Loyalty Hospice Services, Inc.

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) of home visits with a hospice aide, the organization did not ensure that standards of practice to prevent transmission of infections was followed. HOME VISIT 1: The patient was admitted to hospice services on 07/25/2025 with primary and pertinent secondary diagnoses that included cerebral infarction, diabetes, Alzheimer’s, dementia, and anxiety. During the home visit with the hospice aide (Personnel Record 1) on 08/25/2025, the hospice aide washed his hands and donned gloves before providing the patient with a bed bath as written in the Aide Plan of Care effective 07/25/2025. The aide was observed washing the patient’s body, performing a diaper change with perineal care, and applying lotion to the patient’s skin while wearing the same pair of gloves and never performing hand hygiene. The aide then pulled a safety razor from his left breast pocket and proceeded to wet the razor in the patient’s bath basin before shaving his face with it. When the aide was finished shaving the patient, he rinsed the safety razor one final time in the bath basin and placed the razor back in his breast pocket. The Administrative Nurse acknowledged that the safety razor was not handled or cleaned properly by the aide before and after patient use.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) clinical records reviewed in which aide services were provided, the organization did not ensure that the hospice aide provided services included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION CLINICAL RECORD 1/HOME VISIT 1: The patient was admitted to hospice services on 07/25/2025 with primary and pertinent secondary diagnoses that included cerebral infarction, diabetes, Alzheimer’s, dementia, and anxiety. During a concurrent review of the aide plan of care effective 07/25/2025 and an interview with the Administrative Nurse on 08/25/2025, the Administrative Nurse confirmed that the aide plan of care included the following instructions to be performed by the hospice aide during each visit: shampoo, comb hair, brush teeth, active/passive ROM, clean nails, and apply deodorant. During the home visit with the hospice aide (Personnel Record 1), the Hospice Aide did not shampoo, comb the patient’s hair, brush the patient’s teeth, perform active or passive range of motion, clean the patient’s nails, or apply deodorant. The Administrative Nurse acknowledged the discrepancy between the aide written instructions and the tasks not performed by the aide during the 08/25/2025 home visit observation.”

“It is required that a hospice must routinely provide substantially all core services directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by review of the agency’s personnel records and interviews with the Administrative Nurse and Business Office Manager (responsible for Human Resources) which revealed the following issues: Failure to ensure that hospice “core” services were substantially provided directly by hospice employees in 100% personnel records reviewed of “core service” employees [HCDT.2.I/L587]. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice services from the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) home visits revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 03/26/2025 for a diagnosis of nonrheumatic aortic stenosis. The patient resided in a skilled nursing facility (SNF). During Home Visit 1 with the Hospice Aide (Personnel Record 7) on 07/17/2025, the hospice medication profile (printed on 07/16/2025) was compared to the SNF medication profile (printed on 07/17/2025). The following medications were listed on the hospice medication profile and were not listed on the SNF medication profile: Ascorbic acid 250 mg, take 1 tablet daily (ordered 03/26/2025); Ativan 2mg/ml, IM every 6 minutes as needed x 3 doses for seizures (ordered 03/26/2025); Levothyroxine 125 mcg, take daily (ordered 03/26/2025); Metoprolol 25 mg, take daily (ordered 03/26/2025); Multivitamin, take daily (ordered 03/26/2025); Nitroglycerin 0.4 mg, take every 5 minutes as needed for chest pan x 3 doses (ordered 03/26/2025); Simvastatin 30 mg, once daily (ordered 03/26/2025). The following medications were listed on the SNF profile and were not listed on the hospice medication profile: Medihoney, apply daily to buttocks (ordered 07/08/2025); Duoneb, inhale 1 vial every 4 hours as needed (ordered 12/10/2024). Home Visit 2: The patient elected the hospice benefit on 05/28/2025 for a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). During Home Visit 2/Clinical Record 2 with the Registered Nurse (Personnel Record 4) on 07/17/2025, the hospice medication profile (printed on 07/16/2025) was compared to the ALF medication profile (printed on 07/17/2025). The following medications were listed on the hospice medication profile and were not listed on the ALF medication profile: Hospice comfort kit-Morphine, Acetaminophen suppository, Atropine drops, Zofran, Lorazepam (ordered 05/26/2025). The following discrepancy was noted: Hospice had Vitamin D3 1 tablet daily and facility had 2 tablets daily. A joint clinical record review and interview were conducted with the Administrative Nurse on 07/17/2025, in which she stated, “The medications should be reviewed every visit.’ She further stated, “The ALF doesn’t want to put our comfort kit meds on their list until they start using them. We have talked to them about this.””

