Excelacare Hospice

“It is required that the hospice follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 1: Agency Policy: Infection Prevention and Control in the Home Setting, dated 01/06/2026, stated in part, “Hand Hygiene: Hand hygiene shall be performed at a minimum: when arriving to the workplace assignment; before and after contact with the patient; before performing an aseptic task and the donning of gloves; after contact with the patient or objects in the immediate vicinity of the patient; after contact with blood, body fluids or contaminated surfaces; after contact with the patient’s immediate environment; when moving from a contaminated body site to a clean body site during patient care; immediately before applying PPE (e.g., gloves, gown, facemask); immediately after removal of PPE (e.g., gloves, gown, facemask); before eating; after use of the toilet; and immediately prior to leaving the home/assignment. Alcohol-based products shall be the preferred recommended hand hygiene technique used when there is no visible soiling of hands. Handrubs: when decontaminating hands with a waterless antiseptic agent such as an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendation on the volume of product to use. If an adequate volume of an alcohol-based hand rub is used, it should take 15 to 25 seconds to dry. Hand washing: when washing hands with a non-antimicrobial or antimicrobial soap, wet hands first with warm water, apply detergent to hands and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use a towel to turn off the faucet.” HOME VISIT 2/CLINICAL RECORD 1: During the home visit on 06/09/2026 with the Registered Nurse (RN) [Personnel Record], the RN was observed washing their hands with soap and water. After raising their hands, the RN used the hand towel hanging from the wall-mounted hand towel ring. The RN donned gloves and observed the patient’s skin. When done, the RN removed the gloves and rolled the patient from the bedroom to the kitchen. The RN used alcohol hand rub after returning to the kitchen. The RN did not use a disposable towel to dry the hands when washing with soap and water and did not immediately disinfect the hands after removing the gloves. During a joint document review and interview on 06/09/2026, the Executive Director and Director of Hospice Compliance agreed that the staff did not follow the hand hygiene policy.”

“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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. 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 3 (67%) records reviewed with a discharge due to death; the hospice did not ensure that bereavement services were provided to the family and other individuals in a manner that reflects 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. DOCUMENT 2: Agency Policy: Bereavement Services and Coordination, last reviewed 09/24/2025, stated in part, “An initial bereavement assessment is completed as part of the initial comprehensive assessment. The bereavement assessment will identify the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. The bereavement plan of care will note the kind of bereavement services to be offered and the frequency of service delivery... Bereavement services will be available to the family and other individuals in the bereavement plan of care at least one year following the death of the patient. The IDG must supervise the care and services for the hospice patients and families facing terminal illnesses and bereavement... When the hospice is unable to meet the counseling needs of the bereaved or identifies someone who is at risk for complicated bereavement, the IDG will refer the individual to appropriate community counseling resources as needed. Bereavement care discharges occur when: family declines bereavement care follow-up; family moves from geographic area and cannot participate in the bereavement program; and/or after at least 12 months of bereavement follow-up, the family will be discharged from the program unless the team feels that a longer period is necessary. A final letter will be sent to the family with an evaluation form.” CLINICAL RECORD 17: The patient’s date of election was 06/19/2025. The patient died on 10/27/2025. The bereavement risk assessment documented a moderate risk. The Bereavement Plan of Care stated, “Initial within two weeks of date of death; 4 every other contact and then re-assess. Follow said written care plan as established in SOP after reassessment; and letters at 1, 3, 6, 9, and 12 months.” The record lacked documented evidence of visits or phone contacts for the frequency established in the bereavement plan of care. During a joint clinical record review and interview on 06/09/2026, the Bereavement Coordinator for the Parent location stated that only one person was listed in the computer, and that it was not the name and address of the person who should have been in the system. The Bereavement Coordinator stated that an attempt was made to enter the correct name of the bereaved and a calendar was added. The calendar could not be accessed or edited. The Bereavement Coordinator stated that this one “fell through the cracks.” CLINICAL RECORD 18: The patient’s date of election was 12/12/2024. The patient died on 07/25/2025. The bereavement risk assessment documented a high risk. The Bereavement Plan of Care stated, “Initial within two weeks of date of death; 4 every other contact and referral to a counselor. Re-assess and follow said written care plan as established in SOP after reassessment; and letters at 1, 3, 6, 9, and 12 months.” The record contained one visit/phone contact dated 01/06/2026. There was no documented evidence of a re-assessment for the bereavement plan of care after the 01/06/2026 visit/phone contact. The was no evidence of documentation of any other visits or phone contacts at the frequency established in the bereavement plan of care. During a joint clinical record review and interview on 06/09/2026, the Bereavement Coordinator for the ADS 2 location stated that they began employment in November 2025 and that the previous Medical Social Worker had been in charge of the bereavement program. The Bereavement Coordinator stated that they did not know anything prior to when they started in November of 2025 and that the first contact was made in January 2026.”

“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. Upon reviewing the volunteer program, the documented evidence showed a total of 3.52% for the parent and two alternate delivery sites for the 2025 calendar year, despite documented efforts to recruit volunteers and increase the time of current volunteers. Performance improvement projects began in January 2026 for both alternate delivery sites. As of the end of May 2026, the combined percentage for 2026 had increased to 3.79%. During a joint volunteer program review and interview on 06/11/2026, the Director of Hospice Compliance confirmed that the agency did not meet the required 5% total volunteer hours for the 2025 calendar year, and from January through May 2026. Upon reviewing the volunteer program, the documented evidence showed a total of 3.52% for the parent and two alternate delivery sites for the 2025 calendar year, despite documented efforts to recruit volunteers and increase the time of current volunteers. Performance improvement projects were opened for both alternate delivery sites in January 2026. As of the end of May 2026, the combined percentage for 2026 had increased to 3.79%.”