Gaffey Home Nursing & Hospice, Inc.

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: Development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment; The documented discussion of the plan provided to the patient/family and maintained by the hospice; Follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. This standard was not met as evidenced by clinical record review and interview. In 12 of 12 (100%) clinical records reviewed of patients residing at home it was revealed that the agency did not ensure there was documented evidence of an individualized emergency plan. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/20/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/21/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/25/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged on 07/24/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/22/2025 and discharged on 01/07/2026. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/30/2025 and discharged on 10/20/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged on 04/23/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/19/2025 and discharged on 04/19/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/21/2025 and discharged on 06/14/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/21/2025 and discharged on 08/02/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/29/2025 and discharged on 10/07/2025. The patient resided at home. The clinical record included a triage level based on needs. There was no documented evidence of an individualized emergency plan. During an interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the patient’s emergency plan was individualized and reviewed with the patient. Additionally, the Administrator stated, “I have a new form with all the required information that we will start using.” During a joint record review and interview on 03/11/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the patient’s emergency plan was individualized.”

“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 a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 7 (14%) clinical records reviewed of patients receiving hospice aide services it was revealed that the hospice did not ensure the Registered Nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 5/HOME VISIT 1: The hospice aide care plan dated 02/25/2025 included for the aide to take temperature, respirations, and blood pressure each visit. Additionally, “report abnormal vital signs to nurse” was included for each visit. During the home visit with the hospice aide (Personnel Record 8) on 03/11/2026, the hospice aide was observed taking the patient’s temperature, respirations, and blood pressure. The hospice aide visit documentation on 3/11/2026 revealed a temperature 97F, respirations 22, and blood pressure 168/92. There was no documented evidence that the hospice aide care plan included vital sign parameters for the hospice aide to report. The hospice aide was interviewed about reporting parameters, and the hospice aide stated, “Because he is hospice, we don’t do that.” During a joint record review and interview on 03/12/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the aide plan of care included specific instructions for the aide including what the parameters were for abnormal vital signs to be reported. Additionally, the Director of Nursing stated, “The nurses need to type the parameters in the care plan. It wasn’t done.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer hours log detailing the staff hours and volunteer hours revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator provided a volunteer hours log that documented total staff hours and volunteer hours. The volunteer hours log for 01/01/2024-12/31/2024 revealed that the volunteer hours were at 1.04%. The volunteer hours log for 01/01/2025-12/31/2025 revealed that the volunteer hours were at 0.4%. There was no documented evidence that the volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2024 and 2025. During an interview with the Volunteer Coordinator (Personnel Record 6) on 03/12/2026, the Volunteer Coordinator stated, “I don’t keep track of the hours, the Administrator does.” During a joint review of the documentation and interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the volunteer hours equaled at least 5% of the total patient care hours. Additionally, the Administrator stated, “There is lack of follow up by the volunteer coordinator. We need to have additional education for the volunteer coordinator and monthly follow up with supervision.” A review of the volunteer hours log detailing the staff hours and volunteer hours revealed that hospice did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed it was revealed that the hospice did not ensure that the hospice election form informed the patient or representative of their right to request the covered/non covered addendum. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/04/2026. The Medicare Benefit Election Form dated 02/04/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 2:The patient elected the hospice benefit on 02/20/2026. The Medicare Benefit Election Form dated 02/20/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 3: The patient elected the hospice benefit on 02/10/2026. The Medicare Benefit Election Form dated 02/10/2026 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/21/2025. The Medicare Benefit Election Form dated 11/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/25/2025. The Medicare Benefit Election Form dated 11/25/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged on 07/24/2025. The Medicare Benefit Election Form dated 12/04/2024 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/22/2025 and discharged on 01/07/2026. The Medicare Benefit Election Form dated 12/22/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/30/2025 and discharged on 10/20/2025. The Medicare Benefit Election Form dated 04/30/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged on 04/23/2025. The Medicare Benefit Election Form dated 02/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 10: The patient elected the hospice benefit on 02/19/2025 and discharged on 04/19/2025. The Medicare Benefit Election Form dated 02/19/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/21/2025 and discharged on 06/14/2025. The Medicare Benefit Election Form dated 05/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 12: The patient elected the hospice benefit on 07/21/2025 and discharged on 08/02/2025. The Medicare Benefit Election Form dated 07/21/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/29/2025 and discharged on 10/07/2025. The Medicare Benefit Election Form dated 09/29/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/18/2025 and discharged on 04/22/2025. The Medicare Benefit Election Form dated 04/18/2025 did not inform the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. During a joint record review and interview on 03/11/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the election form informed the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. During an interview on 03/12/2026, the Administrator (Personnel Record 1) agreed there was no documented evidence that the election form informed the patient or representative of their right to request an addendum that lists items, services, or drugs deemed unrelated to the terminal illness and not covered by hospice. Additionally, the Administrator stated, “We missed this. I will get this form updated and update the admission books.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed of patients that had a live discharge it was revealed that the hospice did not ensure that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 12/04/2024 and discharged due to no longer terminally ill on 07/24/2025. A discharge summary was documented on 07/24/2025. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/21/2025 and discharged due to moved out of service area-went to hospital on 04/23/2025. A discharge summary was documented on 04/23/2025. There was no documented evidence that the discharge summary was sent to the patient’s attending physician or hospital. During a joint record review and interview on 03/12/2026, the Director of Nursing (Personnel Record 3) agreed there was no documented evidence that the discharge summaries were provided to the patient’s attending physician or hospital. Additionally, the Director of Nursing stated, “These were missed. We need to educate the staff.””