“It is required that the hospice takes action to improve performance and assesses the success of the action after implementing it. This standard was not met as evidenced by document review and interview. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. On 07/17/2025, the Administrative Nurse advised, “They had a consultant who was putting information into an online program for QAPI, but it was not completed.” She advised she had some “raw data” she could provide. When asked about QAPI meetings, it was stated, “We had some 1st Quarter of 2024, but there was a falling out, employees changed, and we have not had any since.” On 07/18/2025, there were QAPI meetings presented for 2023 and 1st Quarter of 2024. These included Performance Improvement Programs (PIP). After the QAPI meeting in early 2024 there was no evidence that the agency took action to improve performance and assessed the success of the action after implementing it. Document 4: Agency Policy titled “Governing Body Policy No 4-0004.2 dated 2003, revised Nov 2018” stated in relevant parts: “7. The Governing Body must ensure the QAPI program. A. Addresses priorities for improved quality of care and patient safety. D. Focuses on indicators related to improved palliative outcomes. E. Takes action to demonstrate improvement in hospice performance.” Document 5: Agency Policy titled “Improving Organization Performance Policy No 4-015.i dated 2023, revised Nov 2018” stated in relevant parts: “Policy: Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organization’s efforts in improving organization performance in governance, management, clinical and support activities. 1. Assigning hospice personnel to participate in QAPI activities. H. Ensure the performance improvement activities are conducted. 2. Assigning qualified individuals or an interdisciplinary group to manage the program.” A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. On 07/17/2025, the Administrative Nurse advised, “They had a consultant who was putting information into an online program for QAPI, but it was not completed.” She advised she had some “raw data” she could provide. When asked about QAPI meetings, it was stated, “We had some 1st Quarter of 2024, but there was a falling out, employees changed, and we have not had any since.” On 07/18/2025, there were QAPI meetings presented for 2023 and 1st Quarter of 2024. These included Performance Improvement Programs (PIP). After the QAPI meeting in early 2024 there was no evidence that the agency took action to improve performance and assessed the success of the action after implementing it.”

“It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review and interview. A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. On 07/17/2025, the Administrative Nurse advised, “They had a consultant who was putting information into an online program for QAPI, but it was not completed.” She advised she had some “raw data” she could provide. When asked about QAPI meetings, it was stated, “We had some 1st Quarter of 2024, but there was a falling out, employees changed, and we have not had any since.” On 07/18/2025, there were QAPI meetings presented for 2023 and 1st Quarter of 2024. These included Performance Improvement Programs (PIP). After the QAPI meeting in early 2024 there was no documentation that the governing body assumed full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program. Document 4: Agency Policy titled “Governing Body Policy No 4-0004.2 dated 2003, revised Nov 2018” stated in relevant parts: “7. The Governing Body must ensure the QAPI program. A. Addresses priorities for improved quality of care and patient safety. D. Focuses on indicators related to improved palliative outcomes. E. Takes action to demonstrate improvement in hospice performance.” A joint review of the Quality Assessment/Performance Improvement (QAPI) program was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. On 07/17/2025, the Administrative Nurse advised, “They had a consultant who was putting information into an online program for QAPI, but it was not completed.” She advised she had some “raw data” she could provide. When asked about QAPI meetings, it was stated, “We had some 1st Quarter of 2024, but there was a falling out, employees changed, and we have not had any since.” On 07/18/2025, there were QAPI meetings presented for 2023 and 1st Quarter of 2024. These included Performance Improvement Programs (PIP). After the QAPI meeting in early 2024 there was no documentation that the governing body assumed full legal authority and responsibility for the organization’s ongoing performance improvement and patient safety program.”

“It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview. A joint review of the Governing Body Meeting minutes was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. During the review, it was identified that an individual responsible for operating the QAPI program had not been appointed for 2023, 2024, or 2025 to date. The Administrative Nurse contacted the Administrator/Owner, who advised, “A consultant had been hired to start working on the quality program.” This person was not appointed by the Governing Body. Document 5: Agency Policy titled “Improving Organization Performance Policy No 4-015.i dated 2023, revised Nov 2018” stated in relevant parts: “Policy: Senior management, as designated and approved by the Governing Body, will have the responsibility of quality management: to guide the organizations efforts in improving organization performance in governance, management, clinical and support activities. 1. Assigning hospice personnel to participate in QAPI activities. H. Ensure the performance improvement activities are conducted. 2. Assigning qualified individuals or an interdisciplinary group to manage the program.” A joint review of the Governing Body Meeting minutes was conducted with the Administrative Nurse on 07/17/2025 and 07/18/2025. During the review, it was identified that an individual responsible for operating the QAPI program had not been appointed for 2023, 2024, or 2025 to date. The Administrative Nurse contacted the Administrator/Owner, who advised, “A consultant had been hired to start working on the quality program.” This person was not appointed by the Governing Body.”

