Hospice of Texarkana Inc.

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. This standard was not met as evidenced by document review and interview. A review of the agency’s emergency plan revealed that the agency did not ensure that the emergency preparedness plan was updated at least every two years as per the agency’s policy. AGENCY POLICY: The agency’s Emergency Preparedness and Response Plan policy (policy number EC.40, last reviewed on 09/01/2024) stated, in part, that “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or ability to provide those services. The plan will... be reviewed and updated, including related policies and procedures, at least every two years.” EMERGENCY MANAGEMENT PLAN: The agency’s Continuity of Operations Business Plan was updated on 03/21/2022. The next documented update of the Continuity of Operations Business Plan was dated on 01/13/2025. During an interview with the Director of Nursing Services (Personnel Record 7) on 05/06/2025, she stated that the agency’s emergency plan is updated through the revision of the Continuity of Operations Business Plan. During an interview with the Director of Nursing Services on 05/07/2025, she stated that there was no additional documented evidence of an update to the Continuity of Operations Business Plan between 03/21/2022 and 01/13/2025. A review of the agency’s emergency plan revealed that the agency did not ensure that the emergency preparedness plan was updated at least every two years as per the agency’s policy.”

“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 hospice EP training program includes the EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 14 (7%) personnel record reviewed, the agency did not ensure that the staff received education on the agency’s emergency preparedness plan annually as per agency policy. AGENCY POLICY: The agency’s Emergency Preparedness and Response Plan policy (policy number EC.40, last reviewed on 09/01/2024) stated, in part, that “The Hospice will provide initial training at orientation and at least annually thereafter on emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers (consistent with their expected role).” PERSONNEL RECORD 14: The personal record for this volunteer, who joined the agency on 09/25/2015 and provided support in the agency’s inpatient unit, included an attestation of completion of New Volunteer Orientation Student Workbook dated on 10/14/2024. The record included no additional documented evidence of education on the agency’s emergency preparedness plan. There was no documented evidence of what was included in the New Volunteer Orientation Student Workbook. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), she stated that the New Volunteer Orientation Student Workbook included training on the agency’s emergency preparedness plan. She also stated that she consulted with the Volunteer Coordinator, who stated that there was no additional documented evidence of education on the agency’s emergency preparedness plan.”

