St. Mary Hospice

“Based on review of hospice policies, hospice documentation, clinical records, personnel files, and interview with the Regional Director of Hospice Services, the hospice failed to prepare a written plan of care in consultation with the interdisciplinary team. This CONDITION is not met as evidenced under the following standards.Cross reference:42 CFR 418.56(1)(1) (TAG 539) - Approach to Service Delivery42 CFR 418.56(c)(1) (TAG 549) - Content of Plan of Care42 CFR 418.56(e)(4) (TAG 557) - Coordination of ServicesThe cumulative effect of these systematic problems resulted in the hospice’s inability to ensure a written plan of care was developed in consultation with the interdisciplinary team.”

“Based on review of hospice policies, hospice documentation, clinical records, personnel files, and interview with the Regional Director of Hospice Services, the hospice failed to provide core services in a manner that met the needs of the hospice patients. Based on review of hospice policies, hospice documentation, clinical records, personnel files, and interview with the Regional Director of Hospice Services, the hospice failed to provide core services in a manner that met the needs of the hospice patients.This CONDITION is not met as evidenced under the following standards.Cross reference:42 CFR 418.64(b)(1) (TAG 591) - Nursing Services42 CFR 418.64(c) (TAG 594) - Medical Social Services42 CFR 418.64(d)(1) (TAG 596) - Counseling Services42 CFR 418.64(d)(3) (TAG 589) - Counseling ServicesThe cumulative effect of these systematic problems resulted in the hospice’s inability to ensure patients had access to core services.”

“Based on a review of hospice call logs, clinical records (CR), and staff interviews, the hospice failed to document response to a telephone call from a patient regarding dissatisfaction with services for one (1) of four (4) CR reviewed. (CR #4) Findings include:Review of hospice on-call log for November, 2025, on 12/1/2025 at approximately 2:15 P.M. revealed a call received from CR #4 on 11/11/2025, stating, “ Caller called requesting to speak to someone in charge, unhappy with services. “ The call log noted that the telephone call was transferred to “ Manager/Director “ . A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #4, benefit election date 6/13/2025. Certification period reviewed 9/11/2025 through 12/9/2025. There was no documentation in the CR of a conversation between the Manager/Director and the patient. A SN visit was documented on 11/11/2025, with no documentation that the patient was unhappy with services. The patient remains active with the agency with no further documentation of complaints or concerns.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of hospice policy, clinical records (CR), and staff interviews, the agency failed to revoke hospice services when requested for one (1) of four (4) CR reviewed. (CR #2). Findings include:A review of hospice policy titled, “Hospice - Transfer, Revocation, Discharge & Termination on 12/5/2025 at approximately 8:00 A.M. stated, “Policy: Patients who choose to no longer receive the agency’s hospice care may: Revoke their hospice benefit election... Revocation of Benefits: 1. The patient that wishes to revoke his/her hospice election loses remaining days in the benefit period and resumes pre-hospice election benefits. He/she may elect hospice coverage for unused hospice election periods. a. The case manager notifies the attending physician and medical director. b. The IDG may assist the patient/family in developing a discharge plan of care as appropriate... 3. For all other insurances, the agency will follow all requirements including signing of the Hospice revocation benefits.”A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. An initial SN visit was conducted by PF #3 on 9/22/2025, at which time the consent form and hospice benefit election form were signed by the patient. The ’ Hospice Admission Plan of Care 9/22/25 ’ stated in the ’ Plan of Care Notes ’ documented by the RN Clinical Manager (PF #3), “ ... [CR #2] has fully come to terms with their current diagnosis and prognosis and has opted not to seek further aggressive treatment ... ‘A visit note dated 10/15/2025 documented by RN (PF #3), stated, “ Pt. is requesting to be discharged from hospice to seek further treatment. [CR #2] has an appointment with the oncologist on Tuesday, Oct. 21, 2025. Palliative care referral will be made ... Hospice clinical manager to make the changes ... “ An Encounter Note dated 10/22/2025 at 6:57 A.M. entered by RN (PF #3) stated, “ Call received from [spouse] ... the [CR #2] went to the ER last night for severe headache. When they call into the service the [spouse] ... reported that [CR #2] was on homecare not hospice, so the VCC suggested them to call 911. After further discussion with [spouse], no aggressive treatment/imaging will be completed, and [CR #2] will be transported home from the ER ... “ There was no documentation in the CR that a referral was made to palliative care or that a hospice revocation form was completed.