Interim Health Care Hospice

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 2 of 10 (20%) personnel records reviewed, the agency did not ensure that hospice provided an emergency preparedness training program at the time of hire and at least every 2 years for all new hospice employees and those providing services under arrangement. PERSONNEL RECORD 2: The Director of Patient Care Services (DPCS) was hired on 01/07’2025. A personnel record review revealed no documented evidence of emergency preparedness training at the time of hire. PERSONNEL RECORD 9: The Hospice Medical Director (contractor) was hired on 10/01/2015. A personnel record review revealed no documented evidence of emergency preparedness training during the period reviewed. Following interview and a joint record review on 07/24/2026, the Administrator and Human Resources Director confirmed that there was no documented emergency preparedness training for these staff members.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 4 (25%) home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current prescription and over-the-counter medications. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/05/2025 with a primary diagnosis of Parkinson’s disease. The patient resided in an assisted living facility (ALF). During a home visit with the Social Worker (SW), a medication reconciliation identified that Sertraline 100 mg daily and ABHR compounded medication (a custom-compounded topical gel or cream containing four active drugs: Ativan (lorazepam), Benadryl (diphenhydramine), Haldol (haloperidol), and Reglan (metoclopramide), 1 gram every 4 hours as needed, were documented on the hospice medication profile but were not documented on the ALF’s medication administration record/profile. Following a joint review and interview on 07/22/2026, the Administrator confirmed that a discrepancy was identified and would be investigated.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care included treatments necessary to meet the needs of the patient. CLINICAL RECORD 16: The patient elected the hospice benefit on 07/02/2025 with a primary diagnosis of amyotrophic lateral sclerosis (ALS). A clinical record identified that the patient had a gastrostomy tube (G-tube) in place for potential future use. However, review of the interdisciplinary plan of care revealed no documented interventions related to the G-tube, including assessment, maintenance, dressing changes, flushing protocols, or other care and monitoring requirements. Following a joint review of the clinical record and interview on 07/23/2026, the Administrator confirmed that the plan of care did not include documentation related to the patient’s G-tube, including assessment, maintenance, monitoring, or care interventions.”

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff reading and recording temperature, pulse, and respiration appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist including bed bath, sponge, tub, and shower bath, hair shampoo (sink, tub, and bed), nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, The remaining subject areas in item 2 above may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record review of a Hospice Aide (HA), the agency did not ensure that the HA had successfully completed a competency evaluation prior to furnishing care to a patient. PERSONNEL RECORD 6: The HA was hired on 07/28/2025. A review of the personnel record revealed no evidence of a competency evaluation completed at hire. The personnel record did not include documentation that the HA’s competency had been assessed and validated in the required area, including observation of performance with a patient or pseudo-patient. During a joint review of personnel records and discussion on 07/24/2026, the Administrator and Human Resources Director confirmed that the required information was not present in the personnel record.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need and the hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 18 (22%) clinical records reviewed for patients receiving Hospice Aide (HA) services, the agency did not ensure HA supervisory visits were conducted at least every 14 days, as required. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/30/2026 with a primary diagnosis of acute/chronic diastolic congestive heart failure. Hospice Aide services were ordered two times per week. During the certification period dated 06/28/2026, the Registered Nurse Case Manager documented visits on 06/10/2026, 06/24/2026, 06/17/2026, 07/01/2026, 07/08/2026, and 07/15/2026. No HA supervisory visits were documented. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/05/2026 with a primary diagnosis of chronic diastolic congestive heart failure. Hospice Aide services were ordered five times per week. During the certification period dated 06/24/2026, the Registered Nurse Case Manager documented visits on 06/08/2026, 06/09/2026, 06/11/2026, 06/15/2026, 06/18/2026, 06/25/2026, 06/30/2026, 07/02/2026, 07/07/2026, 07/14/2026, and 07/16/2026. No HA supervisory visits were documented. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/24/2026 with a primary diagnosis of chronic right heart failure. Hospice Aide services were ordered two times per week. During the certification period dated 06/22/2026, the Registered Nurse Case Manager documented visits on 06/23/2026, 06/30/2026, 07/07/2026, 07/14/2026, and 07/21/2026. No HA supervisory visits were documented. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/22/2026 with a primary diagnosis of chronic diastolic heart failure. The plan of care ordered Skilled Nursing (SN), Social Work, and Hospice Aide services. Hospice aide services were ordered once per week. During the certification period dated 05/22/2026, the Registered Nurse Case Manager documented visits on 06/22/2026, 07/06/2026, 07/09/2026, 07/15/2026, and 07/20/2026. No HA supervisory visits were documented. Following a joint record review and interview on 07/23/2026, the Administrator confirmed that the Registered Nurse Case Manager (RNCM) did not document completion of the required HA supervisory visits. The Administrator stated that the RNCM was new to the role and had selected only the documentation field indicating Licensed Practical Nurse (LPN) supervision but did not complete or select the field indicating HA supervision.”

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards that includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient and guidance specific to individual responsibilities. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of a hospice volunteer, the agency did not ensure that the hospice volunteer received orientation and training consistent with hospice industry standards that included the volunteer’s duties and responsibilities. PERSONNEL RECORD 10: The hospice Volunteer was hired on 10/27/2025. A personnel record review revealed no documented evidence that the hospice volunteer received orientation and training to the volunteer’s duties and responsibilities. There was no evidence that the volunteer received instruction regarding the hospice philosophy, patient rights, confidentiality, volunteer responsibilities, or other agency-specific policies and procedures relevant to the volunteer role. During a joint review of personnel records and discussion on 07/24/2026, the Administrator and Human Resources Director confirmed that the required information was not present in the personnel file.”

“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. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services that equaled at a minimum five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the current hospice volunteer program with the Hospice Volunteer Coordinator revealed that the hospice did not provide the minimum 5% of total patient care hours. The program has one active volunteer, and for the calendar year 2025, the hospice volunteer program provided 0.68% of total patient care hours of all paid hospice employees and contract staff. During interview and review of the hospice volunteer program on 07/22/2026, the Administrator agreed that the hospice program is not meeting the required volunteer hours and stated there is an active process improvement plan in place related to this. Following discussion with the Hospice Volunteer Coordinator and review of the current hospice volunteer program, it was determined that the program did not meet the required 5% volunteer contribution of total patient care hours. The program currently has only one active volunteer, with volunteer hours accounting for approximately 0.68% of total patient care hours.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties including infection control and organization procedures and policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that there was initial orientation completed for each employee upon hire. PERSONNEL RECORD 7:The Spiritual Care Coordinator was hired on 05/04/2026. A personnel record review revealed no evidence that orientation was provided at hire or to date. During a joint review of personnel records and interview on 07/24/2026, the Administrator and HR Director confirmed that the required information was not present in the personnel records.”

“It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of facility patients, the agency did not ensure that the hospice plan of care identified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/09/2026 with a primary diagnosis of unspecified severe protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF) and had multiple wounds located on the hips, legs, and ankles, all of which required ongoing wound care interventions. The hospice plan of care did not include documentation identifying responsibility for providing the wound care. The plan of care did not specify which wound care tasks- wound care assessments, dressing changes, treatment implementation, monitoring of wound progression, and follow-up care were being performed by hospice staff and which were being performed by facility staff. Following a joint clinical record review and interview on 07/21/2026, the Administrator confirmed that the patient’s plan of care did not include documentation identifying responsibility for wound care services.”