“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. The drug profile is updated per the hospice policy and procedure, but at a minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) of clinical records reviewed revealed that the agency did not ensure that the medication profile was updated at the time of each comprehensive assessment or when new medications were added. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 04/03/2024 and resides in a skilled nursing facility (SNF). A review of the comprehensive assessment dated 04/17/2025 and the medication profile printed 05/06/2025 was completed. During the home visit with the social worker (Personnel Record 1) on 05/06/2025 an active medication profile was obtained from the SNF and compared with the agency’s active medication profile. During this comparison, it was revealed that the SNF medication profile was missing Flonase, Metolazone 2.5mg daily prn for edema, Nitroglycerin 0.4mg spray prn chest pain, Tums every 12 hours as needed for indigestion, and Tylenol extra strength 500mg every 4 hours as needed for pain and fever. There was no documented evidence that the SNF medication profile was updated at the time of the last comprehensive assessment dated 04/17/2025. During an interview with the director of nursing on 05/06/2025, she confirmed that the medication profiles were different, and the agency had not ensured that the SNF medication was updated.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed revealed that the agency did not ensure that problems identified in comprehensive assessments were included in the patient’s plan of care with specific planned interventions. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/20/2024 with a diagnosis of Cerebral ischemia. The initial registered nurse (RN) assessment identified depression and anxiety as active problems for the patient. The nurse practitioner (NP) was contacted during the visit and orders for citalopram 10mg and Lorazepam 0.5mg q6hours prn anxiety/dyspnea and Lorazepam scheduled at bedtime. During a joint review of the clinical record and interview with the director of nursing services (DON), there was no documented evidence in plan of care that reflected the patient, and family goals or identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/28/2025 with a diagnosis of malignant neoplasm of the bladder. In the initial RN comprehensive assessment dated 03/28/2025, the RN documented that the patient had a nephrostomy tube that required draining and dressing changes. During a joint review and interview with the DON, there was no documented evidence in plan of care that reflected patient, and family goals or identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/18/2025 with a diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease. The patient takes glimepiride 4mg once daily, and Humulin 70/30 subcutaneously administered 4-10 units 2 times a day before meals per the sliding scale. During the joint review of the clinical record and interview with the DON, there was no documented evidence in the plan of care dated 03/26/2025, that reflected the patient’s and family’s goals or identifies planned interventions based on the problem of the primary diagnosis of Diabetes type 2 identified in the initial and updated comprehensive assessments. There was no documented evidence of who would be responsible for managing or monitoring the glucose checks or diabetic medications. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/22/2025 with a primary diagnosis of Cerebral ischemia and a secondary diagnosis of COPD and COPD exacerbation. On the Initial RN assessment dated 04/22/2025, the RN documented that oxygen 2-4L as needed for sob/wheezing, continue albuterol inhaler two puffs q 6 hours as needed for sob/wheezing/difficulty breathing, and change Duoneb treatments to three times daily and every 4 hours as needed for sob/wheezing were added to the patients plan for treatment. The RN also documented in the assessment dated 4/22/2025, “SOB upon exertion 93% O2 on RA, types of treatment for patient opioids, oxygen, non-medication, and inhalation therapy.” During a joint review of the clinical record and interview with the DON, there was no documented evidence in plan of care dated 04/22/2025 that reflected patient, and family goals or identified planned interventions based on problems identified in the initial and updated comprehensive assessments.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 16 of 21 (76%) Clinical records reviewed revealed that the agency did not ensure that the individualized care plan was reviewed, revised, or updated no less frequently than every 15 calendar days. Agency Policy IM.40-TX Timelines-Addendum states in part, “All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days.” CLINICAL RECORD 1: The patient elected the hospice benefit on 04/03/2024. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 5: The patient elected the hospice benefit on 03/27/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/08/2025At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 20: The patient elected the hospice benefit on 07/11/2024. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/21/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/07/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/24/2024. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 3: The patient elected the hospice benefit on 12/20/2024. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/26/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/12/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 21: The patient elected the hospice benefit on 04/08/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/18/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/30/2025, with updates to the plan of care available to all staff. The patient elected the hospice benefit on 04/18/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/30/2025, with updates to the plan of care available to all staff. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/22/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/30/2025 or any date to present with updates to the plan of care available to all staff. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/21/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for and 04/30/2025 or any date to present with updates to the plan of care available to all staff CLINICAL RECORD 14: The patient elected the hospice benefit on 01/21/2025. At the time of clinical record review, no Interdisciplinary Group Meetings were documented in the patient’s record for 04/16/2025 and 04/30/2025, with updates to the plan of care available to all staff. In an interview with the director of nursing services on 05/07/2025, the IDT meetings for 04/16/2024 and 04/30/2025 were discussed. She stated that the two IDT meetings had not been electronically signed by the staff and had not been closed. This makes it impossible for the updated plans of care to be available to all staff. In an interview with the director of nursing services on 05/07/2025, the IDT meetings for 04/16/2024 and 04/30/2025 were discussed. She stated that the two IDT meetings had not been electronically signed by the staff and had not been closed. This makes it impossible for the updated plans of care to be available to all staff. Agency Policy IM.40-TX Timelines-Addendum states in part, “All clinical and progress notes will be written the day service is rendered and incorporated into the patient’s medical record within 14 working days.””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 14 (7 %) personnel record reviewed, the agency did not ensure that the volunteer received education on infection control annually as per agency policy. AGENCY POLICY: The agency’s Exposure Control Plan policy (policy number IC.5, last reviewed on 05/01/2025) stated, in part, “Hospice Responsibilities: To provide training and information related to airborne and bloodborne pathogens for all HCP [Healthcare Personnel] upon hire and annually thereafter”. It also stated, in part, that “Healthcare Personnel refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials.” PERSONNEL RECORD 14: The personal record for this volunteer, who joined the agency on 09/25/2015 and provided support in the agency’s inpatient unit, included an attestation of completion of New Volunteer Orientation Student Workbook dated on 10/14/2024. The personnel record contained no additional documented evidence of education on infection control during the survey focus period. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), stated that the New Volunteer Orientation Student Workbook included training on infection control. She also stated that she consulted with the Volunteer Coordinator, who stated that there was no additional documented evidence of education on infection control.”