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of agency policy, on-call documentation, clinical records (CR) and staff interviews, the agency failed to provide information about hospice services to one (1) of four (4) CR reviewed. (CR #2). Findings include:Review of an ‘Encounter Note’ dated 10/22/2025 at 6:57 A.M. entered by RN (PF #3) stated, “ Call received from husband ... the [CR #2] went to the ER last night for severe headache. When they call into the service the [spouse] ... reported that [CR #2] was on homecare not hospice, so the VCC (on call center) suggested them to call 911. After further discussion with [spouse], no aggressive treatment/imaging will be completed, and [CR #2] will be transported home from the ER ... “A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. A skilled nursing visit note dated 10/15/2025 documented by RN (PF #3), stated, “ Pt. is requesting to be discharged from hospice to seek further treatment. [CR #2] has an appointment with the oncologist on Tuesday, Oct. 21, 2025. Palliative care referral will be made ... Hospice clinical manager to make the changes ... “ There was no documentation that CR #2 was referred to palliative care. There was no documentation that CR #2 or their spouse were informed that hospice services were terminated. There was no documentation of a revocation of hospice services form signed by CR #2 or their spouse. An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations 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), according to hospice policy, within five (5) days after the election of the hospice benefit for two (2) of four (4) CR reviewed. (CR# 2 and 3). Findings include: Review of hospice policy titled “Hospice - Spiritual Care Services” on 12/4/2025, at approximately 3:30 P.M. stated, “Process: The Hospice Chaplain: 1. Assesses each patient/caregiver within 5 days of admission, ... 3. b. For patients requesting spiritual support from the hospice, the Hospice Chaplain: Schedules a home visit within 48 hours of the referral at a time the patient desires...” A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. The Chaplain (PF #9) completed the initial evaluation virtually, rather than in person, on 9/23/2025. CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/20/2025. A Chaplain evaluation telephone call was documented by PF #9 on 8/28/2025. An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on review of hospice policy, clinical records (CR), and staff interviews, the hospice failed to ensure a MSW and/or a Chaplain participated in interdisciplinary team (IDT) meetings for three (3) of four (4) CR reviewed. (CR #2, 3 and 4). Findings include: Review of hospice policy titled ‘Hospice - Care Planning Process’ on 12/5/2025 at approximately 8:15 A.M. states, “Policy: Hospice Guidelines That Qualify Patients for Care: 6. Within five (5) calendar days from admission, the social worker and chaplain will complete their discipline specific assessment and provide input to the Plan of Care... 7. d. The IDG updates the Plan of Care no less frequently than every 15 days and review changes that have taken place since the initial assessment...” A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. There was no documentation that a MSW present during the IDT meeting on 10/1/2025. CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/16/2025. There was no documentation that a MSW present during the IDT meeting on 9/3/2025, 9/17/2025, and 10/1/2025. There was no documentation of a Chaplain present during the IDT meeting on 10/14/2025.CR #4, benefit election date 6/13/2025. Certification period reviewed 9/11/2025 through 12/9/2025. There was no documentation that a MSW present during the IDT meeting on 9/3/2025, 9/17/2025, 10/1/2025, and 11/26/2025. There was no documentation of a Chaplain present during the IDT meeting on 10/14/2025.