Summit Home Health and Hospice

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination. The primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; formation about the medical management of any of the patient’s conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that the hospice medical director provided a written and signed certification of the terminal illness that anticipated the patient’s life expectancy of six months or less if the illness runs its normal course. CLINICAL RECORD 4: The patient elected hospice benefit on 06/18/2025, Dx Malignant Neoplasm of Unspecified and Alzheimer’s Disease; and the certification period of 06/18/2025-08/07/2028. There was no documented evidence that the physician certification of terminal illness was completed for the first benefit period. During a joint review of the clinical record and interview on 07/07/2025, the Clinical Manager confirmed that the medical director had not completed the CTI. No further information was provided.”

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, and describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review, personnel record review, and interviews with the Administrator/ Clinical Supervisor/Volunteer Coordinator and the Clinical Team Manager which revealed the agency had not reviewed and revised the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failure to ensure the emergency preparedness plan was reviewed and updated every 2 years [HSEP.2.D/E4]; Failure to ensure the emergency preparedness plan included a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served [HSEP.2.D/E6]; Failure to ensure EP policies and procedures were reviewed and updated at least every 2 years [HSEP.3.D/E13]; Failure to ensure the emergency preparedness communication plan was reviewed and updated at least every 2 years [HSEP.4.D/E29]; Failure to ensure staff were provided with emergency preparedness training initially and at least every two years [HSEP.5.D/E37]; Failure to ensure the emergency preparedness training program was reviewed and updated at least every 2 years [HSEP.5.D/E36]; and Failure to ensure the emergency preparedness plan was tested annually [HSEP.6.I/E39]. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.113: Emergency Preparedness. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving care from the agency. During a document review and interview which revealed the agency: Failed to develop and maintain an emergency preparedness plan based on and included a documented facility-based and community-based risk assessment, utilizing an all-hazards approach, hazard vulnerability analysis for the geographic area that the organization serves for 2023 or 2024 as confirmed by the Administrator {HSEP.2/6}; Failed to ensure they developed and maintained an EP communication plan that complies with local, state, and federal requirements {HSEP.3/29}; Failed to ensure they developed and maintained an emergency preparedness (EP) training program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan {HSEP.7/36}; Failed to ensure they developed and maintained an emergency preparedness (EP) testing program {HSEP.8/36}; Failed to conduct exercises to test the emergency preparedness (EP) plan annually, including participation in a full-scale exercise that is community-based {HSEP.9/39}; and to analyze its response to and maintain documentation of drills, tabletops exercises and emergency events and revised the emergency plan as needed {HSEP.10/39}.”

“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. The agency did not ensure the emergency preparedness plan was reviewed and updated every 2 years. Review of the agency’s emergency preparedness plan revealed no documented evidence that the emergency plan was reviewed and updated for 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the EP plan lacked evidence of review and update at least every two years. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP program. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP program had not been reviewed and updated for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2023 and 2024.”

“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. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) plan included a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. Review of the agency’s emergency preparedness plan revealed no documented evidence that the emergency plan included documentation of a hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the EP plan did not include a hospice-based and community-based risk assessment, with an “all-hazards” approach for 2023, 2024, and 2025. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP program. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP plan, including a hospice-based and community-based risk assessment had not been reviewed and updated for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2023 and 2024.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure EP policies and procedures were reviewed and updated at least every 2 years. Review of the agency’s emergency preparedness plan and program revealed no documented evidence that the emergency preparedness policies and procedures were reviewed and updated for 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the agency did not have documentation that the EP policies and procedures were reviewed and/or updated at least every 2 years, for 2023, 2024, and year to date for 2025. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP program. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP policies and procedures had not been reviewed and updated for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were reviewed and updated at least every two (2) years.”

“It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan, including all contact information, is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) communication plan was reviewed and updated at least every 2 years. Review of the agency’s emergency preparedness plan revealed no documented evidence that the EP communication plan was reviewed and updated for 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the EP communication plan had not been reviewed and updated for 2023, 2024, and 2025. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP program. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP communication plan had not been reviewed and updated for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) communication plan, including all contact information, was reviewed and updated at least every two (2) years.”

“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. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) training program was reviewed and updated at least every 2 years. The agency was unable to provide information related to an EP training program, based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan, that was reviewed and updated at least every 2 years. The agency did not have documentation of an EP training program for 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the emergency preparedness training program had not been reviewed or updated in 2023, 2024, and 2025. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP training program. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP training program had not been reviewed and updated for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2023 and 2024. The documentation lacked evidence that the training program was updated for 2023 and 2024.”