“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. 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, document review and interview. In 3 of 3 (100%) clinical records, in which bereavement services were accepted, revealed that the agency did not ensure that a bereavement plan of care was developed. AGENCY POLICY: (State) The policy entitled, “Bereavement (PC.130)” and dated 11/01/2021 included in part that “...After the death of the patient, the Bereavement Coordinator will complete a follow-up assessment and develop a POC for the bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. This POC will be discussed at the next IDG/IDT meeting...The bereavement POC will include delineation of services and frequency to be provided, which may include...individual bereavement counseling, support groups, telephone calls, memorial services, cards, letters, mailings, and referrals to community services as appropriate...” CLINICAL RECORD 17: The patient elected the hospice benefit on 10/08/2024 and expired on hospice services on 11/05/2024. The master social worker (MSW) conducted the post-death assessment on 11/18/2024. There was no post-death Interdisciplinary Group (IDG) documented in the medical record at the time of record review. There was no documented evidence that bereavement plan of care was developed to include interventions with the expected frequency and timelines for those interventions. CLINICAL RECORD 18: The patient elected the hospice benefit on 08/26/2024 and expired on hospice services on 12/03/2024. The MSW conducted the post-death assessment on 12/7/2024. There was no post-death IDG documented in the medical record at the time of record review on 05/08/2025. There was no documented evidence that a bereavement plan of care was developed to include interventions with the expected frequency and timelines for those interventions. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/17/2024 and expired on hospice services on 12/26/2024. There was no post-death IDT documented in the medical record at the time of record review on 05/08/2025. . There was no documented evidence that a bereavement plan of care was developed to include interventions with the expected frequency and timelines for those interventions. During a joint clinical record review and interview with the Patient Care Coordinator on 05/08/2025, she confirmed that the clinical records did not include documentation of a bereavement plan of care planning interventions and frequencies. AGENCY POLICY: (AR & TX) The policy entitled, “Bereavement (PC.130)” and dated 11/01/2021 included in part that “...After the death of the patient, the Bereavement Coordinator will complete a follow-up assessment and develop a POC for the bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. This POC will be discussed at the next IDG/IDT meeting...The bereavement POC will include delineation of services and frequency to be provided, which may include...individual bereavement counseling, support groups, telephone calls, memorial services, cards, letters, mailings, and referrals to community services as appropriate...””

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition, and Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6. This standard was not met as evidenced by document review, interview, and observation. An observation of the stored oxygen cylinders revealed that the agency did not ensure they were stored and labeled per regulation. Full, partial or empty cylinders. A critical aspect of oxygen use and storage is related to identifying each cylinder as full or empty. In an emergency, it is critical for staff to easily identify which cylinders are full. NFPA 99 section 11.6.5.3 specifically requires that empty cylinders be “marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.” Agency Policy EC.45, Fire Safety (reviewed on 09/01/2024), stated in part, “The Hospice will identify and meet all applicable Federal, State, and local laws related to fire safety.” During a tour of the IPU on 05/08/2025, which was observed by the IPU Manager (Personnel Record 9), “E-tank” oxygen cylinders were stored in a closet without identification or segregation of empty or full cylinders. There was no signage on the closet identifying the presence of oxygen nor a “no smoking” sign. During an interview with the IPU Manager on 05/08/2025, he confirmed that the routine storage of the “e-tank” cylinders was as observed during the IPU tour. A tour of the agency’s inpatient unit (IPU) on 05/08/2025 revealed that the agency did not ensure compliance with NFPA regulations pertaining to safe storage of flammable gases, as oxygen containers were not segregated between full and empty cylinders and did not have the proper signage.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition, and Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6. This standard was not met as evidenced by interview and observation. A tour of the agency’s inpatient unit (IPU) on 05/08/2025 revealed that the agency did not ensure compliance with NFPA regulations pertaining to corridor doors to the IPU did not fully self-close. Agency Policy EC.4, Fire Safety policy (reviewed on 09/01/2024) stated in part, “The Hospice will identify and meet all applicable Federal, State, and local laws related to fire safety.” During a tour of the IPU on 05/08/2025, which was observed by the IPU Manager (Personnel Record 9) and the Maintenance System Consultant, the fire doors in the IPU corridor (the doors that sectioned off one area of the facility from the other side) did not fully close when they were released from the magnet holding devices that were keeping them open. The doors did not fit in the frame properly which prevented them from fully closing. During an interview with the Maintenance System Consultant on 05/08/2025, he confirmed that the doors were not closing as intended and the doors would need to be fixed. A tour of the agency’s inpatient unit (IPU) on 05/08/2025 revealed that the agency did not ensure compliance with NFPA regulations pertaining to smoke barrier doors, as the smoke barrier doors within the IPU did not fully self-close.”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure that fire drills were held at least quarterly for each clinical work shift. Agency Policy, number Vol II Sec 7 EC.4, Inpatient Safety policy (reviewed on 03/31/2020), stated in part, “Staff will participate in quarterly fire drills. All shifts will participate in fire drills. IPU will have drills at varied times on all shifts.” The fire drill records for the inpatient unit (IPU) documented fire drills held on 09/06/2022 during the day shift, on 01/05/2023 during the day shift, on 04/23/2024 during the day shift, on 05/02/2024 during the day shift, on 07/22/2024 during the day shift, on 10/22/2024 during the day shift, on 01/21/2025 during the day shift, and on 03/17/2025 during a combination of the day and night shift. There was no documented evidence of additional fire drills in the IPU. During an interview on 05/06/2025 with the IPU Manager (Personnel Record 9), he stated that additional fire drills were not held other than what was represented in the fire drill records. An inspection of the agency’s fire drill records revealed that the agency did not ensure that fire drills were held at least once per quarter for each work shift in the inpatient unit (IPU) as per agency policy.”

