Immediate Homecare and Hospice

“Based on a review of agency policy, personnel files (PF), and an interview with the administrator, the agency failed to provide Emergency Preparedness training for three (3) of seven (7) PFs reviewed, (PF #2, 4, and 5). Findings include: A review of agency policy titled “Emergency Operations Plan Training Program” conducted on May 8, 2026, at approximately 2:50 PM states, “Hospice will do the following: Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers consistent with their expected roles. Provide emergency preparedness training at least biennially…”A review of PFs was conducted on May 8, 2026, at approximately 11:00 AM.PF #2, Chaplain, Date of Hire: 8/18/25, did not contain any documentation of Emergency Preparedness training at hire.PF #4, LPN, Date of Hire: 1/15/24, did not contain any documentation of Emergency Preparedness training at hire and for 2026.PF #5, SW, Date of Hire: 12/2/25, did not contain any documentation of Emergency Preparedness training at hire.An interview with the administrator conducted on May 8, 2026, at approximately 3:15 PM confirmed the above findings.”

“Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to provide services as per the plan of care for one (1) of five (5) CRs reviewed, (CR #3).Based on a review of agency policy, personnel records (PF), and an interview with the administrator, the agency failed to follow its policy regarding contents of the personnel file for two (2) of seven (7) PFs reviewed, (PF #1 and 2).Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to complete the pronouncing portion of the death certificate for one (1) of two (2) death discharges reviewed, CR #2).Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to provide documentation of nursing notes for one (1) of five (5) CRs reviewed, (CR #5). Findings Include:A review of agency policy titled “Coordination of Patient Care” conducted on May 8, 2026, at approximately 2:50 PM states, “Staff provides the physician, Medical Director, and IDG with patient information on an ongoing basis regarding outcomes of care and services...”A review of CRs was conducted on May 8, 2026, at approximately 10:15 AM.CR #3, Benefit Election date: 2/22/26. A review of file found that a registered nurse (RN) missed visit occurred during the week of 4/12/26 with no documentation of the missed visit and no documentation sent to the physician of the missed visit. A social worker (SW) missed visit occurred during the week of 4/19/26 with no documentation of the missed visit and no documentation sent to the physician of the missed visit. 2. A review of agency policy titled “Personnel Records” conducted on May 8, 2026, at approximately 2:45 PM states, “The personnel record for an employee will include, but not be limited to, the following: CPR; PPD (tuberculosis) tests or chest x-ray results…”A review of PFs was conducted on May 8, 2026, at approximately 11:00 AM.PF #1, CNA, Date of Hire: 3/10/25, did not contain any documentation for CPR training.PF #2, Chaplain, Date of Hire: 8/18/25, contained documentation of only one (1) negative tuberculosis skin test dated 11/8/25. 3. A review of agency policy titled “Post-mortem Care” conducted on May 8, 2026, at approximately 11:15 AM states, “After death care is provided with regard to the desires of the patient, family, cultural and religious practices. Policies and procedures include but are not limited to: Pronouncement of death according to state/federal law...”A review of CRs was conducted on May 8, 2026, at approximately 10:15 AM.CR #2, Benefit Election date: 1/17/26, Date of Death: 2/14/26. Death certificate did not contain any documentation of pronouncement date and did not contain any signature or license number of person who pronounced date and time of death.4. A review of agency policy titled “Coordination of Patient Care” conducted on May 8, 2026, at approximately 2:55 PM states, “Hospice has developed and maintains a system of communication and integration to: Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings...”A review of CRs was conducted on May 8, 2026, at approximately 10:15 AM.CR#5, Benefit Election date: 3/11/26, File did not contain any documentation of nursing notes for certification period reviewed (3/11/26 to 6/8/26). Administrator did mention that all visits were completed and notes had not been entered into their electronic system as of this date and no paper notes were available for review.An interview with the administrator conducted on May 8, 2026, at approximately 3:15 PM confirmed the above findings.”