“It is required that the hospice EP training program includes the following 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 personnel record review and interview. In 11 of 11 (100%) personnel records reviewed, the agency did not ensure staff were provided with emergency preparedness (EP) training initially and at least every two years. PERSONNEL RECORD 1: Administrator/Clinical Supervisor/Volunteer Coordinator date of hire 09/29/2023. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 2: Clinical Team Manager/Registered Nurse date of hire 06/18/2024. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 3: Hospice Medical Director date of hire 10/01/2021. Personnel record review revealed no documented evidence of emergency preparedness training was provided at least every two years, when there was no evidence of EP training for 2023, 2024, and year to date for 2025. PERSONNEL RECORD 4: Associate Medical Director (contracted) date of contract 11/22/2024. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 5: Registered Nurse date of hire 04/03/2025. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 6: Medical Social Worker date of hire 09/06/2024. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 7: Chaplain date of hire 03/20/2025. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 8: Certified Nurse Aide date of hire 02/06/2024. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 9: Certified Nurse Aide date of hire 01/05/2018. Personnel record review revealed no documented evidence of emergency preparedness training was provided at least every two years, when there was no evidence of EP training for 2023, 2024, and year to date for 2025. PERSONNEL RECORD 10: Volunteer date of hire 05/22/2024. Personnel record review revealed no documented evidence of initial emergency preparedness training upon hire to the agency. PERSONNEL RECORD 11: Registered Nurse date of hire 04/28/2021. Personnel record review revealed no documented evidence of emergency preparedness training was provided at least every two years, when there was no evidence of EP training for 2023, 2024, and year to date for 2025. During a joint review of the personnel files and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the personnel records did not include documentation of emergency preparedness training provided by the agency for 2023, 2024, and year to date for 2025. The Administrator explained that they had looked through their EP documentation and personnel records and were unable to provide any additional information related to EP staff training. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why EP training had not been provided to staff for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2023 and 2024. The documentation lacked evidence that the training program was updated for 2023 and 2024.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) plan was tested annually. Review of the agency’s emergency preparedness plan revealed no documented evidence that the emergency plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. The agency did not have documentation that the EP plan was tested in 2023, 2024, and year to date for 2025. During the EP document review and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the EP plan was not tested annually, including participation in a full-scale exercise that is community-based and an additional exercise every two (2) years opposite the year that a full-scale exercise was conducted for 2023, 2024, and year to date for 2025. The Administrator explained that they had looked through their EP documentation and were unable to provide any additional information related to the EP program testing. The Administrator was hired 09/29/2023 and was unable to provide an explanation as to why the EP program had not been tested for 2023, 2024, and 2025. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted for 2023 and 2024.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. 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 the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 15: The patient elected the hospice benefit on 05/15/2024 and was transferred and discharged from the hospice on 06/20/2024. Clinical record review revealed the comprehensive assessment completed by the Registered Nurse on 05/15/2025 did not include an initial bereavement assessment. There was no documented evidence in the clinical record that a bereavement assessment was completed for the patient. During a joint clinical record review and interview on 05/30/2025, the Clinical Team Manager (Personnel Record 2) confirmed that the comprehensive assessment did not include an initial bereavement assessment and that a bereavement assessment had not been completed or documented during the patient’s hospice episode.”

“It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. 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 hospice care and services provided to the patient followed an individualized plan of care established by the IDG in collaboration with the attending physician, the patient, and the primary caregiver. CLINICAL RECORD 15: The patient elected the hospice benefit on 05/15/2024 and was transferred from the hospice on 06/20/2024. Review of the clinical record revealed no documented evidence that a plan of care was developed for the patient from the start of care on 05/15/2024 through the date of transfer on 06/20/2024, a total of 36 days. The clinical record contained physician orders for medications and wound care, but did not include an individualized plan of care. During a joint clinical record review and interview on 05/30/2025, the Clinical Team Manager (Personnel Record 2) agreed there was no documented evidence of a plan of care in the clinical record. The Clinical Team Manager stated that a performance improvement project (PIP) was started on 03/31/2025 when the agency discovered that some records were lacking a plan of care, but they had not been working on the PIP very long.”