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review and observation. An observation of the inpatient unit (IPU) patient room water temperature revealed that the agency did not ensure the water temperatures were regulated for use at an appropriate temperature. Interpretive Guidelines §418.110(i)/L832 stated in part, “The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot…The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees. During a tour of the IPU on 05/08/2025 the water from the sink of a patient room, located farthest from the water heater, was tested and registered at 113 degrees Fahrenheit. A review of the water temperature logs, as documented by the IPU staff, revealed that there were multiple times that the water temperatures ranged above 110 degrees but less than 120 degrees Fahrenheit.”

“It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review and interview. A review of the agency’s food temperature logs revealed that the agency did not ensure that all food served to patients in the inpatient unit (IPU) was served at the proper temperatures. Agency Policy, number Vol II Sec 5 (State).23, Inpatient Foodservice (last reviewed 01/07/2025), stated in part, “Dietary items will be held at proper temperatures to prevent growth of foodborne bacteria and will be served promptly.” The food temperature logs for the IPU included records for 06/20/2022 and then no additional entries until 01/07/2025 and onward. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), she stated that the previous IPU Manager did not ensure that food temperature logs were maintained. She also stated that this situation was discovered in early 2025 and logs were re-established. She confirmed that no additional documented evidence of food temperature checks was available. A review of the agency’s food temperature logs revealed that the agency did not ensure that all food served to patients in the inpatient unit (IPU) was served at the proper temperatures.”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review and interview. A review of the agency’s refrigerator and freezer temperature logs revealed that the agency did not ensure that all food served to patients in the inpatient unit (IPU) was stored at the proper temperatures as per agency policy. Agency Policy, number Vol II Sec 5 (State).23, Inpatient Foodservice (last reviewed 01/07/2025), stated in part, “All meals and food items will be procured, stored, prepared, distributed and served under sanitary conditions and in accordance with all regulatory guidelines.” The refrigerator and freezer temperature logs for the inpatient unit (IPU) included records for 01/07/2025 and after. There was no documented evidence of refrigerator and freezer temperature checks for the survey focus period before that date (2022, 2023, 2024). During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), she stated that the previous IPU Manager did not ensure that refrigerator and freezer temperature logs were maintained, starting in June of 2022. She also stated that this situation was discovered in early 2025 and the logs were re-established. She confirmed that no additional documented evidence of refrigerator and freezer temperature checks covering the timeframe prior to 01/07/2025 were available. A review of the agency’s refrigerator and freezer temperature logs revealed that the agency did not ensure that all food served to patients in the inpatient unit (IPU) was stored at the proper temperatures as per agency policy.”

“It is required that the required hospice education, training, and demonstrated knowledge in the management of patients who are restrained or secluded must include techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances requiring the use of restraint or seclusion. This standard was not met as evidenced by document review, interview, and personnel record review. In 4 of 4 (100%) personnel records reviewed, for clinical staff in the inpatient unit (IPU), the agency did not ensure that staff received training on alternatives to restraint or seclusion annually as per agency policy. Agency Policy, number Vol II Sec 5 (State).29, The agency’s Restraint Free Inpatient Facility policy (no date) stated in part, “Staff training on restraint free policies and alternative interventions will be provided on hire and annually thereafter.” PERSONNEL RECORD 4: The personnel record for this registered nurse in the IPU, hired on 03/22/2004, contained evidence of completion of education on 10/24/2024 which included how to address wandering patients without using restraint or seclusion. There was no additional documented evidence of training on alternatives to restraint or seclusion during the survey focus period. PERSONNEL RECORD 5: The personnel record for this registered nurse in the IPU, hired on 11/13/2007, contained evidence of completion of education on 10/24/2024 which included how to address wandering patients without using restraint or seclusion. There was no additional documented evidence of training on alternatives to restraint or seclusion during the survey focus period. PERSONNEL RECORD 9: The personnel record for this IPU Manager, hired on 11/21/2022, contained evidence of completion of education on 10/24/2024 which included how to address wandering patients without using restraint or seclusion. There was no additional documented evidence of training on alternatives to restraint or seclusion during the survey focus period. PERSONNEL RECORD 12: The personnel record for this Medical Director, contracted on 06/18/2015 contained no documented evidence of education on alternatives to restraint or seclusion. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), she stated that additional education for the IPU staff pertaining to alternatives to restraint and seclusion had not been provided.”