“It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 5: The hospice aide care plan(s) dated 07/14/2025 included the following tasks: “Turn and position, incontinent care, dress, bed bath, comb, shampoo, apply lotion, visualize condition of skin and report to RN, peri care, change linens.” Aide frequency of twice weekly. All tasks were to be completed on every visit. The initial nursing assessment dated 07/14/2025 noted the following: “Stage III-buttock and IV-sacrum pressure ulcers. Cover with foam dressings.” The hospice aide care plan did not notify the aide of the wounds, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet. CLINICAL RECORD 7: The hospice aide care plan(s) dated 04/07/2025 included the following tasks: “shower, incontinent care, comb hair, dress, apply lotion, visualize skin, change linens.” All tasks were to be completed on every visit. Aide frequency of twice weekly. A physician’s order dated 06/09/2025 noted the following: “cleanse right thigh with wound cleanser, pat dry, apply Mupirocin ointment, cover with sterile dressing daily.” A physician’s order dated 06/16/2025 noted the following: “cleanse right shoulder wound with wound cleanser, pat dry, apply Mupirocin ointment, cover with sterile dressing daily.” The hospice aide care plan did not notify the aide of the wound, nor provide specific instructions to notify the nurse if the wound dressing became soiled, dislodged, or wet A joint clinical record review and interview were conducted with the Administrative Nurse on 07/17/2025 in which she stated, “The aides should have been given information about the wounds.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 7 (14%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure hospice aide provided services included in the plan of care. Home Visit 1: The hospice aide care plan dated 03/26/2025 included the following relevant tasks: “Shower; assist to chair/bed; turn and reposition; incontinent care; shampoo hair; comb hair; mouth care-brush teeth; skin care-apply lotion; assist with dressing; clean nails;” All tasks were to be completed on every visit. Aide visit frequency was twice weekly. Home Visit 1/Clinical Record 1 was conducted on 07/17/2025 with the Hospice Aide (Personnel Record 7). The aide was observed completing all of the tasks on the care plan except brushing teeth and applying lotion to the patient’s skin. A joint clinical record review and interview were conducted with the Administrative Nurse on 07/17/2025, in which she stated, “all tasks on the care plan should’ve been completed.””

“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. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 9 (33%) personnel records reviewed revealed the agency did not ensure the skills and competencies of all individuals providing care, including volunteers were assessed. Document 2: Agency Policy titled “Competency Assessment Policy No 1-008.1 dated November 2018” stated in relevant part: “1. Competency assessments will be completed at least 1 (one) time per year.” Personnel Record 3: A personnel record review was conducted on 07/16/2025, which revealed that there were no documented skills competencies in 2024 for an employee (Registered Nurse) hired on 10/17/2023. Personnel Record 5: A personnel record review was conducted on 07/16/2025, which revealed that there were no documented skills competencies in 2024 for an employee (Social Worker) hired on 03/23/2023. Personnel Record 6: A personnel record review was conducted on 07/16/2025, which revealed that there were no documented 2024 skills competencies for an employee (spiritual counselor) hired on 08/21/2023. A joint personnel record review and interview were conducted with the Administrative Nurse and Business Office Manager on 07/17/2025, in which they advised, “We didn’t know which form to use as we only see the Initial Competency in the policy manual.””

“It is required that the criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 9 (44%) Personnel Record 2: A personnel record review was conducted on 07/16/2025, which revealed that there was a background check was completed on 06/25/2025. This was not within three (3) months for an employee (Administrator) with a hire date of 01/01/2023. Personnel Record 5: A personnel record review was conducted on 07/16/2025, which revealed that there was no documented background check for an employee (Social Worker) hired on 03/23/2023 Personnel Record 6: A personnel record review was conducted on 07/16/2025, which revealed that there was a background check completed on 06/24/2025. This was not within three (3) months for an employee (Spiritual Counselor) with a hire date of 08/21/2023. Personnel Record 8: A personnel record review was conducted on 07/16/2025, which revealed that there was no documented background check for an employee (Volunteeer Coordinator) hired on 01/01/2024. A joint personnel record review and interview were conducted with the Administrative Nurse and Business Office Manager on 07/17/2025 in which they advised, “We began running background checks on everyone this year when we realized they weren’t in the files.””