“It is required that the Interdisciplinary Group (IDG), 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 and interview. In 8 of 19 (42%) clinical records reviewed, the organization did not ensure the individualized plan of care was reviewed, revised, and documented by the IDG no less frequently than every 15 calendar days. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/25/2025. Clinical record review revealed the plan of care was reviewed during the IDT meeting on 04/26/2025. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 04/27/2025 through 05/30/2025 (a total of 33 days). CLINICAL RECORD 6: The patient elected the hospice benefit on 09/25/2024. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 09/25/2024 through 11/13/2024 (a total of 49 days), 11/22/2024 through 12/23/2024 (a total of 32 days), and 04/25/2025 through 05/30/2025 (a total of 35 days). CLINICAL RECORD 7: The patient elected the hospice benefit on 04/05/2022. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 03/29/2024 through 06/05/2024 (a total of 69 days), 08/12/2024 through 11/11/2024 (a total of 91 days), 11/22/2024 through 12/23/2024 (a total of 31 days), and 04/26/2025 through 05/30/2025 (a total of 34 days). CLINICAL RECORD 8: The patient elected the hospice benefit on 09/15/2023. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 04/12/2024 through 06/05/2024 (a total of 54 days), 08/19/2024 through 11/11/2024 (a total of 84 days), 01/31/2025 through 04/17/2025 (a total of 76 days), and 04/26/2025 through 05/30/2025 (a total of 34 days). CLINICAL RECORD 9: The patient elected the hospice benefit on 04/01/2025. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 04/01/2025 through 04/17/2025 (16 days), and 04/26/2025 through 05/30/2025 (34 days). CLINICAL RECORD 12: The patient elected the hospice benefit on 05/08/2024. The clinical record contained no documented evidence that the IDT reviewed or revised the plan of care from 05/08/2024 through 07/03/2024 (57 days), 08/19/2024 through 11/11/2024 (84 days), 12/20/2024 through 04/17/2025 (118 days), and 04/26/2025 through 05/30/2025 (34 days). CLINICAL RECORD 15: The patient elected the hospice benefit on 05/15/2024. The patient was transferred and discharged on 06/20/2024. There was no documented evidence in the clinical record that the IDG reviewed or revised the plan of care. The clinical record contained no evidence of an IDG meeting from 05/15/2024 through 06/20/2024. CLINICAL RECORD 16: The patient elected the hospice benefit on 02/19/2024. The patient revoked the hospice benefit on 03/07/2025 and was discharged from hospice care. There was no documented evidence in the clinical record that the IDG reviewed or revised the plan of care. The clinical record contained no evidence of an IDG meeting from 02/19/2024 through 03/07/2024. During a joint clinical record review and interview on 05/30/2025, the Clinical Team Manager (CTM) (Personnel Record 2) confirmed that the clinical records did not have information to confirm that the IDG met and reviewed the plans of care every 15 days. The CTM agreed that there was no IDG plan of care reviews for clinical records 15 and 16. The CTM provided documentation of a Performance Improvement Project (PIP) that was initially started on 01/07/2025. The PIP identified that the plans of care were not reviewed and update by the IDG every 15-days. The CTM reported that all clinical records were being audited for the IDG meeting documentation of plan of care reviews since starting the PIP but agreed that there are still significant gaps from one meeting to the next.”

“It is required that the hospice follow accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure clinical staff performed hand hygiene as required by agency policy. Agency policy IC.15 Hand Hygiene, last revised 09/01/2024, required in part, “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situation described below: after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings and used supplies (PPE [personal protection equipment]) if hands are not visibly soiled; and after removing gloves.” HOME VISIT 3: During the home visit on 05/28/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN was observed to don [apply] gloves and remove the dressing from the right lower leg wound. The RN removed the gloves and put on a new pair. The RN applied Silvasorb to the wound bed. The RN removed the gloves and put on new ones. The RN did not decontaminate hands after removal of gloves and/or between glove changes. During a review of the home visit observation and interview on 05/28/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) agreed that the nurse did not follow the agency’s hand hygiene policy.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/25/2025. The plan of care dated 04/25/2025 included an order for “Hospice aide 3/wk. [three times a week].” Clinical record review revealed the hospice aide provide one visit the week of 04/27/2025 to 06/03/2025 and did not provide aide visits the weeks of 05/04/2025 to 05/10/2025 and 05/11/2025 to 05/17/2025. The hospice aide did not provide visits as ordered on the plan of care. During a joint clinical review and interview on 05/30/2025, the Clinical Team Manager (Personnel Record 2) confirmed that that the hospice aide had not provided visits as ordered on the plan of care and there was no documentation in the record that the physician had discontinued aide services.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure documentation and demonstration of viable ongoing efforts to recruit and retain volunteers. Review of the agency’s volunteer program revealed no documented evidence of efforts to recruit volunteers for 2023 and 2024; and no documented evidence of efforts to retain volunteers for 2023, 2024, and year to date for 2025, as of the date of program review on 05/29/2025. During a joint review of the volunteer program and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that recruitment and retention efforts were lacking for 2023, 2024, and through 05/29/2025. The Administrator/Clinical Supervisor/Volunteer Coordinator reported that there had been changes in the Volunteer Coordinator position in the past year and stated that two volunteers had recently started and would be assisting with volunteer recruitment and retention efforts. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to recruit and retain volunteers. The documentation lacked documented efforts to recruit volunteers for the alternate delivery site location for 2023, 2024, and through 05/29/2025. The documentation lacked documented efforts to recruit volunteers for the parent site for 2023 and 2024. There was documentation of the parent office having an active status with Volunteer Match from 03/01/2025 through 05/29/2025. The documentation lacked evidence of retention efforts for 2023, 2024, and through 05/29/2025.”