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on review of agency policy, clinical records (CR) and staff interviews, the hospice failed to ensure the Plan of Care (POC) included the drugs and treatment necessary to meet the needs of the patient for one (1) of four (4) CR reviewed (CR #3). Findings include:Review of hospice policy titled ‘THAH - Medical Orders’ on 12/5/2025 at approximately 8:30 A.M. states “Procedure: 1. Plan of Care: II. Verbal Orders: All verbal orders must be entered directly into the Electronic Health Record at the time they are received from the physician/practitioner. After the verbal orders have been recorded, the staff member taking the verbal order will read the information back to the physician/practitioner to ensure accuracy. Verbal Orders must be received and signed by a licensed professional nurse, licensed practical nurse or therapist, per state regulation, and countersigned by the physician/practitioner.”A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/20/2025. On 8/26/2025, the RN (PF #3) documented, “On assessment [CR #3’s] mouth had a white coat on it which represented thrush. New order obtained for nystatin swish and swallow (magic mouthwash).” There was no documentation of a verbal order and no evidence that the medication was added to the Plan of Care.On 9/13/2025 the RN (PF #12) documented, “ Stage 2 noted on sacrum removed foam dressing, no dressings available will need to be reordered, applied magic butt paste and left OTA. “ An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on a review of agency policy, clinical records (CR), interdisciplinary group (IDG) updates, and an interview with agency staff, the hospice failed to follow agency policy regarding sharing of information of patient care for three (3) of four (4) clinical records (CR#2, 3 and 4). Findings include: Review of hospice policy titled ‘Hospice - Care Planning Process’ on 12/5/2025 at approximately 8:15 A.M. states, “Policy: Hospice Guidelines That Qualify Patients for Care: 6. Within five (5) calendar days from admission, the social worker and chaplain will complete their discipline specific assessment and provide input to the Plan of Care... 7. d. The IDG updates the Plan of Care no less frequently than every 15 days and review changes that have taken place since the initial assessment...” A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. There was no documentation that a MSW present during the IDT meeting on 10/1/2025. CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/16/2025. There was no documentation that a MSW present during the IDT meeting on 9/3/2025, 9/17/2025, and 10/1/2025. There was no documentation of a Chaplain present during the IDT meeting on 10/14/2025.CR #4, benefit election date 6/13/2025. Certification period reviewed 9/11/2025 through 12/9/2025. There was no documentation that a MSW present during the IDT meeting on 9/3/2025, 9/17/2025, 10/1/2025, and 11/26/2025. There was no documentation of a Chaplain present during the IDT meeting on 10/14/2025.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on review of clinical records (CR) and staff interviews the hospice nurse failed to ensure the nursing needs of the patient were met for () of four (4) CR reviewed. (CR# 2, 3, 6, 11, 12 and 14). Findings include:A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #1, benefit election date 10/21/2025. Certification period reviewed, 10/21/2025, through 1/18/2026. Hospice aide visits were ordered 2 times per week for 12 weeks beginning 10/26/2025. No hospice aide visits were provided the week of 12/2/2025 through 11/8/2025.CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/20/2025. Hospice aide visits were ordered 3 visits every week for 13 weeks. Only two (2) HA visits were conducted during the week of 10/12/2025 through 10/18/2025.CR #4, benefit election date 6/13/2025. Certification period reviewed 9/11/2025 through 12/9/2025. Skilled nursing visits were ordered effective 9/4/2025, 2 SN visits per week for 13 weeks. The order was updated on 10/26/2025 to 1 SN visit per week for 7 weeks. SN missed visits were documented on 9/12/2025 and 9/26/2025.