St Gabriels Hospice and Palliative Care LLC

“Based on record review and interview, the interdisciplinary group- (core group of a physician, registered nurse, chaplain, and social worker that provided/supervised all care and services, ensuring a holistic approach to terminal illness and bereavement), in collaboration with the individual’s attending physician, if any, failed to review, revise, and document the patient’s individualized plan of care as frequently as the patient’s condition required but no less frequently than every 15 days, in that the interdisciplinary group failed to revise the plan of care regarding the frequency of staff visits for 3 (Patient #2, Patient #7, and Patient #8) of 10 active patient records reviewed. The failure placed the patients at risk of receiving care that was not appropriate to meet their specific needs. Patient #2: Record review of Patient #2’s clinical record revealed an Initial Plan of Care dated 3/12/2026. The Plan of Care indicated that Patient #2 started on the hospice’s services on 3/16/2026. The Plan of Care listed Alzheimer’s Disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks) as the terminal diagnosis. The Plan of Care contained orders for the Hospice Aide to provide visits 3 times each week and the Social Worker to visit monthly. Review of the interdisciplinary group’s plan of care documentation, dated 7/9/2026, contained orders for Patient #2 to receive visits from the Social Worker once a month and the hospice aide three times each week. Review of the interdisciplinary group’s plan of care documentation, dated 7/23/2026, contained orders for Patient #2 to receive visits from the Social Worker once a month and visits from the Hospice Aide three times each week. Review of the interdisciplinary group’s plan of care documentation, dated 8/6/2026, contained orders for Patient #2 to receive visits from the Social Worker once a month and visits from the hospice aide three times each week. Review of the interdisciplinary group’s plan of care documentation, dated 8/20/2026, contained orders for Patient #2 to receive visits from the Social Worker once a month and visits from the hospice aide three times each week. Review of the clinical notes for Patient #2, between 7/1/2026 to 8/31/2026, indicated that the Social Worker did not make a monthly visit and the Hospice Aide did not conduct visits three times each week. The interdisciplinary team met on 7/9/2026, 7/23/2026, 8/6/2026, and 8/20/2026. The Interdisciplinary team failed to revise the Plan of Care for the Social Worker frequency and the Hospice Aide frequency. Patient #7:Review of Patient #7’s clinical record revealed an Initial Plan of Care dated 5/31/2026. The Plan of Care indicated Patient #7 started on the hospice’s services on 5/31/2026. The Plan of Care listed Hypertensive Heart and Chronic Kidney Disease with Heart Failure (long-term, unmanaged high blood pressure damages the heart and the kidneys, causing the heart to weaken and fail to pump blood effectively) as the terminal diagnosis. The Plan of Care contained orders for the Social Worker to visit once a month. Review of the interdisciplinary group’s plan of care documentation, dated 6/2/2026, contained an order for Patient #7 to receive a visit from the Social Worker once a month. Review of the interdisciplinary group’s plan of care documentation, dated 6/16/2026, contained an order for Patient #7 to receive a visit from the Social Worker once a month. Review of the interdisciplinary group’s plan of care documentation, dated 6/25/2026, contained an order for Patient #7 to receive a visit from the Social Worker once a month. Review of the interdisciplinary group’s plan of care documentation, dated 7/9/2026, contained orders for Patient #7 to receive visits from the Social Worker once a month. Review of the interdisciplinary group’s plan of care documentation, dated 7/23/2026, contained orders for Patient #7 to receive visits from the Social Worker once a month. Review of the clinical notes between 5/31/2026 and 8/1/2026 indicated the Social Worker C conducted a social work visit on 6/9/2026. A Social Worker did not provide a visit to Patient #7 in July 2026. The interdisciplinary group met on 6/16/2026, 6/25/2026, 7/9/2026, and 7/23/2026. The Interdisciplinary group failed to revise the Plan of Care for the Social Work frequency. Patient #8: Record review of Patient #8’s clinical record revealed an Initial Plan of Care dated 9/5/2025. The Plan of Care indicated that Patient #8 started on the hospice’s services on 9/5/2026. The Plan of Care listed Alzheimer’s Disease with Late Onset (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks) as the terminal diagnosis. The Plan of Care contained orders for no visits from the Chaplain or Social worker. Review of the Interdisciplinary group’s plan of care documentation for 7/9/2026 contained an order for the social worker to visit once a month. Review of the Interdisciplinary group’s plan of care documentation for 7/23/2026 contained an order for the social worker to visit once a month. Review of the Interdisciplinary group’s plan of care documentation for 8/6/2026 contained an order for the social worker to visit once a month. Review of the Interdisciplinary group’s plan of care documentation for 8/20/2026 contained an order for the social worker to visit once a