Terrace Hospice

“Based on policy review, record review, and staff interview, it was determined the agency failed to ensure it had a volunteer program. Failure to have a volunteer program limited the hospice’s ability to address potential psychosocial and supportive needs of patients, families, and caregivers. In addition, hospice patients were not afforded access to volunteer services that may enhance the overall quality of their hospice experience. Findings include: Refer to L-0644 as it refers to the hospice’s inability to demonstrate any role volunteers were used in. Refer to L-0646 as it refers to the hospice’s inability to demonstrate cost savings achieved by the use of volunteers. Refer to L-0647 as it refers to the hospice’s inability to demonstrate that volunteers accounted for a minimum of 5 percent of all patient care hours. The inability of the hospice to have an effective volunteer program had the potential for unmet patient needs.”

“Based on policy review, Governing Body meeting minute review, QAPI review, and staff interview, it was determined the Governing Body failed to provide oversight to the specific requirements of hospice. This had the potential to cause vital elements of hospice to be overlooked and not provided to hospice patients. Findings include: Refer to 0574 as it relates to the Governing Body’s failure to provide executive responsibility. Refer to 0651 as it relates to the Governing Body’s failure to provide any oversight to hospice services or the QAPI program. These deficiencies led to the lack of executive oversight of the entire hospice program.”

“Based on document review and staff interview, the hospice failed to ensure that allegations or suspicions of abuse and neglect were investigated and documented in accordance with hospice policy for 1 of 1 patients (Patient #3) with an allegation of abuse and neglect. This deficient practice had the potential to place all hospice patients at risk by failing to ensure that allegations of abuse or neglect were promptly investigated, addressed, and appropriate protective actions implemented.Findings include: Review of the hospice policy, “Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation,” revised 02/2021, stated, in part, “Hospice will identify and report possible victims of neglect, exploitation, mistreatment, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone furnishing services on behalf of Hospice.” The policy further stated that the Administrator will “...immediately investigate all alleged violations.”The hospice failed to follow its policy. An example included:For example, Patient #3 was a 76-year-old female admitted to hospice on 04/14/2025 and expired on 05/09/2025. The primary hospice diagnosis was unspecified severe protein-calorie malnutrition with an additional documented diagnoses included a Stage IV pressure ulcer of the sacral region and pressure-induced deep tissue injury of the right heel.Review of the hospice clinical record did not identify documentation that allegations or concerns related to abuse or neglect had been assessed, investigated, or resolved.Review of the hospice incident reporting documentation identified an incident categorized as “Abuse/Neglect,” with the description: “Inadequate care of patient (e.g., not providing adequate food, meds, housing, hygiene), Inadequate supervision of patient (e.g., leaving patient alone).” The incident report did not include the date of the occurrence, details describing the circumstances, findings of an investigation, actions taken, or documentation demonstrating the allegation had been reviewed and resolved.The current Hospice Administrator was interviewed on 08/04/26 beginning at 11:00 AM. The adminstrator stated they were not employed by the hospice at the time of the reported incident and were unable to provide documentation or evidence that an investigation had been completed.The absence of documentation demonstrating a timely investigation and follow-up of an allegation of abuse or neglect prevented the hospice from demonstrating compliance with its policy and had the potential to place all hospice patients at risk by failing to identify, investigate, and address allegations of abuse or neglect to protect patient health and safety. Review of the hospice policy, “Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect or Exploitation,” revised 02/2021, stated, in part, “Hospice will identify and report possible victims of neglect, exploitation, mistreatment, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone furnishing services on behalf of Hospice.” The policy further stated that the Administrator will “...immediately investigate all alleged violations.”The hospice failed to follow its policy. An example included:Patient #3 was a 76-year-old female admitted to hospice on 04/14/2025 and expired on 05/09/2025. The primary hospice diagnosis was unspecified severe protein-calorie malnutrition with an additional documented diagnoses included as a Stage IV pressure ulcer of the sacral region and pressure-induced deep tissue injury of the right heel.Review of the hospice clinical record did not identify documentation that allegations or concerns related to abuse or neglect had been assessed, investigated, or resolved.Review of the hospice incident reporting documentation identified an incident categorized as “Abuse/Neglect,” with the description: “Inadequate care of patient (e.g., not providing adequate food, meds, housing, hygiene), Inadequate supervision of patient (e.g., leaving patient alone).” The incident report did not include the date of the occurrence, details which described the circumstances, findings of an investigation, actions taken, or documentation demonstrating the allegation had been reviewed and resolved.The current Hospice Administrator was interviewed on 08/04/26 beginning at 11:00 AM. The adminstrator stated they were not employed by the hospice at the time of the reported incident and were unable to provide documentation or evidence that an investigation had been completed.The absence of documentation demonstrating a timely investigation and follow-up of an allegation of abuse or neglect prevented the hospice from demonstrating compliance with its policy and had the potential to place all hospice patients at risk by failing to identify, investigate, and address allegations of abuse or neglect to protect patient health and safety.”

“Based on Governing Body meeting minutes, policies, and interviews, it was determined the GB failed to provide oversight and management of the QAPI program. This resulted in a lack of leadership and direction for the QAPI program and had the potential to overlook trends or concerns related to the hospice program. Findings include: A policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan,” revised 5/2023 was reviewed. Within this policy, under “Responsibillity/Accountability,” it stated: “1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan.” This policy was not followed. An example included: On 8/04/26, a request for Governing Body meeting minutes was made to the Administrator. Surveyors received Governing Body meeting minutes labeled “Terrace Home Health-Boise”. Another request was made for the Governing Body meeting minutes for hospice. Surveyors were informed there were no other Governing Body meeting minutes available. Governing Body Meeting Minutes were provided for 5/07/25, 8/12/25, 11/6/25, and 3/26/26. The meeting minutes for each of the listed dates stated, under “Action Items: Approval of prior meeting minutes of Terrace Home Health and Hospice - Boise.” There was no further mention of, or delineation of, Terrace Hospice. Within these Governing Body Meeting Minutes, there was no mention of hospice annual QAPI program evaluation. The Governing Body failed to provide any oversight to the hospice QAPI program.”