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of hospice policy, clinical records (CR), personnel files (PF) and interview with hospice staff, agency failed to ensure a Medical Social Worker (MSW) was conducting in person visits in accordance with the Hospice Plan of Care for two (2) of four (4) CR reviewed. (CR #1 and 4). Findings include: A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #1, benefit election date 10/21/2025. Certification period reviewed, 10/21/2025, through 1/18/2026. The MSW (PF #8) conducted an initial visit on 10/22/25 but did not complete a visit note. An Interdisciplinary Group (IDG) meeting was held on 10/29/2025. MSW visits were updated to 2 visits every month for 3 months and 3 PRN effective 10/28/2025. There was only one (1) MSW visit documented in October 2025. CR #4, benefit election date 6/13/2025. Certification period reviewed 9/11/2025 through 12/9/2025. The initial MSW visit was conducted on 6/15/2025. MSW missed visits were documented on 9/23/2025 and 10/10/2025. A MSW phone call was documented on 10/17/2025 and 11/17/2025. An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on review of hospice bereavement program, clinical records (CR), bereavement console documentation, 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 three (3) of three (3) bereavement CR reviewed. (CR #1, 2, and 3). Findings include: A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #1, benefit election date 10/21/2025, date of death 11/9/2025. The bereavement console documentation indicated that a sympathy card was sent on 11/26/2025. A 5 day post mortem phone call was documented on 11/13/2025, stating “ [PF #2] spoke with [CR #1’s spouse], who is unsure if she wants bereavement support at this time... Please see [PF #2’s] documented telephone call. “ There was no documentation identifying the staff member that entered the note. A 10 day post mortem phone call was documented on 11/14/2025 stating that a voice mail was left by the Chaplain [PF #2] offering support. The Chaplain documented the telephone call from 11/14/2025 on 11/26/2025. There was no documentation found for the telephone call made on 11/13/2025. CR #2, benefit election date 9/22/2025. Date of death 10/23/2025. The bereavement console documentation indicated that an assessment was completed, a sympathy card sent and the 10 day post mortem telephone call was made on 11/7/2025. There was no documentation of a 5 day post mortem telephone call completed. There was no documentation identifying the staff member completing the bereavement services.CR #3, benefit election date 8/23/2025. Date of death 11/9/2025. The bereavement console documentation indicated that an assessment was completed on 11/14/2025, a sympathy card was sent on 11/26/2025, and a 10 day post mortem telephone call was made on 11/21/2025. There was no documentation of a 5 day post mortem telephone call completed. There was no documentation identifying the staff member completing the bereavement services. An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of hospice policy, clinical records (CR), personnel file (PF) and staff interviews, the hospice failed to ensure patient and family spiritual needs were met for two (2) of four (4) CR reviewed. (CR #2 and 3). Findings include:Review of hospice policy titled “Hospice - Spiritual Care Services” on 12/4/2025, at approximately 3:30 P.M. stated, “Process: The Hospice Chaplain: 1. Assesses each patient/caregiver within 5 days of admission, ... 3. b. For patients requesting spiritual support from the hospice, the Hospice Chaplain: Schedules a home visit within 48 hours of the referral at a time the patient desires...”A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #2, benefit election date 9/22/2025. Certification period reviewed 9/22/2025 through 11/15/2025. The Chaplain (PF #9) completed the initial evaluation virtually via telephone on 9/23/2025. The Chaplain conducting the initial evaluation is employed by another Trinity Health Systems hospice in California (PF #9). No in-person Chaplain visits were documented. CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/20/2025. A Chaplain evaluation telephone call was documented by PF #9 on 8/28/2025. An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of clinical records (CR) and staff interviews, the agency failed to ensure that the Pennsylvania Orders for Life-Sustaining Treatment (POLST) was signed by the physician in a timely manner for one (1) of four (4) CR reviewed. (CR #4) Findings include:A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #4, benefit election date 6/13/2025. Upon review of the CR, no POLST form was present. A POLST form was later provided with a date of 12/1/2025, which was the date of the survey and more than five (5) months after the benefit election date.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based upon review of clinical records (CR) and staff interviews, the agency failed to ensure that the Pennsylvania Orders for Life-Sustaining Treatment (POLST) was signed by the physician in a timely manner for one (1) of four (4) CR reviewed. (CR #4) Findings include:A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #4, benefit election date 6/13/2025. Upon review of the CR, no POLST form was present. A POLST form was later provided with a date of 12/1/2025, which was the date of the survey and more than five (5) months after the benefit election date.