Regal Hospice Inc.

“Based on record review and staff interview, the hospice agency failed to ensure the registered nurse (RN) completed an initial assessment within 48 hours after the election of hospice care in 1 of 2 active clinical records reviewed (Patient (P)2) for a current hospice census of two patients.Failure to complete an initial assessment within 48 hours had the potential to allow the patient’s immediate physical, emotional, and spiritual needs to remain unmet for patients who were currently receiving hospice services and for future hospice patients.Findings include: Review of the electronic medical record (EMR) revealed an “Election of Hospice Medicare Benefit and Patient Authorization” was signed by the patient on 09/04/25. Review of the EMR “Nursing Assessment” revealed the admitting RN, who was the agency Director of Nursing (DON), failed to document an initial assessment until 09/08/25, four days later.During an interview on 09/19/25 at 11:00 AM, the DON verified the initial assessment had not been done until four days after the patient had elected hospice care. The DON stated “normally we do get out to the home right away. Other than it being a weekend, I really can’t tell you why I didn’t get it done until 09/08/25.” A policy requesting time frame for completion of the initial assessment was requested but not received.”

“Based on record review, review of agency policy, and staff interview, the hospice agency failed to ensure the plan of care included measurable outcomes anticipated from implementing the plan of care 2 of 2 active clinical records reviewed (Patient (P)1 and P2) for a current hospice census of two patients.Failure to identify measurable outcomes presents a potential inability to accurately evaluate the patient’s progress in meeting goals of care. This had the potential to affect the two patients who were currently receiving hospice services and future hospice patients/patient family units. Findings include: 1.Review of the electronic medical record (EMR) “Plan of Care” revealed P1 was admitted to the hospice agency on 05/29/25. Review of the “Plan of Care”, dated 05/29/25, revealed that the outcomes included in the plan were generalized, generic, and not individualized for this specific patient. Examples of outcomes in the 05/29/25 plan included “prevent pain and discomfort,” “pain will remain in comfortable level during care,” and “needs will be met on a day-to-day basis as communicated.”2.Review of the EMR “Plan of Care” revealed P2 was admitted to the hospice agency on 09/04/25. Review of the “Plan of Care,” dated 09/08/25, revealed that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 09/08/25 plan included “needs will be met on a day-to-day basis as communicated,” “healing road to peace with conformation with faith,” and “facilitate resolution of issues in helping with final decision.”During an interview on 09/19/25 11:00 AM, these findings were discussed with the Director of Nursing (DON) and the hospice Administrator. The DON was asked how goals that were not measurable could allow specific data collection and outcome evaluation for quality improvement efforts. The DON confirmed the findings and stated, “our plan of care goals are not measurable enough to evaluate progress. I can see how we need to improve in this area.”Review of the agency policy titled “Patient Focused Performance Improvement,” revised November 2024, indicated “At the time of admission and on an ongoing basis, an individualized plan of care/service including specific and measurable goals will be developed for each patient.””

“Based on review of Quality Assessment and Performance Improvement (QAPI) records, interview, and review of hospice policy, the hospice failed to document an assessment of the hospice’s performance in the areas of palliative outcomes such as pain and symptom management.This failure had the potential for unidentified ineffectiveness in these areas and did not reflect improved outcomes. This deficient practice had the potential to affect all current and future hospice patients. Findings include: A review of QAPI documents revealed there was no documentation of an assessment of how the hospice performed in the areas of palliative outcomes such as controlling pain, shortness of breath, or other patient symptoms with the implementation of hospice interventions.During an interview on 09/19/25 at 10:30 AM, the Administrator who, together with a consultant, was responsible for the QAPI program, acknowledged this finding and stated, “We don’t really look at how well we do with relieving pain or other symptoms. I agree that documenting that would be helpful.”Review of the agency policy titled “Improving Organizational Performance,” revised November 2024, stated “Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety. Objectives: To show measurable improvement in indicators that demonstrate an improvement in palliative outcomes.””