“Based on policy review, volunteer documentation review, and staff interview, it was determined the agency failed to ensure volunteers were used in day-to-day administrative and/or direct patient care roles. This compromised the agency’s ability to use volunteers in any capacity, which is a vital portion of the hospice program and benefits hospice patients and their families and support people. In addition, hospice patients were not afforded access to volunteer services that may have enhanced the overall quality of their hospice experience. Findings include: A facility policy titled, “Volunteer Services,” revised May 2023 was reviewed. It stated, “Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator.” This policy was not followed. An example includes: On 8/04/26, the surveyor requested the hospice’s volunteer files and documentation of volunteer services. No volunteer files or documentation were provided for review. The Administrator was interviewed on 8/04/26 at 2:40 PM. When asked if the hospice had ever had a volunteer she said, “I don’t believe so.” The hospice did not provide documentation showing the use of volunteers, volunteer activities, or evidence that volunteer hours equaled at least 5 percent of total patient care hours. Additional documentation was provided after survey exit of a volunteer who had completed her training at a hospice located out of state, which was a sister company of the hospice agency. Staff stated she had transferred to the hospice locally, however they were unable to provide documentation the volunteer had transferred to the local agency or had ever completed volunteer hours at the local agency. The agency failed to demonstrate any roles volunteers were performing at the hospice.”

“Based on policy review, review of volunteer documentation, and staff interview, it was determined the hospice failed to demonstrate the use of volunteers and failed to maintain required documentation of volunteer services which contributed to cost savings of the hospice as required by regulation. This failure compromised the agency’s ability to demonstrate the essential role of volunteers in its operations. Findings include: An agency policy titled “Volunteer Services,” revised May 2023 stated, “Hospice will document the cost savings achieved through the use of volunteers.” This policy was not followed. An example includes: On 8/04/26, the surveyor requested the hospice’s volunteer files and documentation of volunteer services. No volunteer files or documentation were provided for review. The Administrator was interviewed on 8/4/26 at 2:40 PM. When asked if the hospice had ever had a volunteer she said, “I don’t believe so.” The hospice did not provide documentation showing the use of volunteers, volunteer activities, or evidence that volunteer hours equaled at least 5 percent of total patient care hours. Additional documentation was provided after survey exit of a volunteer who had completed her training at a hospice located out of state, which was a sister company of the hospice agency. Staff stated she had transferred to the hospice locally, however they were unable to provide documentation the volunteer had transferred to the local agency or had ever completed volunteer hours at the local agency. The agency failed to demonstrate cost savings provided by volunteer services.”

“Based on policy review, volunteer document review and staff interview, It was determined the hospice failed to demonstrate the use of volunteers in an amount that equaled at least 5 percent of the total patient care hours of all paid hospice employees and contract staff. Failure to demonstrate any volunteer hours limited the hospice’s ability to address potential psychosocial and supportive needs of patients, families, and caregivers. In addition, hospice patients were not afforded access to volunteer services that may have enhanced the overall quality of their hospice experience. Findings include: An agency policy titled, “Volunteer Services,” revised May 2023 stated, “Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.” This policy was not followed.On 8/04/26, the surveyor requested the hospice’s volunteer files and documentation of volunteer services. No volunteer files or documentation were provided for review. The Administrator was interviewed on 8/04/26 at 2:40 PM. When asked if the hospice had ever had a volunteer she said “I don’t believe so.” Additional documentation was provided after survey exit of a volunteer who had completed her training at a hospice located out of state, which was a sister company of the hospice agency. Staff stated she had transferred to the hospice locally, however they were unable to provide documentation the volunteer had transferred to the local agency or had ever completed volunteer hours at the local agency The hospice did not provide documentation showing the use of volunteers, volunteer activities, or evidence that volunteer hours equaled at least 5 percent of total patient care hours.”

“Based on Governing Body meeting minutes, policies, and interviews, it was determined the GB failed to provide oversight and management of the QAPI program as well as the other operations of hospice specific services. This had the potential to omit integral hospice services from the hospice core services. Findings include: A policy titled, “Quality Assurance and Performance Improvement (QAPI) Plan,” revised 5/2023 was reviewed. Within this policy, under “Responsibillity/Accountability,” it stated: “1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan.” This policy was not followed. An example included: On 8/04/26, a request for Governing Body meeting minutes was made to the Administrator. Surveyors received Governing Body meeting minutes labeled “Terrace Home Health-Boise”. Another request was made for the Governing Body meeting minutes for hospice. Surveyors were informed there were no other Governing Body meeting minutes available. Governing Body Meeting Minutes were provided for 5/07/25, 8/12/25, 11/6/25, and 3/26/26. The meeting minutes for each of the listed dates stated, under “Action Items: Approval of prior meeting minutes of Terrace Home Health and Hospice - Boise.” There was no further mention of, or delineation of, Terrace Hospice. The Meeting minutes did not include input from the core hospice staff which included: Medical Director, Chaplain, Bereavement coordinator, Social Worker, or Volunteer coordinator. Within these Governing Body Meeting Minutes, there was no mention of hospice specific reports, updates, data integration or outcomes. The Governing Body failed to provide oversight to hospice specific services.”