“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 volunteers provided day-to-day administrative or direct patient care services that equaled five percent of the total patient care hours. During a joint review of the agency’s volunteer program and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed the agency’s volunteer percentage for the last 12 months was 1.5% of the total patient care hours. The Administrator/Clinical Supervisor/Volunteer Coordinator reported that there had been changes in the Volunteer Coordinator position over the past year. It was reported that two volunteers had recently started. Upon reviewing the volunteer program, the documentation revealed 215.04 documented volunteer hours and 14252.14 patient care hours, for a total of 1.5% of total patient care hours of all paid hospice employees and contract staff. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services equaled five percent of the total patient care hours.”

“It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS): complies with federal regulation regarding disclosure of ownership and control information, ensures hospice multiple locations are approved by Medicare and licensed in accordance with state licensure laws, and ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review and interview. The agency was operating a second location and providing care to patients without documentation of approval for the second location by Medicare. During document review and interviews with the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) on 05/29/2025 it was discovered that the agency was operating an alternate delivery site (ADS) and providing hospice care to patients at a separate location that was located approximately 155 miles from the main office. The agency did not have documentation of Medicare approval for the ADS. The Administrator explained that the ADS was operating out of a home health office owned by the organization. The Administrator confirmed the ADS had an active census of 14 hospice patients, out of a total active census of 87 patients and the unduplicated admissions for the last twelve months was 31 for the ADS. He also explained that they have hospice staff for this location that are dedicated to the ADS and separate from the parent location, including Registered Nurses, Licensed Vocational Nurses, Social Workers, Chaplains, and Aides. The ADS location did not have Volunteers. The ADS conducted its own interdisciplinary group (IDG) meetings with the hospice Medical Director (MD) being the primary Medical Director for the ADS and the Alternate Medical Director being the primary Medical Director for the parent location. The Administrator explained that the MD attended IDG at the ADS location in person or by video conference. There was an Inpatient Respite Facility Contract for the ADS dated 03/20/2020, and a Pharmacy Contract Agreement for the ADS dated 11/30/2020. The site visitor visited the ADS location/office on 05/29/2025 and observed the office space was mostly dedicated to the home health agency with some space dedicated for the hospice staff and meeting rooms. The Clinical Team Manager (CTM) was at the location providing in-services to staff on the day of the visit. The agency’s admission packet provided to patients at admission included the parent location and the ADS location as service locations, included one 24-hour phone number for both locations, and an emergency number for the parent location and the ADS location. During a document review and interview on 05/30/2025, the Clinical Team Manager (CTM) (Personnel Record 2) stated that the Administrator/Clinical Supervisor/Volunteer Coordinator had been making monthly visits for administrative oversight and the CTM reported making visits for in-service meetings and interviews. The agency had no documented evidence that the ADS had been approved by Medicare before it provided hospice care and services to Medicare patients at the location. During document review and interview on 05/30/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator confirmed that the agency did not have documentation of Medicare approval for an alternate delivery site. The Administrator/Clinical Supervisor/Volunteer Coordinator reported having previous experience with the ADS process and stated that the agency initiated the process for the alternate location on 05/30/2025. . During a document review, it was discovered that the agency was operating out of a home health office without the designation or approval as an ADS located approximately 155 miles from the main office. The alternate location has a separate staff for hospice, including registered nurses, licensed vocational nurses, social workers, chaplains, and aides, and conducts its interdisciplinary group (IDG) meetings. The alternate location comprises 16% of the agency’s census. The admission packet has the primary and alternate locations as service locations. There was one 24-hour phone number for both locations. There was an Inpatient Respite Facility Contract for the alternate site, dated 03/20/2020, and a Pharmacy Contract Agreement, dated 11/30/2020. The agency lacked evidence of documentation that an alternate delivery site had been approved by Medicare before providing hospice care and services to Medicare patients.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed with recertification, the agency did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness to meet the hospice care benefit requirement. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/08/2024 and was recertified for a second benefit period on 07/02/2024. There was no documented evidence in the clinical record that the physician recertification of terminal illness was completed for the second benefit period. During a joint review of the record and interview on 05/30/2025, the Clinical Team Manager (Personnel Record 2) agreed that the record did not include the physician recertification for the certification period that started on 07/02/2024.”

