All Faith Hospice Care, Inc.

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to ensure volunteers were provided in day-to-day administrative and/or direct patient care roles in the prior two and half years {HCDT.21. I/L644/418.78(b)}; and Failed to ensure that that volunteers had provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and the cost savings achieved through volunteers for 2024, 2025, and through July 2026 {HSLG.7.I/L647/418.78(e)}. The cumulative effect of these systemic problems 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 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure an initial comprehensive assessment was conducted no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: The patient election of benefit was dated 06/06/2025. The initial nursing comprehensive assessment was dated 06/06/2025, and the initial psychosocial assessment was completed on 06/10/2025. The initial spiritual assessment on 06/08/2025, was noted in red and documented as “not started”. CLINICAL RECORD 12: The patient election of benefit was dated 12/11/2025. The initial nursing assessment completed on 12/11/2025, and the initial psychosocial assessment was completed on 12/13/2025. The initial spiritual assessment on 12/17/2025 (6 days), was noted in red and documented as “not started”. CLINICAL RECORD 13: The patient election of benefit was dated 06/06/2025. The initial nursing assessment was completed on 06/06/2025, and the initial psychosocial assessment completed on 06/09/2025. The initial spiritual assessment on 06/08/2025, was noted in red and documented as “not started”. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that she did not know the spiritual assessments were not documented and that she checked the paper file in case they had not been uploaded into the electronic medical record. They were not found in the paper chart either, but they would provide additional education to clinical staff and audit all admissions.”

“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 and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plan as often as the patient’s condition required, but no less often than every 15 calendar days. CLINICAL RECORD 5: The patient’s election of benefit was dated 10/31/2024. A review of the benefit period from 10/31/2024 to 01/28/2025, revealed the IDG reviewed, revised, and documented the individualized care plan on the following dates: 12/02/2024 (32 days) and for benefit period 04/29/2025 to 06/13/2025 the Interdisciplinary Group reviewed, revised, and documented the individualized care plan on the following dates: 05/06/2025, 05/20/2025, and 06/17/2025 (23 days). During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/26/2026, she stated that she did not know why the IDG was not reflected in the electronic medical record, but that it had been done.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed of patients who elected hospice aide services revealed that the agency did not ensure hospice aides were supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 1: A review of the plan of care dated 10/04/2025 to 12/02/2025 included an order for the hospice aide two times a week (2xweek), starting 10/07/2025. The hospice aide supervisory visits were dated 10/16/2025, 10/29/2025, 11/06/2025, 11/21/2025 (15 days). CLINICAL RECORD 8: A review of the plan of care dated 04/12/2026 to 06/07/2026 included an order for the hospice aide frequency two times a week (2x/week) starting on 04/14/2026. The hospice aide supervisory visits were dated 04/22/2026, 05/07/2026 (15 days), 05/14/2026, 05/21/2026, 05/30/2026, and 06/04/2026. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that they have been monitoring and educating the staff to do the aide supervisory visits weekly so that if a visit needs to be rescheduled by a day, then they are still in compliance, but they will continue to educate and monitor.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview which revealed during the review of the volunteer program, that the agency did not ensure that volunteers were used in day to day administrative and/or direct patient care roles. The agency had no active volunteers for the past two and a half (2 ½) years. There were no volunteer personnel files, no volunteer time sheets, or volunteer activity since August 2023. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that they have been unable to locate any volunteers at this time but have just hired a dedicated volunteer coordinator, who has begun volunteer recruitment efforts. During a review of the volunteer program, it was discovered that the agency had no active volunteers for the past 2 1/2 years. No volunteer files, no timesheets, or volunteer activity was noted since August 2023.”

“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 which revealed during the review of the volunteer program, the agency did not ensure that volunteers provided 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. There was no documented evidence of volunteer hours for 2024 and 2025, and through July 2026 volunteer hours were 0%. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that they just hired a dedicated volunteer coordinator who has begun volunteer recruitment efforts, and they have a couple who are expected to come in and submit an application, hopefully next week. During a review of the volunteer program, it was noted that volunteer hours for 2024, 2025, and 2026 through July were 0%. No volunteer hours documented.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed for patients transferred to another hospice agency revealed that the agency did not ensure a copy of the hospice discharge summary was sent to the receiving agency. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit on 04/30/2026 and transferred to another hospice agency on 05/04/2026. The discharge summary was dated 05/04/2026; however, there is no documented evidence that the discharge summary was forwarded to the receiving hospice. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that they will review the policy and update staff on this requirement.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed for patients who were discharged from hospice services revealed the agency did not ensure a copy of the patient’s hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 12: A review of the clinical record revealed that the patient elected the hospice benefit on 12/11/2025 and was discharged on 06/28/2026 because the patient was out of the service area. The discharge summary was dated 06/28/2026; however, there is no documented evidence that it was forwarded to the patient’s attending physician. CLINICAL RECORD 13: A review of the clinical record revealed that the patient elected the hospice benefit on 06/06/2025 and was discharged on 06/11/2026 for an extended prognosis. The discharge summary was dated 06/11/2026; however, there is no documented evidence that it was forwarded to the patient’s attending physician. During an interview with the Administrator/Director of Nurses (Personnel Record 1) on 08/27/2026, she stated that they will review the policy and update staff on this requirement.”