Covenantcare Hospice

“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. 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 2 of 2 (100%) clinical records reviewed of patients who died on hospice services it was revealed that the agency did not ensure bereavement services were provided per a bereavement plan of care that included the types of bereavement services offered and the frequency of services. CLINICAL RECORD 12: The hospice benefit was elected on 10/13/2025, and the date of death was 12/08/2025. The clinical record review lacked documented evidence of a bereavement plan of care that specified the types of bereavement services offered and their frequency. Bereavement documentation included the following post-death activities: condolence call 12/09/2025, condolences card mailed 12/10/2025, phone call 01/28/2026, call 02/09/2026, bereavement letter mailed 02/25/2026, and call 03/16/2026. Activities were being completed, however, there was no documented evidence of a bereavement plan of care. CLINICAL RECORD 11: The hospice benefit was elected on 08/30/2025, and the date of death was 09/17/2025. The clinical record review lacked documented evidence of a bereavement plan of care that specified the types of bereavement services offered and their frequency. Bereavement documentation included the following post-death activities: initial call to discuss bereavement services on 09/18/2025, condolence care mailed 09/19/2025, phone call on 11/07/2025, letter mailed 11/14/2025, call 01/13/2026, letter mailed 01/29/2026. Activities were being completed, however, there was no documented evidence of a bereavement plan of care. During an interview with the Administrator (Personnel Record 6) on 03/26/2026 she stated she and the volunteer coordinator have discussed the bereavement plan of care and have figured out how to input the plan of care into the electronic medical record so that this will no longer be an issue in the future.”

“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 4 of 13 (31%) clinical records reviewed 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 2: In the benefit period dated 12/06/2025 to 02/03/2026, the nurse documented on-site supervisory visits for the hospice aides on 12/09/2025, 12/15/2025, 12/22/2025, 01/01/2026, 01/06/2026, 01/13/2026, and 02/04/2026 (22 days). CLINICAL RECORD 3: In the benefit period dated 01/08/2026 to 03/08/2026, the nurse documented on-site supervisory visits for the hospice aides on 01/13/2026, 01/20/2026, 01/27/2026, 02/03/2026, 02/10/2026, 02/17/2026, and then 03/10/2026 (21 days). CLINICAL RECORD 10: In the benefit period dated 08/22/2025 to 10/20/202, the nurse documented on-site supervisory visits for the hospice aides on 08/22/2025, 09/02/2025, and 10/28/2025 (56 days). CLINICAL RECORD 12: In the benefit period dated10/13/2025 to 12/08/2025, the nurse documented on-site supervisory visits for the hospice aides on 10/24/2025, and 11/05/2025. No other aide supervisory visits were documented. The date of death was 12/08/2025 (33 days). During an interview with the Administrator (Personnel Record 6) and hospice clinical supervisor (Personnel Record 5) on 03/25/2026 they stated they did not know how the aide supervisory visits were not documented but they will continue to educate the clinical staff on importance of an aide supervisory visit being completed weekly so as not to miss the fourteen day requirement.”

“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 that revealed the agency did not ensure 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. The document review of the volunteer hours lacked evidence that hospice volunteers provided 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 was evidenced by the volunteer percentage for the last 12 months as follows: March 2025 -February 2026 was 0.86%. During an interview with the volunteer coordinator (Personnel Record 6) on 03/24/2026 she stated that she has recently taken over the roll and is aware that the hours were not meeting the requirement but they are working on increasing the volunteer percentage, they have had improvement the last couple of months but still have some work to do. The document review of the volunteer hours lacked evidence that hospice volunteers provided 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 was evidenced by the volunteer percentage for the last 12 months as follows: March 2025 0.38%, April 2025 0.54, May 2025 0.56%, June 2025 0.59%, July 2025 1.08, August 2025 0.81, September 2025 0.47, October and Novemeber 2025 0%, December 2025 0.66%, January 2026 2.27%, and February 2026 2.99%, this is an average of 0.86% for the last 12 months.”

“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 1 of 8 (25%) personnel records reviewed revealed the agency did not ensure to assess the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary. The agency Policy titled “Hospice Human Resources” Policy No. H: 3-001.1 CHAP Hospice Manual/Revised April 2018 stated in part, “Clinical competencies will be assessed during the orientation process and annually thereafter for professional and paraprofessional personnel providing direct patient care.” PERSONNEL RECORD 5: The registered nurse (RN) Nursing Supervisor was hired on 11/03/2023. The personnel record review lacked documented evidence of an annual competency as required by agency policy . The RN Nursing supervisor provided patient care as needed. There was no documented evidence of a nursing competency for 2024 or 2025. PERSONNEL RECORD 6: The Volunteer Coordinator was hired on 08/01/2016. The Volunteer Coordinator performed volunteer assessments. The personnel record review lacked documented evidence of an annual competency as required by agency policy for 2023 2024, and 2025. During an interview with the Administrator (Personnel Record 6) on 04/24/2026 she stated that she did not know why the annual competency was not completed but they would review and revise their process and educate staff of the requirement.”