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation, act only within the scope of their state license or state certification or registration and keep their qualifications current at all times. Personnel qualifications for certain disciplines must be met for Physician, Hospice Aide, Social Worker, Speech Language Pathologist, Occupational Therapist, Occupational Therapy Assistant, Physical Therapist, Physical Therapist Assistant, Registered Nurse, Licensed Practical Nurse, Marriage and Family Therapist, and Mental Health Counselor. This standard was not met as evidenced by personnel record review and interview. In 1 of 11 (9%) personnel records reviewed, the agency did not ensure the Hospice Aide maintained a current/active state certification. PERSONNEL RECORD 9: Hospice Aide/Certified Nurse Aide (CNA) date of hire 01/05/2018. The state licensure portal search found in the personnel record dated 05/28/2025, included the documentation that the CNA’s state certification “Expired” on 04/11/2024. The personnel record included annual on-site skills evaluations for the aide with the most recent skills evaluation dated 05/15/2025. The agency provided information that the CNA had made 22 aide visits from 04/12/2024 to 04/30/2024, 17 aide visits in May 2024, 14 visits in June 2024, 21 visits in July 2024, 25 visits in August 2024, 35 visits in September 2024, 85 visits in October 2024, 35 visits in November 2024, 71 visits in December 2024, 59 visits in January 2025, 63 visits in February 2025, 82 visits in March 2025, 98 visits in April 2025, and 74 visits from 05/01/2025 through 05/29/2025. The CNA initiated the certification renewal process on 05/30/2025 and the application was accepted as of 05/30/2025. However, the document did not indicate that the aide’s certification was active as of the date of record review on 05/30/2025. During a joint personnel record review and interview on 05/30/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the CNA did not have an active certification through the state. The Administrator stated that the CNA had been part of the home health side of the organization and transitioned to hospice in 2024. The Administrator stated that the CNA had been removed from the schedule until the certification became active once again.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by personnel record review and interview. In 2 of 11 (18%) personnel records reviewed, the agency did not ensure criminal background checks were obtained for employees with direct patient contact and/or access to patient records. PERSONNEL RECORD 4: Associate Medical Director date of contract 11/22/2024. Hospice Medical Director Contract Agreement, effective 11/22/2024, stated in part, “Responsibilities of Hospice: G. … Hospice is responsible for checking criminal background history, and for checking the OIG Exclusion List on a monthly basis.” Personnel record review revealed the criminal background check was completed on 05/28/2025, 6 months after the date of contact. There was no documented evidence in the personnel record that a criminal background check was completed from the time of hire through 05/28/2025. PERSONNEL RECORD 10: Volunteer date of hire 05/22/2024. Personnel record review revealed no documented evidence that a criminal background check was completed for this volunteer with direct patient access and/or access to patient records. During a joint review of personnel records and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the contracted Associate Medical Director’s record and the Volunteer’s record did not include criminal background checks a required.”

“It is required that criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 2 of 11 (18%) personnel records reviewed, the agency did not ensure criminal background checks were obtained within three months of the date of employment. PERSONNEL RECORD 4: Associate Medical Director date of contract 11/22/2024. Hospice Medical Director Contract Agreement, effective 11/22/2024, stated in part, “Responsibilities of Hospice: G. … Hospice is responsible for checking criminal background history, and for checking the OIG Exclusion List on a monthly basis.” Personnel record review revealed the criminal background check was completed on 05/28/2025. There was no documented evidence in the personnel record that a criminal background check was completed within three months of the date of employment/contract. PERSONNEL RECORD 10: Volunteer date of hire 05/22/2024. Personnel record review revealed no documented evidence that a criminal background check was completed within three months of the date of hire. During a joint review of personnel records and interview on 05/29/2025, the Administrator/Clinical Supervisor/Volunteer Coordinator (Personnel Record 1) confirmed that the contracted Associate Medical Director’s record and the Volunteer’s record did not include criminal background checks within three months of the date of employment.”