“Based on a review of agency policy, clinical records (CR), and an interview with the administrator, the agency failed to provide documentation that the attending physician signed the certification of terminal illness for one (1) of seven (7) CRs reviewed, (CR #4). Findings include:A review of agency policies revealed that the agency did not have a policy pertaining to having the physician sign the certification of terminal illness.A review of CR’s was conducted on May 8, 2026, starting at approximately 10:15 AM.CR #4, Benefit Election Date: 12/31/26. File did not contain any documentation of a physician signed certificate of terminal illness.An interview with the administrator conducted on May 8, 2026, at approximately 3:15 PM confirmed the above findings.”

“Based on a review of hospice policy, clinical records (CR), and an interview with hospice staff, the hospice failed to ensure that the plan of care was developed in consultation with the Interdisciplinary Group (IDG) within five (5) days after the election of the hospice benefit for seven (7) of fourteen (14) CR reviewed. (CR# 1, 2, 4, 6, 8, 10, and 12). Findings Include: Review of hospice policy titled “;Initial Assessment/Comprehensive Assessment” on July 22, 2024, at approximately 9:30 A.M. states, “;Procedure: ... 4. The Hospice IDG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the patients election of Hospice care.” A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #1, start of care and hospice benefit election date March 28, 2024. The social worker documented an initial assessment March 27, 2024, which was one (1) day prior to the start of care and hospice benefit election date. There was no documentation of a visit by the social worker within the five (5) days after the patients election of hospice benefit. CR #2, start of care and hospice benefit election date October 19, 2023. There was no documentation of an initial assessment by the social worker or the chaplain within the first five (5) days of hospice benefit election. There was no documentation that the chaplain or the social worker contacted the patient and/or the family to schedule a visit. CR #4, start of care and hospice benefit election date June 17, 2024. An initial assessment by the social worker was conducted on July 3, 2024, sixteen (16) days after hospice benefit election. There was no documentation the social worker contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #6, start of care and hospice benefit election date May 28, 2024. An initial assessment by the social worker was conducted on June 14, 2024, sixteen (16) days after hospice benefit election. There was no documentation the social worker contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #8, start of care and hospice benefit election date January 3, 2024. There was no documentation of an initial assessment completed by the chaplain and the social worker in the first five (5) days of hospice benefit election. There was no documentation that the chaplain or the social worker contacted the patient and/or the family to schedule a visit. CR #10, start of care and hospice benefit election date September 21, 2023. An initial assessment by the social worker was conducted on October 18, 2023, twenty-seven (27) days after hospice benefit election. There was no documentation the social worker contacted the patient and/or family within the first five (5) days of hospice benefit election. CR #12, start of care and hospice benefit election date January 3, 2024. There was no documentation of an initial assessment conducted by the chaplain in the first five (5) days of hospice benefit election. There was no documentation the chaplain contacted the patient and/or to schedule a visit. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on a review of hospice policy, clinical records (CRs), and staff interviews, the hospice Interdisciplinary Group (IDG) failed to revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for three (3) of fourteen (14) CRs reviewed. (CR #5, 7, and 13). Findings Include: Review of hospice policy “IDG Care Planning Process” conducted on July 22, 2024, at approximately 9:40 A.M. states, “Procedure: ... 9. The IDG (in collaboration with the patients attending physician, if any) reviews, revises, and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days...” A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #5, start of care and hospice benefit election date April 5, 2024. Certification reviewed June 4, 2024, through August 2, 2024. IDG meetings were documented on June 13, 2024, and July 3, 2024, which was twenty (20) days between IDT meetings and review of the plan of care. CR #7, start of care March 5, 2024. Certification period reviewed March 5, 2024, through March 6, 2024. There was no documentation of an IDG meeting to develop a plan of care. CR #13, start of care May 14, 2024. Certification period reviewed May 14, 2024, through August 11, 2024. The first IDG meeting documented for the certification period was May 30, 2024, which was at least sixteen (16) days between IDT meetings and review of the plan of care. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on review of hospice policies, clinical records (CR), and interview with hospice staff, the hospice failed to provide services as ordered for thirteen (13) of fourteen (14) CR reviewed. (CR # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) Findings include: Review of hospice policy titled, “;IDG Care Planning Process” on July 22, 2024, at approximately 9:45 A.M. states, “;Policy ... The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.” There was no policy provide pertaining to the handling of missed visits. A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #2, start of care and hospice benefit election date October 19, 2023. Certification period reviewed February 23, 2024, through March 22, 2024. The hospice plan of care (POC) contained orders effective February 22, 2024, for two (2) registered nurse (RN) visits per week, three (3) licensed practical nurse (LPN) visits per week, social worker visits every fourteen (14) days, and chaplain visits every fourteen (14) days. The week of February 25, 2024, there was only one (1) RN visit documented. On March 7, 2024, the RN visits were decreased to one (1) visit per week and the LPN visits were decreased to two (2) visits per week. There was only one (1) LPN visit documented the week of March 3, 2024, through March 9, 2024, and the week of March 10, 2024, though March 16, 2024. A chaplain visit was documented on February 26, 2024. There were no chaplain visits documented from February 27, 2024, through March 21, 2024, (twenty-three (23) days). A social worker visit was documented on March 4, 2024. There were no social worker visits documented from March 5, 2024, through March 21, 2024 (sixteen (16) days). There was no documentation of missed or declined visits for the RN, LPN, chaplain, or social worker. CR #3, start of care and hospice benefit election date February 29, 2024. Certification period reviewed May 29, 2024, through August 26, 2024. The hospice POC contained an order for one (1) RN visit per week, and one (1) social worker visit every fourteen (14) days. There was no documentation of a RN visit the week of June 2, 2024. There was no documentation of a social worker visit from June 21, 2024, through July 9, 2024 (eighteen (18) days). There was no documentation of missed or declined visits for the RN or social worker. CR #4, start of care and hospice benefit election date June 17, 2024. Certification period reviewed June 17, 2024, through September 14, 2024. The hospice POC contained an order for home hospice aide (HHA) services five (5) times per week, to begin on June 24, 2024. HHA services were provided four (4) times the week of June 30, 2024, through July 6, 2024. Social worker services were ordered beginning June 17, 2024, one (1) visit every fourteen (14) days. There was no documentation of a social worker visit from June 17, 2024, through July 2, 2024 (sixteen (16) days). Volunteer services were ordered monthly, effective June 20, 2024. There was no documentation of volunteer services provided in June. There was no documentation of missed or declined visits for the HHA, social worker, or volunteer. CR #5, start of care and hospice benefit election date April 5, 2024. Certification period reviewed June 4, 2024, through August 2, 2024. The hospice POC contained orders for one (1) RN visit per week, one (1) LPN visit per week, and one (1) HHA visit per day. There was no documentation of HHA visits completed from June 4, 2024, through July 11, 2024. There were no LPN visits documented from June 9, 2024, through July 11, 2024. There was no RN visit documented the week of June 23, 2024, through June 29, 2024. There was no documentation of missed or declined visits for the RN, LPN, or HHA. CR #7, start of care and hospice benefit election March 5, 2024. Certification period reviewed March 5, 2024, through March 6, 2024. The clinical record contained no documentation of a hospice POC. One (1) social worker visit was documented on March 5, 2024, and one (1) RN visit was documented on March 6, 2024. There were no orders for services to be provided. The patient transferred to another hospice on March 6, 2024. CR #6, start of care and hospice benefit election May 28, 2024. Certification period reviewed May 28, 2024, through July 26, 2024. The hospice POC contained orders for one (1) LPN visit per week, one (1) HHA visit per day, and one (1) social worker visit every fourteen (14) days. There was no documentation of an LPN visit the week of June 30, 