Trinity Hospice, LLC

“Based on personnel file review and staff interview, the agency failed to implement an Emergency Preparedness (EP) training program for new employee orientation for two of two Volunteer’s (Volunteer #1 and #2), out of a total of 7 personnel files reviewed. Findings include: Review of the personnel files indicated the following:1. Volunteer #1 had a hire date of 3/27/2025. Review of the Volunteer Orientation Checklist indicated that Emergency Preparedness was not included in the orientation.2. Volunteer #2 had a hire date of 5/5/2025. Review of the Volunteer Orientation Checklist indicated that Emergency Preparedness was not included in the orientation.During an interview on 11/12/2025 at 1:00 P.M. the Director of Volunteer Services said she was unaware that the EP training was to be included as a topic for new volunteer orientation.During an interview on 11/12/2025 at 2:00 P.M. the Administrator and the Director of Volunteer Services said the new volunteer orientation should include Emergency Preparedness training but did not.”

“Based on record review and interview, the agency staff failed to conduct an initial Bereavement Assessment of the needs of the patient’s family that may potentially impact their ability to cope with the patient’s death for 3 patients (#10, #16, and #19), out of a total sample of 19 patients.Findings include: Review of the agency policy entitled, Bereavement Services, revised November 2024, indicated the following:*A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.*After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed. 1. Patient #10 was admitted to the agency in September 2025 with a diagnosis of Alzheimer’s disease.Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.2. Patient #16 was admitted to the agency in July 2025 with a diagnosis of moderate protein-calorie malnutrition.Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.3. Patient #19 was admitted to the agency in October 2025 with a diagnosis of cerebrovascular disease (variety of medical conditions that affect the blood vessels of the brain and cerebral circulation).Review of the clinical record did not contain documentation indicating that an initial Bereavement Risk Assessment was completed upon admission to the agency.During an interview on 11/12/25 at 4:17 P.M., the Clinical Director, after reviewing the clinical record, said the initial Bereavement Risk Assessment was not completed upon admission, as required.”

“Based on record review, policy review and interview, the agency failed to ensure all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for 5 patients (#2, #10, #1, #4, and #9), out of a total sample of 19 patients.Findings include: 3.Patient #1 was admitted to the agency in August 2025 with a diagnosis of End Stage Renal Disease and required hospice services.Review of the clinical record included a physician ordered Hospice POC, dated 8/15/25 through 11/11/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.4.Patient #4 was admitted to the agency in August 2025 with a diagnosis of Parkinson’s Disease without Dyskinesia and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care POC, dated 8/15/25 through 11/12/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.5.Patient #9 was admitted to the agency in August 2025 with a diagnosis of Malignant Neoplasm of Prostate and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care POC, dated 8/11/25 through 11/8/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.During an interview on 11/12/25 at 3:08 P.M., the Clinical Director said the POC should have been signed by the physician within the required timeframe of 30 days for Patients #2, #10, #1, #4, and #9. Review of the agency’s policy entitled Verification of Physician Orders, revised November 2024, indicated but was not limited to the following:-Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation.1.Patient #2 was admitted to the agency in August 2025 with a diagnosis of Alzheimer’s disease and required hospice services.Review of the clinical record included a physician ordered Hospice Plan of Care (POC), dated 8/15/25 through 11/12/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.2.Patient #10 was transferred/admitted to the agency in September 2025 with a diagnosis of Alzheimer’s disease and required hospice services.Review of the clinical record included a physician ordered Hospice POC, dated 8/1/25 through 9/29/25. Further review of the POC indicated the physician signed it on 10/1/25, not within 30 days, as required, per the policy.”