Divine Grace Healthcare Inc.

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observations, and interview. In 2 of 14 (14%) home visit observations, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 08/20/2025 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a group home. During the home visit observation on 10/15/2025 with the Hospice Aide (HA) (Personnel Record 6), a medication review was completed by comparing the patient’s home medications at the group home to the hospice medication profile (printed on 10/14/2025). The following medications were listed as current medications at the group home and were not listed on the hospice medication profile: Diazepam 10 mg, take 1 nightly (dated 09/09/2025); Breztri inhaler, take daily (no date); Metformin 1000 mg, twice daily (dated 06/11/2025). HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2024 with a diagnosis of Dementia. The patient resided in a group home. During the home visit observation on 10/15/2025 with the Registered Nurse (RN) (Personnel Record 3), a medication review was completed by comparing the patient’s home medications to the hospice medication profile (printed on 10/14/2025). The hospice medication profile had Lorazepam 2 mg/ml, take 1/2 ml to 1 ml every 6 hours as needed (dated 01/02/2025) and the group home had every 2 hours as needed (dated 09/26/2025). The hospice medication profile had Donepezil 10 mg, take one tablet every night (dated 02/26/2024) and the group home had twice daily (dated 09/26/2025). The hospice medication profile included Haldol 5 mg/ml. 1 mg every 8 hours as needed (dated 03/19/2024), Haldol was not listed on the group home medication list. A joint clinical record review and interview was conducted with the Administrator/Director of Nursing and Assistant Director of Nursing on 10/15/2025. The Administrator stated the “Haldol is IM (intramuscular) and they have to have a nurse give it so they don’t keep it at the group home but will order it if the patient needs it. The patient hasn’t needed it in a while.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific written instructions for the hospice aide. CLINICAL RECORD 1: The hospice aide care plan dated 05/28/2025 assigned the aide the following tasks: “Shower, bed bath, peri care, toilet-commode, oral care, hair care-brush, shampoo-weekly, skin care, tidy patient area, tidy bathroom, change linen, report to RN (registered nurse).” The tasks were to be completed every visit except shampoo which was weekly. The aide frequency was three times weekly. The aide care plan did not provide the aide with specific instructions for the bath type to be given. CLINICAL RECORD 6: The hospice aide care plan dated 06/01/2025 assigned the aide the following tasks: “Shower, bed bath, peri care, toilet-commode, oral care, hair care-brush, shampoo-weekly, skin care, tidy patient area, tidy bathroom, change linen, report to RN (registered nurse).” The tasks were to be completed every visit except shampoo which was weekly. The aide frequency was three times weekly. The aide care plan did not provide the aide with specific instructions for the bath type to be given. During a joint clinical record review and interview on 10/15/2025 with the Administrator/Director of Nursing and the Assistant Director of Nursing, the Administrator stated, “sometimes the patients refuse the shower and want a bed bath.””

“It is required that a hospice aide provides services that are included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 7 (14%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care. HOME VISIT 1/CLINICAL RECORD 1: The hospice aide care plan dated 05/28/2025 assigned the aide the following tasks: “Shower, bed bath, peri care, toilet-commode, oral care, hair care-brush, shampoo-weekly, skin care, tidy patient area, tidy bathroom, change linen, report to RN (registered nurse).” The tasks were to be completed every visit except shampoo which was weekly. The aide frequency was three times weekly. The aide care plan did not provide the aide with specific instructions for the bath type to be given. The aide care plan did not notify the aide the patient was on oxygen or give the aide instructions for use of the oxygen during tasks. During the home visit observation on 10/15/2025 with the Hospice Aide (Personnel Record 6), the aide was observed to remove the oxygen from the patient, assist the patient to ambulate to the bathroom, showered the patient, and completed other assigned tasks. The aide then returned the patient to the bed and handed the patient the oxygen to place back on. A joint clinical record review and interview was conducted with the Assistant Director of Nursing (ADON) on 10/15/2025. The ADON was present at the home visit observation with the aide and agreed the aide “should not have removed the oxygen without it being on the care plan.””