“Based on observation, interview, and review of agency policy, the hospice failed to ensure t2 of 2 staff members (Director of Nursing (DON) and Home Hospice Aide (HHA)1) followed standard precautions and wore personal protective equipment (PPE) properly during home visits for 2 of 2 patients (Patient (P)1 and P2) out of a total sample of two patients.Failure to use recommended standard precautions and PPE appropriately while providing care in the home presents the potential for cross contamination and may expose patients and staff to infectious material. This had the potential to affect patients who were currently receiving hospice services and future hospice patients.Findings include: On 09/18/25 at 9:10 AM, a home visit was conducted with HHA1 for P1 who resided in group home setting. HHA1 was observed providing personal care, shower, change of clothes, and a bed linen change for P1. HHA1’s hair which was long, past mid back area, was not secured and hung freely over the shoulders. During the shower, HHA1’s hair was observed coming into contact with multiple parts of P1’s body, arms, chest, and groin each time HHA would lean over to soap and rinse the patient. The same observation was noted during the bed linen change as HHA1’s long free flowing hair came into contact with the contaminated linen removed from the patient’s bed.After the visit was concluded, HHA1 was asked about the proper procedure for securing long hair while providing care, HHA1 stated “I know I’m supposed to tie it back, but that’s kind of hard with my hair because it’s so fine.” When HHA1 was informed of the above observations, and of the potential contamination to self and the patient, HHA1 stated “I never realized any of that, I guess that could be really bad.”During an interview on 09/18/25 at 3:45 PM, the above infection control concerns were discussed with the Director of Nursing (DON) who stated, “Our policy is that all long hair must be secured. This HHA should know that.”On 09/18/25 at 2:45 PM, a home visit was conducted with and the DON, who was completing a skilled nurse visit to P2 residing in a private home. At the onset of the visit, the DON completed hand hygiene and donned a pair of clean gloves. The DON then proceeded to complete the entire 50-minute home visit, which included a physical assessment, blood pressure, pulse, lower leg and foot examination, reaching into a uniform pocket to retrieve a writing pen, again to retrieve a penlight, and documentation of all information in a notebook with the same pair of gloves donned at the beginning of the visit. The DON used the same contaminated gloves to scratch his/her nose and face and sweep hair back from his/her forehead on eight separate occasions during the visit. The DON failed to remove and replace the initial pair of gloves and/or to complete hand hygiene at any time during this home visit. At the conclusion of the visit, the DON was observed returning all used, contaminated equipment (blood pressure cuff, stethoscope, thermometer, and notebook) into the clean nursing supply bag without first cleaning and disinfecting any of the equipment.During an interview on 09/18/25 at 3:45 PM, the above infection control concerns were discussed with the DON who stated, “I had no idea I was doing all that with my hands. I was unaware of touching my face and hair, and I should have changed my gloves.”When asked why the used, contaminated equipment was placed back in the clean supply bag, the DON replied, “I didn’t bring anything to clean it with.”During an interview on 09/19/25 at 4:00 PM, observations noted above were discussed with the hospice Administrator. The Administrator stated, “these observations do not meet the requirements of our infection control policies.” Review of the facility’s policy’s titled, “Hand Hygiene” revised November 2024 indicated, “Hand decontamination using an alcohol-based hand rub should be performed: After contact with a patient’s skin (when taking a pulse, blood pressure) … When moving from a contaminated body site to a clean body site during patient care.” Review of the facility’s policy’s titled, “Standard Precautions” revised November 2024 indicated, “Hand hygiene will be performed to prevent cross-contamination between the patient and personnel. Gloves are to be changed: Between tasks and procedures on the same patient.” Review of the facility’s policy’s titled, “Bag Technique” revised November 2024 indicated, “When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriated solution, hands will be washed, and equipment and supplies will be returned to the bag.””

“Based on interview, record review, and review of agency policy, the hospice failed to implement Tuberculosis (TB) screening in one of nine direct patient care clinical staff files (Home Hospice Aide (HHA) 2) reviewed.Failure to implement required TB screening increased the potential for current patients receiving hospice care and agency staff to contract TB.Findings include: Review of HHA2’s personnel file revealed a date of hire of 06/09/25. The personnel file revealed no evidence a two-step TB screen had been completed prior to hire as required by agency policy. The initial TB test was administered on 03/26/25 and read as negative on 03/28/25. The second step TB was not administered until 05/09/25, 43 days later. No further TB testing was completed by the hospice agency upon the 06/09/25 hire date. During an interview 09/19/25 at 4:00 PM, the hospice Administrator verified the findings and acknowledged TB screening had not been completed correctly for this employee. The Administrator stated, “I didn’t realize it wasn’t done.”The agency policy titled “Tuberculosis Exposure Control Plan,” revised November 2024, read: “Where required by state and / or local regulations, a two (2) step TST (Tuberculosis Screening Test) will be given to all personnel upon hire. If 1st step is negative, the 2nd injection should be administered no earlier than 7 days and no later than 21 days after the read date of the 1st injection. If your 2-step does not follow this, it will be rejected.””