month. Review of the clinical notes for Patient #8 between 7/31/2026 and 8/31/2026 indicated that the social worker did not make a monthly visit in July 2026 or August 2026. The interdisciplinary team met on 7/9/2026, 7/23/2026, 8/6/2026, and 8/20/2026. The Interdisciplinary team failed to revise the Plan of Care for the Social Worker frequency. During an interview on 9/2/2026 at 11:17 AM with the Director of Nursing and Alternate Administrator, the Surveyor asked what constituted the hospice patient’s plan of care. The Surveyor asked if the Initial Plan of Care, interim orders, and the interdisciplinary group’s documentation would be the Plan of Care. The Director of Nursing stated, “Yes.” During an interview on 9/2/2026 at 3:10 PM with the Director of Nursing, the Surveyor discussed the interdisciplinary group plan of care documentation contained orders for a Social Worker to visit Patient #2 once a month and the hospice aide to visit 3 times each week; review of the clinical documentation indicated that the Social Worker did not provide visits once a month and the Hospice Aide did not provide visits 3 times each week. The Surveyor asked why the visits had not been made. The Director of Nursing stated, “The Aide was discontinued. The order to discontinue that Aide was not put in the record. Social Worker frequency looked like it was added to the assignments without an order on 4/20/2026 on accident. It was added by mistake.” The Surveyor asked who would be responsible for documenting the revision of the Plan of Care. The Director of Nursing informed the Surveyor that the Case Manager would be responsible to do so. The Surveyor asked if the Case Manager’s knew they were responsible to revise and document the Plan of Care. The Director of Nursing stated, “They know.” During an interview on 9/4/2026 at 1:40 PM with the Administrator, Alternate Administrator, and the Director of Nursing, the Surveyor discussed the Plans of Careand interdisciplinary group plan of care documentation for Patient #2, Patient #7, and Patient #8, contained orders for Social Work visits but the Social Worker was not providing visits, and the Aide for Patient #2 was not providing visits. The Director of Nursing informed the Surveyor that the Social Work visits were accidentally added to the Plans of Care. The Hospice Aide was discontinued for Patient #2. During an interview on 9/9/2026 with Registered Nurse E (Registered Nurse Case Manger that went as needed employee status), the Surveyor asked what Registered Nurse E’s responsibility for the interdisciplinary group was. Registered Nurse E informed the Surveyor that Registered Nurse E would do the assessment. The Surveyor asked what Registered Nurse E would be responsible regarding documentation for the interdisciplinary group. Registered Nurse E informed the Surveyor that Registered Nurse E was responsible for putting in registered nurse clinical notes. The Surveyor asked who was responsible for revising changes in the interdisciplinary group plan of care. Registered Nurse E stated, “If it was medication changes, that would be done in the same visit, changes to the plan of care was not my responsibility. “The Surveyor asked who would be responsible if changes were made in frequencies for the Chaplain or Social Worker. Registered Nurse E informed the Surveyor that anyone can do it; Registered Nurse, the Director of Nursing, or they can do their own. Registered Nurse E stated, “Everyone was responsible for the interdisciplinary group documentation, not just the registered nurse case manager. During an interview of 9/9/2026 with Registered Nurse D, (case manager), the Surveyor asked what Registered Nurse D’s responsibilities for the interdisciplinary group were. Registered Nurse D stated, “We do our own notes. We sit in on interdisciplinary group meetings. The Surveyor asked who would be responsible for changes in the plan of care, changes in frequency. Registered Nurse D state, “That would be the case manager.” Registered Nurse D informed the Surveyor that Registered Nurse D had struggled with that; writing an order was not a one stop, had to go to multiple places to get it done, write an order, go to the scheduler (electronic medical record schedule); the agency’s electronic medical record system was new for Registered Nurse D. The Surveyor asked who would be responsible to revise for changes in Chaplain or Social Worker frequencies. Registered Nurse D stated, “It would be the case manager, then go into the scheduler. The scheduler (electronic medical record software scheduler) was not user friendly; would have to go in and make sure the scheduler does not reflect its weekly visits.” Review of the agency’s policy titled “Plan of Care Process PC.30,” last reviewed on 3/16/2026 read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy...III. The Hospice will review and revise patient care in accordance with changes in the patient’s condition; spiritual status; psychosocial status, residential environment; patient’s response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions, and limitations. Procedure...The Hospice IDG/IDT, in collaboration with the individual’s attending physician, if any, will review, revise, and document the individualized plan of as frequently as the patient’s conditions requires, but no less frequently than every 15 calendar days...””