2024, through July 6, 2024. There was no documentation of HHA visits from May 28, 2024, through June 24, 2024. Only four (4) HHA visits were documented the weeks of June 23, 2024, through June 29, 2024, June 30, 2024, through July 6, 2024, and July 7, 2024, through July 11, 2024. There was no documentation of a social worker visits from May 28, 2024, through June 13, 2024 (sixteen (16) days). There was no documentation of missed or declined visits for the RN, LPN, HHA, or social worker. CR #9, start of care and hospice benefit election date June 29, 2024. Certification period reviewed, June 29, 2024, through August 27, 2024. The CR contained documentation of a social worker visit on July 2, 2024. There was no documentation of an order for social worker services in the hospice POC. CR #10, start of care and hospice benefit election date September 21, 2023. Certification period reviewed, May 18, 2024, through July 16, 2024. The hospice POC contained an order for one (1) HHA visit per day. HHA visits were documented three (3) times per week from May 20, 2024, through June 7, 2024, two (2) times per week from June 9, 2024, through June 22, 2024, and three (3) times per week from June 23, 2024, through July 10, 2024. There was no documentation of missed or declined visits for the HHA. CR #11, start of care and hospice benefit election date March 6, 2024. Certification period reviewed, June 4, 2024, through September 1, 2024. Chaplain visits were documented on June 4, 2024, June 19, 2024, and July 8, 2024. Social worker visits were documented on June 13, 2024, and June 27, 2024. There were no orders in the hospice POC for chaplain or social worker services. CR #12, start of care and hospice benefit election date January 3, 2024. Certification period reviewed, April 2, 2024, through June 30, 2024. The hospice POC contained orders for one (1) RN visit per week, one (1) LPN visit per week, and one (1) social worker visit every fourteen (14) days. There were no LPN visits and only one (1) RN visit documented from April 2, 2024, through May 11, 2024. An order to discontinue LPN visits was noted on May 16, 2024. Social worker visits were documented on June 5, 2024, and June 26, 2024, which was twenty-one (21) days between visits. There was no documentation of missed or declined visits for the LPN, RN, or social worker. CR #13, start of care and hospice benefit election date May 14, 2024. Certification period reviewed May 14, 2024, through August 11, 2024. The hospice POC contained an order for one (1) social worker visit every fourteen (14) days. A social worker visit was documented on June 21, 2024, with no visit conducted as of July 10, 2024, which was twenty (20) days between visits. There was no documentation of missed or declined visits for the social worker. CR #14, start of care and hospice benefit election date March 21, 2023. Certification period reviewed, March 21, 2023, through May 19, 2023. The hospice POC contained orders for three (3) to five (5) HHA visits per week. There was no documentation of HHA visits provided during the certification period. There was no documentation of missed visits or declined visits for the HHA. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on review of hospice policy, clinical records (CR), personnel files (PF), and staff interviews, the hospice failed to ensure that the registered nurse (RN) documented supervision of the services provided by the licensed practical nurse (LPN) for four (4) of fourteen (14) CR reviewed. (CR #3, 6, 11 and 13) Findings include: Review of hospice policy titled “;Nursing Services” on July 22, 2024, at approximately 9:15 A.M. states, “;Procedure: ... 2. Professional nursing service will be provided by a registered nurse and include: ... Supervising LVN/LPNs and paraprofessionals providing services at least every 30 days...” A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #3, start of care and hospice benefit election February 29, 2024. Certification period May 29, 2024, through August 26, 2024. There was no documentation of LPN supervision conducted from May 29, 2024, through July 9, 2024, which was more than 30 days. CR #6, start of care and hospice benefit election May 28, 2024. Certification period reviewed May 28, 2024, through July 26, 2024. There was no documentation of LPN supervision conducted from May 28, 2024, through July 11, 2024, which was more than 30 days. CR #11, start of care and hospice benefit election March 6, 2024. Certification period reviewed June 4, 2024, through September 1, 2024. There was no documentation of LPN supervision conducted from June 4, 2024, through July 10, 2024, which was more than 30 days. CR #13, start of care and hospice benefit election May 14, 2024. Certification period reviewed May 14, 2024, through August 11, 2024. There was no documentation of LPN supervision conducted from May 14, 2024, through July 10, 2024, which was more than 30 days. Review of personnel files (PF) on July 11, 2024, from approximately 12:30 P.M. to 2:00 P.M. revealed no documentation of LPN supervisory visits in the LPNs PF. