Everhome Hospice, LLC

“Based on record review, interview, and policy review, the Hospice Agency failed to ensure an initial bereavement assessment was completed and documented in the electronic medical record (EMR) for three of 14 patients (Patient (P)2, P3, and P6) reviewed. This failure had the potential for significant negative effects on the families of deceased patients, including increased risk of mental health issues from difficulty of coping with grief such as depression and/or anxiety due to a lack of support following a death. Findings include: 1. Review of the “Intake” tab located in the EMR revealed P2 had a “Start of Care (SOC)” date of 06/19/26 for a terminal diagnosis of Huntington’s disease (a neurological disease). Review of the “Bereavement” tab located in the EMR revealed no documentation of an initial bereavement assessment. During an interview on 06/22/26 at 1:18 PM, the Administrator stated that he/she was responsible for the initial bereavement assessments. The Administrator further stated, “I know I completed the assessment, but it appears that it was not documented.” 2. Review of the “Intake” tab located in the EMR revealed P3 had a “SOC” date of 01/16/26 for a terminal diagnosis of senile degeneration of the brain. Review of the “Bereavement” tab located in the EMR revealed no documentation of an initial bereavement assessment. During an interview on 06/22/26 at 1:18 PM, the Administrator stated, “I was out for surgery when P3 was admitted, and it appears no one else picked up and completed the assessment.” 3. Review of the “Intake” tab located in the EMR revealed P6 had a “SOC” date of 01/05/26 for a terminal diagnosis of Leukemia (a cancer of the blood). During an interview on 06/24/26 at 9:41 AM, the Administrator stated, “I know I completed the initial bereavement assessment, but it is not in the EMR, this is very frustrating.” Review of an undated agency policy titled, “Bereavement Risk Assessment,” revealed, “… Hospice patients and family members, caregivers and significant others are assessed for grief and bereavement needs before and after the patient’s death…During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social, and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient’s death…””

“Based on interview and record review, the Hospice agency failed to ensure one of two hospice aides (HA1) had the qualifications required to provide hospice aide services. This failure had the potential to place patients at risk of injury from unqualified personnel. Findings include: Review of HA1’s personnel record revealed HA1 had a hire date of 02/13/26. HA1 completed her orientation on 02/18/26. Review of an 02/28/26 “Competency Evaluation” located in the personnel record revealed that HA1 had received verbal and observational instruction by a Registered Nurse/Case Manager (RN/CM) employed at the Hospice agency and not through a required training program. In addition, HA1’s personnel file did not contain documentation of certified nurse aide training through classroom and on-site practicum by a qualified trainer. During an interview on 06/24/26 at 11:20 AM, the Director of Clinical Services (DCS) was asked if HA1 had received CNA certification. The DCS stated, “No, we looked online and found that the requirements had been lessened. When we had our initial certification, we were told that HA1 was not required to complete a training program, but that we could complete her on-the-job competency.” The DCS further stated, “HA1 did complete a CNA class however, she failed the competency test.” Review of an undated agency policy titled, “Hospice Aide Qualifications” revealed, “…Individuals who currently meet the personnel requirements specified in hospice regulations and who have successfully completed a competency evaluation program as required by regulations, provide hospice aide services under the supervision of a hospice registered nurse…””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed of patients receiving aide services, it was revealed that the agency did not ensure the correct aide frequencies were ordered on the plan of care. CLINICAL RECORD 3: The home health plan of care dated 01/30/2025 ordered hospice aide frequencies as 2x a week. The patient was seen by the aide on 01/31/2025 (which is only 1 x the 1st week of the benefit period). The record lacked evidence as to why the patient was only seen once by the aide that first week. CLINICAL RECORD 5: The home health plan of care dated 02/13/2025 ordered hospice aide frequencies as 2x a week. The patient was seen by the aide on 02/14/2025 (which is only 1 x the 1st week of the benefit period). The record lacked evidence as to why the patient was only seen once by the aide that first week. CLINICAL RECORD 10: The home health plan of care dated 12/06/2024 ordered hospice aide frequencies as 2x a week. The patient was seen by the aide on 12/06/2024 (which is only 1 x the 1st week of the benefit period). The record lacked evidence as to why the patient was only seen once by the aide that first week. This was shared with leadership on 02/19/2025 and in an interview on the same day with the administrator who stated, “Our medical record will not let us separate out the first week frequency for the hospice aide”. She agreed that the aide visit frequencies were not followed as ordered.”