“Based on review of bereavement plans of care, staff interview, and review of agency policy, the hospice failed to ensure that an organized program for the provision of bereavement services was established and individualized bereaved plans of care were developed in five of five closed records where death had occurred (Patient (P)4, P5, P6, P9, P10).Failure to administer a bereavement program has the potential to allow pathological grief reactions that may interfere with eventual resolution of loss to remain unidentified. This had the potential to affect patients who were currently receiving hospice services and all future hospice patients.Findings include: The Spiritual Counselor, who was responsible for the hospice bereavement program, was interviewed on 09/17/25 at 3:30 PM. When asked about the hospice’s bereavement program, the Spiritual Counselor stated, “I do the initial bereavement assessment when I do my comprehensive assessment at the time of admission.”When asked about the bereavement plan of care development, the Spiritual Counselor stated “I know we have certain steps that are outlined in the policy, but I don’t track those things. I think the office manager takes care of it and documents it somewhere.”When asked if bereavement plans of care could be produced for review, the Spiritual Counselor responded, “I didn’t know there had to be a specific plan of care so, no, as far as I know, we don’t have them.” 1.P4 (Date of Death 08/22/25): Review of the record failed to reveal an individualized bereaved plan of care that documented an evaluation of the needs of the bereaved and identified the kind of bereavement services to be delivered and the frequency of service delivery. 2.P5 (Date of Death 07/21/25): Review of the record failed to reveal an individualized bereaved plan of care that documented an evaluation of the needs of the bereaved and identified the kind of bereavement services to be delivered and the frequency of service delivery. 3.P6 (Date of Death 05/25/25): Review of the record failed to reveal an individualized bereaved plan of care that documented an evaluation of the needs of the bereaved and identified the kind of bereavement services to be delivered and the frequency of service delivery. 4.P9 (Date of Death 02/04/25): Review of the record failed to reveal an individualized bereaved plan of care that documented an evaluation of the needs of the bereaved and identified the kind of bereavement services to be delivered and the frequency of service delivery5.P10 (Date of Death 11/08/24): Review of the record failed to reveal an individualized bereaved plan of care that documented an evaluation of the needs of the bereaved and identified the kind of bereavement services to be delivered and the frequency of service deliveryThese findings were discussed at length with the hospice Administrator and Director of Nursing (DON) on 09/19/25 at 10:15 AM. The DON verified these findings and stated that the hospice policy for development of bereavement plans of care had not yet been implemented. The agency policy titled “Bereavement Services,” revised November 2024, stated “A bereavement file will be maintained on each family/caregiver. Each file will contain the following information: Initial bereavement assessment; All bereavement assessments made; A bereavement plan of care that includes needs and goals for ongoing support; All bereavement clinical notes that have been written and/or letters sent to the bereaved.””

“Upon client record review, 2 of 8 (Patient #1, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Admission 5/29/25. RN did psychosocial assessment and noted MSW visit needed. 5/29/25 order for MSW eval within 5 days and frequency1/month plus 2 prn. The MSW eval visit was not made until 6/19/25 with no documented explanation for delay. Patient #3: Admission 6/21/25 with order for BC frequency 1/week as of 6/21/25 start date. No evidence of additional visits after initial bereavement assessment 6/23/25.”

“Upon patient record review, 2 of 8 (Patient #2, 3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: Seizure medications prescribed. Seizure precautions is blank on Hospice aide assignment. Patient #3: Patient experienced significant changes in condition with orders on 7/5/25 to be NPO and Oxygen 2LPM initiated. There was no update to Hospice aide assignment.”

“Upon patient client record review, 5 of 8 (Patient #1, 3, 5, 6, 8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Admitted 5/29/25. The election statement space allocated for effective date of election is blank. The patient chose to receive addendum, but no evidence it was provided. Patient #3: Admitted 5/21/25. The patient chose to receive addendum, but no evidence it was provided. The space allocated for patient to choose or choose not to choose physician is blank. Patient #5: Admitted 2/11/25.The election statement space allocated for effective date of election is blank. The patient chose to receive addendum but no evidence it was provided. The space allocated for patient to choose or not to choose physician is blank. Patient #6: Admitted 11/5/24.The election statement space allocated for effective date of election is blank. The space allocated for patient to choose or not to choose physician is blank. Patient #8: The patient chose to receive addendum but no evidence it was provided.”