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on review of hospice bereavement program, clinical records (CR), “Bereavement Log”, and staff interviews, the hospice failed to document that bereavement services were made available to the family following the death of the patient, in accordance with the bereavement program, for one (1) of two (2) bereavement CR reviewed. (CR #14). Findings include: A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #14, start of care March 21, 2023, date of death April 26, 2023. The “;Bereavement Log” indicated that a sympathy card was sent on April 30, 2023. A three (3)-week follow-up assessment was documented on May 23, 2023. The remaining contacts at three (3), six (6), and nine (9) months, and the anniversary of the death contained no documentation that the contacts were completed. No other documentation was present in the clinical record regarding bereavement contacts with the family. An interview was conducted with the Bereavement Coordinator on July 11, 2024, at approximately 2:00 P.M. and the bereavement program was reviewed. The Bereavement Coordinator stated that a bereavement call is placed to the family within the first 24 hours and the death is discussed at morning “;stand-up” telephone call. A tracking log is initiated, and the family is contacted regarding funeral arrangements. The Bereavement Coordinator stated that they attend most funerals and deliver the sympathy card at that time. The bereaved are scheduled to receive mailings at three (3), six (6), nine (9) and twelve (12) months. Additional support is provided as needed or requested. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on a review of hospice policy, clinical records (CRs), and staff interviews, the hospice failed to ensure that a registered nurse documented an on-site visit to the patient’s home no less frequently than every 14 days (two weeks) to assess the quality of care and services provided by the home hospice aide (HHA) for three (3) of fourteen (14) CR reviewed. (CR #4, 6, and 10) Findings include: Review of hospice policy titled, “;Hospice Aide Supervision” on July 22, 2024, at approximately 9:45 A.M. states, “;Policy: All Hospice Aide supervisory visits will be made at least every 14 days. Hospice will conduct the 14-day supervisory visit during an on-site visit, in person visit...” A review of clinical records conducted on July 9, 2024, from approximately 12:30 P.M. to 5:30 P.M., July 10, 2024, from approximately 11:00 A.M. to 6:00 P.M., and July 11, 2024, from approximately 9:30 A.M. to 12:00 P.M. revealed the following: CR #4, start of care and hospice benefit election date June 17, 2024. Certification period reviewed, June 17, 2024, through September 14, 2024. The registered nurse (RN) conducted a HHA supervision on June 24, 2024. There were no additional HHA supervisory visits documented by the RN. CR #6, start of care and hospice benefit election date May 28, 2024. Certification period reviewed May 28, 2024, through July 26, 2024. HHA services were provided June 25, 2024, through July 11, 2024. There were no HHA supervisory visits documented by the RN. CR #10, start of care and hospice benefit election date September 21, 2023. Certification period reviewed, May 18, 2024, through July 16, 2024. There were no HHA supervisory visits documented by the RN. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”

“Based on review of the hospice volunteer program, documentation of volunteer service hours provided, and staff interviews, the hospice failed to document day-to-day administrative and/or direct patient care services provided by volunteers in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Findings include: Review of hospice volunteer program documentation on July 11, 2024, at approximately 2:00 P.M. revealed incomplete documentation of volunteer service hours, which did not equal at least five (5) percent of the total patient care hours of all paid hospice employees. The hospice has one (1) active volunteer at the current time. An interview with the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M. revealed that the hospice has a new volunteer starting next week and the hospice is continuing recruiting efforts. An interview with the hospice Administrator and the Director of Operations and Development, HBPC and Palliative Care on July 11, 2024, at approximately 3:00 P.M, and a follow-up telephone call with the Director of Operations and Development, HBPC and Palliative Care on July 22, 2024, at approximately 11:00 A.M. confirmed the above findings.”