Visiting Nurse & Hospice of Fairfield County, Inc.

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; Consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, personnel record review, and interview with the Associate Administrator, which revealed the following findings: Failure to ensure that aide supervision was documented every 14 days in 3 of 12 (25%) clinical records [HSRM.25.I/L629]; Failure to ensure the hospice aide received written patient instructions to meet the patient’s needs in 8 of 12 (67%) clinical records [HCDT.15.I/L625]; Failure to ensure the hospice aide services were provided as included in the plan of care in 2 of 12 (17%) clinical records [HCDT.16.I/L626]; and failure to ensure the hospice aide reported changes in the patient’s needs. [HCDT.18.I/L628] in 3 of 12 (25%) clinical records reviewed. The cumulative effect of these systemic problems has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 418.76, 4 Hospice aide and homemaker services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by 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; other alternative treatments that could affect drug therapy. This standard was not met, as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that 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. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 05/26/2026 with a diagnosis of acute chronic diastolic congestive heart failure. During the home visit on 06/09/2026 with the registered nurse (RN) (Personnel Record 1), the hospice medication profile was compared to the current active medication list in the home. The patient’s home medications included Tramadol 25 mg 1 tablet by mouth every 8 hours as needed for pain, filled on 12/09/2025 but was not listed on the hospice medication profile. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/10/2026, she stated, “The nurse has updated the patient’s drug profile to reflect the tramadol in the patient’s home.””

“It is required that durable medical equipment (DME) related to the palliation and management of the patient’s terminal illness and related conditions is identified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical record reviews, the agency did not ensure DME was identified in the plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/10/2026 with a diagnosis of hypertensive heart disease. The clinical record included documentation of a delivery receipt on admission for a 5L DME concentrator, humidifier bottle, no-smoking sign, O2 e cylinder x 2, oxygen regulator, and standard wheelchair. The plan of care dated 04/10/2026 to 07/08/2026 had DME as gloves - unsterile, no other DME identified. The clinical record review lacked evidence that the DME related to the palliation and management of the patient’s terminal illness was identified in the plan of care. CLINICAL RECORD 14: The patient elected the hospice benefit on 05/29/2026 with a diagnosis of liver cell carcinoma. The clinical record included documentation of a delivery receipt on admission for a bed bariatric w/rails and mattress, low-air-loss pad and pump, and bed full electric w/full rails and std mattress. The plan of care for 05/29/2026 to 07/27/2026 had DME as gloves - unsterile, no other DME identified. The clinical record review lacked evidence that the DME related to the palliation and management of the patient’s terminal illness was identified in the plan of care. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/11/2026, she stated, she did not know why the DME was not updated on the plan of care, but the agency would be providing additional education to the clinical staff.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records in which the patients were discharged by death, the agency did not ensure that there was a bereavement plan of care. CLINICAL RECORD 15: This patient elected the hospice benefit on 07/22/2025 for a terminal diagnosis of senile degeneration of the brain. The patient died on 07/27/2025. The clinical record included documented evidence that bereavement phone calls and letters were sent to the bereaved, but no bereavement plan of care was documented in the clinical record. CLINICAL RECORD 16: This patient elected the hospice benefit on 11/21/2025 for a terminal diagnosis of malignant neoplasm of the lower lobe of the right bronchus or lung. The patient died on 11/25/2025. The clinical record included documented evidence that bereavement phone calls and letters were sent to the bereaved, but no bereavement plan of care was documented in the clinical record. CLINICAL RECORD 17: This patient elected the hospice benefit on 11/07/2025 for a terminal diagnosis of hypertensive heart disease with heart failure. The patient died on 03/05/2026. The clinical record included documented evidence that bereavement phone calls and letters were sent to the bereaved, but no bereavement plan of care was documented in the clinical record. During an interview with the Bereavement Coordinator (Personnel Record 12) on 06/11/2026, he stated he did not know why there was no bereavement plan of care, but he would conduct an audit and review the bereavement plan of care process.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an 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 8 of 12 (67%) clinical records reviewed of patients who elected hospice aide services it was revealed that the agency did not ensure that written patient care instructions for the hospice aide were prepared by an RN who was responsible for supervising the aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/03/2025 with a diagnosis of senile degeneration of the brain. The aide plan of care dated 05/29/2026 to 07/27/2026 did not include frequencies for all tasks assigned to be performed. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/30/2026 with a diagnosis of senile degeneration of the brain. The aide plan of care dated 05/29/2026 to 07/27/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/12/2025 with a diagnosis of chronic diastolic congestive heart failure. The aide care plan dated 04/08/2026 to 06/06/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/19/2025 with a diagnosis of senile degeneration of the brain. The aide care plan dated 05/18/2026 to 07/16/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 8: The patient elected the hospice benefit on 02/10/2026 with a diagnosis of chronic obstructive pulmonary disease. The aide care plan dated 05/11/2026 to 08/08/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/10/2026 with a diagnosis of hypertensive heart disease. The aide care plan dated 04/10/2026 to 07/08/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/27/2026 with a diagnosis of chronic obstructive pulmonary disease. The aide care plan dated 04/27/2026 to 07/25/2026 did not include a frequency for all tasks assigned to be performed. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/18/2026 with a diagnosis of chronic lymphocytic leukemia of B-cell type. The aide care plan dated 05/18/2026 to 08/15/2026 did not include a frequency for all tasks assigned to be performed. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/11/2026, she stated, “They will provide education to the clinical staff on the required elements for the hospice aide plan of care.