“Based on record review and interview, the hospice failed to have individuals that provided hospice aide services, complete a competency evaluation where tasks listed at 42 Code of Federal Regulations Chapter 418, at 418.76(b)(3), (iii), (ix), (x), and (xi) were evaluated by observation of the aide’s performance of the tasks with a patient or pseudo-patient for 3 (Hospice Aide F, Hospice Aide G, and Hospice Aide H) of 3 hospice aides where their personnel records were reviewed. The failure placed patients at risk of receiving inadequate or unsafe care from the hospice aides. The 42 Code of Federal Regulations, dated 6/7/2024, Chapter 418 at 418.76 (b)(3), (i), (iii), (ix), (x) and (xi) listed the following tasks that a registered nurse must observe an aide perform were: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other hospice staff; . . . (iii) Reading and recording temperature, pulse, and respiration; . . . (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include— (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning...” Hospice Aide F:Record review of Hospice Aide F’s personnel record revealed an application for employment that was dated 3/6/2026; a signed job description for Hospice Aide dated 3/6/2026; and Orientation dated 3/7/2026. Hospice Aide F’s personnel record did not contain an evaluation by observation of Hospice Aide F performing the tasks for reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that included a bed bath; sponge, tub, and shower bath; Hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. Hospice Aide G:Record review of Hospice Aide G’s personnel record revealed an application for employment that was not dated; a job description for Hospice Aide signed by the Alternate Administrator dated 4/27/2026; and Orientation, undated. Hospice Aide G’s personnel record did not contain an evaluation by observation of Hospice Aide G performing the tasks for reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that included a bed bath; sponge, tub, and shower bath; Hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. Hospice Aide H:Record review of Hospice Aide H’s personnel record revealed an application for employment dated 8/18/2026; a signed job description for Hospice Aide dated 8/19/2026; and Orientation dated 8/19/2026. Hospice Aide H’s personnel record did not contain an evaluation by observation of Hospice Aide H performing the tasks for reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that included a bed bath; sponge, tub, and shower bath; Hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. The Hospice Aide Job Description listed under Job Qualifications read in part; “Skills...Successful completion of the Aide Competency Evaluation Skills Checklist that meets 418.76 and written Skills Test.” Hospice Aide F, Hospice Aide G, and Hospice Aide H’s personnel records contained documents titled “Hospice Aide- Skill Competency Checklist Determined by Direct Observation of the Aide.” The documents were blank. During an interview with the Administrator, Alternate Administrator, and the Director of Nursing, the Surveyor discussed that the Hospice Aide F, Hospice Aide G, and Hospice Aide F that the hospice aides had blank Competency Checklists documents. The Surveyor asked why the Competency had not been done and who would be responsible for them being done. The Director of Nursing stated, “I didn’t know they had to be done.” Record review of the agency’s policy titled “Hospice Aide/Homemaker Competency Evaluation HR (Human Resources).45,” last reviewed on 9/1/2024, read in part; “Purpose To establish the competency evaluation for both written and skills demonstration for hospice aides...Policy I. The Hospice will ensure that each hospice aide successfully completes a hospice aide skills and competency evaluation in accordance with federal and state laws and regulations prior to the aide performing care independently...Procedure I. Hospice Aides...B. The competency evaluation and skills checklist will be administered by a Registered Nurse in consultation with other skilled professionals as appropriate and will be scheduled during the orientation period. The Registered Nurse will document observation of skills as required and will sign and date the completed checklist; 1. The following subject areas must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient: a. Communication, including the ability to read, write, and verbally report clinical information to patients, representatives and caregivers, and other Hospice staff; b. Reading and recording temperature, pulse, and respiration;c. Appropriate and safe techniques in performing personal hygiene and grooming tasks, including: (1) Bed bath, (2) Sponge, tube and shower bath, (3) Hair shampooing in sink, tub, and bed, (4) Nail and Skin care, (5) oral hygiene, (6) Toileting and elimination, (7) Normal range of motion and positioning, and (8) Safe transfer techniques and ambulation...””