Hygiene 1. Hand hygiene will be performed to prevent cross-contamination between the patients and personnel”. The DPCS stated the SC should have done hand hygiene to prevent cross contamination. The DPCS further stated the agency did not follow the standard infection prevention control policy.”

“Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure the written plan of care include individualized patient goals that were specific, measurable, and time bound. For example, on all records reviewed there were goals that were not specific, measurable and time bound. In RRHV#1 an example was Facilitate bowel movement -Pt xxx/Family/PCG will verbalize having elimination needs met at an acceptable level. and Promote rest status for Pt XXX/Family/PCG. In RRNHV#2 a goal was Pt will maintain optimum peripheral circulation. -Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects of metoprolol 25 mg The target date for verbalizing understanding for medications was for over a three 3 month period. In RRNHV#3 an example was Facilitate bowel elimination and comfort and PCG will verbalize having elimination needs met at an acceptable level. Further examples could be seen in RRNHV#4 and RRNHV#5. These observations were reviewed with the Administrator/Owner and Alt Administrator.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided the patient/family with information about the scope of services that the hospice would provide and any limitations on those services. In review of the hospice binder for RRHV #1 and in discussion with the patient’s primary caregiver/daughter there was no evidence that the organization had provided information regarding the scope or frequency of services. The daughter stated that she did not know the purpose of the hospice program or when hospice staff would visit. This was discussed with the Administrator/Owner.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not provide care in accordance with their Bereavement Services Policy No. 2-010.1 which states an initial bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Although all bereavement risk assessments were completed, in review of the medical record RRNHV #1 the bereavement risk assessment was completed by the Bereavement/Volunteer Coordinator who is not a hospice social worker. This also occurred in review of medical records for an additional 13 records which were reviewed.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided education and training to the primary caregiver(s). In review of the hospice binder in the home for RRHV #1 and in conversation with three of the patient’s daughters there was no evidence that the hospice had provided education and training on medications, symptom management, an individual emergency plan, basic home safety practices, and advance directives. The hospice binder did not include the materials that the organization usually provides to patients and families on admission. This was discussed with the Administrator/Owner.”

“Observed in Record Review. In 8 of 10 patient records reviewed, the written plan of care did not include patient specific goals, time frames and services to meet those goals. For example, in review of the medical record for RRHV #3 the care plan included a problem for Pain with the goal: Pt/Family/PCG will verbalize confidence in the management of patient`s pain. However failed to identify what the patient’s goal was for pain and a time frame for which to achieve the goal. This was also observed in review of the medical records for RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7. This was discussed with the Administrator/Owner and DPCS.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided education and training to the primary caregiver(s). In review of the hospice binder in the home for RRHV #1 and in conversation with three of the patient’s daughters there was no evidence that the hospice had provided education and training on infection prevention and control and safe use of durable medical equipment including home oxygen. The hospice binder did not include the materials that the organization usually provides to patients and families on admission. Additionally, the organization had not provided an individualized emergency plan for the patient/family in the event of a natural disaster or emergency. 
The surveyor also noted that for RRHV #2 and RRHV #3 the organization had not provided an individualized emergency plan. This was discussed with the Administrator/Owner.”

“Observed in Record Review. In 1 of 3 patient records reviewed, of deceased patients, the medical record did not include complete and accurate documentation of the events. In review of the medical record for RRHV #1 the sequencing of the documentation by the LVN at the time of death indicated that the LVN pronounced the death of the patient when the Medical Director confirmed that he had pronounced the death of the patient. The LVN documented that she, responded to call that patient was breathing rapidly at 40-44 RR. Patient noted unresponsive and not breathing on arrival, SN assessment done upon arrival, no signs of life, unresponsive to verbal, tactile, and pain stimuli, cool to touch. No BP 0, HR 0, RR 0, pupils dilated and fixed, nonreactive to light and accommodation, pronounced dead at 0602, and then notified the Medical Director of the assessment. This was discussed with the Administrator/Owner. 
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