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical record reviews of patients who elected hospice aide services revealed that the agency did not ensure hospice aide services were provided as included in the plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/10/2026 with a diagnosis of hypertensive heart disease. The plan of care dated 04/10/2026 to 07/08/2026 ordered the hospice aide frequency of 2x/week. Hospice aide visits were documented on 04/15/2026 and 04/17/2026 for the first week. No other hospice aide visits were documented in the clinical record. During an interview with the Hospice Supervisor (Personnel record 10) on 06/11/2026, she stated that they will be providing additional education to hospice aides on documenting hospice aide visits as ordered.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical record reviews of patients who elected hospice aide services revealed that the agency did not ensure the hospice aide reported changes in the patient’s needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/30/2026 with a diagnosis of senile degeneration of the brain. The hospice aide’s visit on 05/18/2026, documented that the following tasks were not performed: Assisting with a partial/complete bath and assisting with a tub/shower bath. The clinical record did not have documented evidence on why it was not done or that the registered nurse (RN) was notified. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/19/2025 with a diagnosis of senile degeneration of the brain. The hospice aide visit on 05/27/2026, documented that the following tasks were not performed: Assisting with tub/shower bath, combing or brushing hair, mouth care, and assisting with showering. The clinical record did not have documented evidence on why it was not done or that the RN was notified. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/11/2026, she stated, “They will be providing additional education to hospice aides on documenting hospice aide visits as ordered.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical record review of patients who elected hospice aide services it was revealed that the agency did not ensure hospice aides were supervised by a registered nurse who made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/03/2025. The plan of care dated 09/01/2025 to 11/29/2025 included orders for the hospice aide to visit five times per week. The nurse documented an on-site supervisory visit of the hospice aide on 09/10/2025, and the next supervisory visit was documented on 10/07/2025, a total of 27 days and 13 days outstanding. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/10/2026. The plan of care dated 04/10/2026 to 07/08/2026 included orders for the hospice aide to visit two times per week. The nurse documented an on-site supervisory visit of the hospice aide on 06/09/2026, a total of 60 days and 46 days outstanding. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/27/2026. The plan of care dated 04/27/2026 to 07/25/2026 included orders for the hospice aide to visit seven times per week. The nurse documented an on-site supervisory visit of the hospice aide on 05/05/2026, 05/08/2026, and 05/19/2026. No other aide supervision was documented in the clinical record as of 06/11/2026, a total of 23 days and 9 days outstanding. During an interview with the Hospice Supervisor (personnel record 10) on 06/11/2026, she stated that they will be providing a lot of education to the clinical staff after this survey.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed of patients who elected spiritual services, the agency did not ensure the spiritual counselor documented an assessment of the patient’s and family’s spiritual needs. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/26/2026 with a diagnosis of acute chronic diastolic congestive heart failure. There was no documented evidence in the clinical record that a Chaplain’s assessment/evaluation was conducted. The initial plan of care (POC) dated 05/26/2026 included an order for spiritual counseling requested by phone. However, the clinical record did not contain any record of a spiritual phone call. The plan of care dated 05/26/2026 to 07/24/2026 has a clergy frequency of 1 x wk x 2 wk (05/26/2026 to 06/06/2026) and 1 x day x 1 day (06/01/2026 to 06/01/2026), but there is no documentation of spiritual services provided to the patient. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/10/2026, she stated that she does not know why the documentation was not present in the electronic medical record.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care; Hospice election form and any advance directives; Physician certification and recertification of the terminal illness; hospice medication information; and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by interview and observation. In 3 of 3 (100%) home visits it was revealed that the agency did not ensure the designated IDG member provided the SNF/NF with the following information for each patient/resident was provided to the facility; the most recent hospice plan of care; hospice election form and any advance directives; physician certification and recertification of the terminal illness; hospice medication information; and hospice physician and attending physician (if any) orders. HOME VISIT 1: During the observation visit on 06/09/2026, it was identified that the information provided to the facility did not include the most recent hospice plan of care, hospice election form, any advance directive information, the physician certification and recertification of the terminal illness, hospice medication information, and any orders. HOME VISIT 2: During the observation visit on 06/09/2026, it was identified that the information provided to the facility did not include: the most recent hospice plan of care, hospice election form, any advance directives, physician certification and recertification of the terminal illness, hospice medication information, and any orders. HOME VISIT 3: During the observation visit on 06/09/2026, it was identified that the information provided to the facility did not include the most recent hospice plan of care, hospice election form, any advance directives, physician certification and recertification of the terminal illness, hospice medication information, and any orders. During an interview with the Hospice Supervisor (Personnel Record 10) on 06/10/2026, she stated she was unaware that the documents were not provided to the facility.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 3 (67%) contracts reviewed it was revealed that the agency did not ensure the contract included language that all contracted employees who had direct patient contact or access to patient records obtained a criminal background check. CONTRACT2: The pharmacy contract, dated 12/22/2025, did not contain language that stated all contracted employees who had direct patient contact or access to patient records obtained a criminal background check. During an interview with the Administrator (Personnel Record 11) on 06/08/2026, he stated that he had also reviewed the contract and was unable to find the background check information in it, but they would be completing an addendum as soon as possible with that information.”