“It is required that homemakers provide environmental support that is coordinated by a member of the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed with homemakers provided, the agency did not ensure homemakers provided tasks in coordination with the interdisciplinary group. CLINICAL RECORD 4: The homemaker care plan dated 06/06/2024 included the following tasks: “shampoo-once a week and PRN (as needed), tidy patient area, tidy bathroom, laundry, light meal prep, feeding assistance-as needed, wash dishes, change linens-weekly and PRN, provide companionship.” The homemaker visit dated 07/09/2025 included documentation that a “Shampoo-showered” was provided to the patient. A joint clinical record review and interview was conducted with the Administrator/Director of Nursing and Assistant Director of Nursing on 10/15/2025. During the interview they confirmed the “homemakers should not be completing these tasks and thought the patients should be doing them by themselves.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 4 of 8 (50%) personnel records reviewed, the agency did not ensure the skills and competencies of staff were assessed during the orientation period and/or annually as required by agency policy. Agency policy No. 3-004.1 Annual Core Competency, no date, required in part, “1. Hospice personnel, including volunteers, will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process.” Agency policy No. 3-002.2 Clinical Competency Program, no date, required in part, “4. The method to evaluate each indicator will be documented on the checklist. 5. When the competency skills checklist is completed, it is reviewed by the preceptor and the assistant director of nursing.” PERSONNEL RECORD 2: Director of Nursing/Registered Nurse (RN) date of hire 10/31/2022. Review of the personnel record revealed no documented evidence that the skills and competencies of the RN were assessed in 2023 and 2024. PERSONNEL RECORD 5: Spiritual Counselor (SC) date of hire 11/10/2022. Review of the personnel record revealed no documented evidence that the skills and competencies of the SC were assessed in 2023 and 2024. PERSONNEL RECORD 6: Hospice Aide (HA) date of hire 11/01/2024. Review of the personnel record revealed the aide skills and competency form was signed by the HA; however, the form was incomplete and left blank. PERSONNEL RECORD 7: Volunteer date of hire 02/17/2023. Review of the personnel record revealed the volunteer competency dated 04/21/2025 was initialed by employee under “Needs further instructions.” Volunteer competency dated 07/28/2025 was incomplete and left blank under dates/initials. During a joint personnel record review and interview on 10/16/2025, the Administrator/Director of Nursing and Assistant Director of Nursing agreed the competencies “had not been completed per agency policy.””

“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; and Information 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 14 of 14 (100%) clinical records reviewed, the agency did not ensure the Hospice Medical Director provided written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/20/2025. The certification of terminal illness (CTI) was signed by the physician and included the statement “I confirm that I have composed the above narrative based on my review of the patient’s medical record and/or clinical assessment of the patient.” During an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2024. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 3: The patient elected the hospice on 08/25/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/06/2024. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/30/2024. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 6: The patient elected the hospice benefit on 06/01/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/18/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/01/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/07/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 10: The patient elected the hospice benefit on 07/11/2024. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/01/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 12: The patient elected the hospice benefit on 03/13/2025. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 13: The patient elected the hospice benefit on 10/13/2023. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness. CLINICAL RECORD 14: The patient elected the hospice benefit on 12/01/2024. The CTI was signed by the Medical Director, however, during an interview with the Administrator/Director of Nursing and the Assistant Director of Nursing on 10/15/2025, they confirmed that they had “written the narrative for the CTI and the Medical Director had signed his name to the bottom.” The Medical Director did not compose the CTI narrative and provide written certification of terminal illness.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 4 (75%) clinical records reviewed with a discharge summary required, the agency did not ensure the patient’s discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Agency policy “Revoking the Election of Hospice Care,” dated 01312015, required in part, “Clinical Record, the hospice discharge summary, which includes: a. A summary of the patient’s stay including treatments, symptoms, and pain management.” CLINICAL RECORD 9: The patient elected to revoke the hospice benefit on 03/10/2025. The discharge summary dated 07/21/2024 included the following note: “Per family member wanted (the patient) off hospice services.” The discharge summary did not include a summary of the patient’s hospice stay including treatments, symptoms, and pain management. CLINICAL RECORD 10: The patient elected to revoke the hospice benefit on 10/15/2024. The discharge summary dated 10/15/2024 included the following note: “Patient verbalizes want for aggressive treatment.” The discharge summary did not include a summary of the patient’s hospice stay including treatments, symptoms, and pain management. CLINICAL RECORD 12: The patient elected to revoke the hospice benefit on 09/12/2025. The discharge summary dated 09/12/2025 included the following note: “revoked for higher level of care.” The discharge summary did not include a summary of the patient’s hospice stay including treatments, symptoms, and pain management. A joint clinical record review and interview was conducted with the Administrator/Director of Nursing and Assistant Director of Nursing on 10/16/2025. During the interview, they stated, “they understood the discharge summaries needed to include more information.””

“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. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 1 (100%) personnel record reviewed for the social worker, the agency did not ensure the social worker was licensed in accordance with state regulation. State Administrative Code, required in part, License required to practice. (A) person may not engage in or represent that the person is engaged in the practice of marriage or family therapy, professional counseling, psychology, or social work within the state, unless the person is licensed or otherwise authorized to practice by law. PERSONNEL RECORD 4: Social Worker (SW) date of hire 02/26/2025. Review of the personnel record revealed the SW had a bachelor’s degree in social work; however, there was no documented evidence that the SW was licensed with the state. The agency job description for Medical Social Worker signed on 02/06/2025 included documentation of “Job Qualifications: Licensure: (State) certification.” During a joint personnel record review and interview on 10/16/2025, the Administrator/Director of Nursing stated, “we have a MSW (master’s degree social worker) to review her notes.””