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on review of agency policy, clinical records (CR) and staff interviews, the hospice failed to ensure the Plan of Care (POC) included the drugs and treatment necessary to meet the needs of the patient for one (1) of four (4) CR reviewed (CR #3). Findings include:Review of hospice policy titled ‘THAH - Medical Orders’ on 12/5/2025 at approximately 8:30 A.M. states “Procedure: 1. Plan of Care: II. Verbal Orders: All verbal orders must be entered directly into the Electronic Health Record at the time they are received from the physician/practitioner. After the verbal orders have been recorded, the staff member taking the verbal order will read the information back to the physician/practitioner to ensure accuracy. Verbal Orders must be received and signed by a licensed professional nurse, licensed practical nurse or therapist, per state regulation, and countersigned by the physician/practitioner.”A review of CR on 12/1/2025, from approximately 10:00 A.M. to 1:00 P.M., 12/3/2025 from approximately 11:00 A.M. to 4:00 P.M., and 12/4/2025 from approximately 9:00 A.M. to 3:00 P.M. revealed the following:CR #3, benefit election date 8/23/2025. Certification period reviewed 8/23/2025 through 11/20/2025. On 8/26/2025, the RN (PF #3) documented, “On assessment [CR #3’s] mouth had a white coat on it which represented thrush. New order obtained for nystatin swish and swallow (magic mouthwash).” There was no documentation of a verbal order and no evidence that the medication was added to the Plan of Care.On 9/13/2025 the RN (PF #12) documented, “ Stage 2 noted on sacrum removed foam dressing, no dressings available will need to be reordered, applied magic butt paste and left OTA. “ An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Based on observations and interview with agency staff, the agency failed to provide access to documentation needed to conduct a complaint investigation. Findings include:Upon arrival at the agency location at 41 University Drive, Suite 103, Newtown, PA 18940, on 12/1/2025, at approximately 10:00 A.M., an entrance conference was conducted with the Regional Operations Business Director. The Regional Director of Hospice Operations was with a patient and would be returning to the hospice office at the conclusion of the visit.The surveyors requested documentation needed to conduct the complaint investigation. A request was made for access to the electronic medical record (EMR). The surveyors were informed that it would take most of the day to obtain the access and that hospice staff would be able to assist with review of the files requested. The patient files were reviewed via projection screen with the Regional Director of Hospice Services. Some documentation was printed for the surveyors to review. Personnel files were reviewed with Senior Colleague Relations Partner virtually while on-site.On 12/2/2025 a second request was made for access to the EMR to review additional documentation. The surveyors were told that access would not be possible. The surveyors then requested copies of the four (4) clinical records reviewed to be sent via email. The files were received on the afternoon of 12/3/2025.An exit conference conducted on 12/5/2025 at approximately 10:00 A.M. which included the Regional Director of Hospice Operations, the Director of Quality Compliance, the National Director of Quality & Clinical Services, the National Director of Quality and Performance Improvement, the VP of Hospice and Palliative Care, the COO of Trinity Health at Home, and the VP of Homecare Operations confirmed the above findings.”

“Observed in Individual Tracer. In 2 of 10 patient records reviewed, did not have a comprehensive assessment that addressed all symptoms related to palliation and treatment. RR#2 HV had a Pleurx catheter to address ascites which was being managed by the hospice RN. Neither the initial assessment nor the follow up revisit described the insertion site, any drainage, or how the patient tolerated the draining of the fluid. RR#5 also had a pleural catheter which was being managed by the hospice. There was no mention/description of the insertion site in the initial assessment or several subsequent revisits Per the manager, this was not consistent with the hospice policy titled-Pleural Catheter.”