Silver Springs Healthcare

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy DOC ID: 6.13.5 Infection Control, last revised 08/05/2023, required in part, “Hand Hygiene: Hand Hygiene should be performed: prior to patient contact; before performing aseptic task; after contact with the patient or objects in the immediate vicinity of the patient; after contact with blood, body fluids, or contaminated surfaces; before moving from a contaminated body site to a clean body site during patient care; and after removal of PPE [personal protective equipment].” HOME VISIT 1: During the home visit observation on 12/23/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN was observed to assess the patient’s lower extremity strength by touching the shoes, which appeared dirty. The RN removed the patient’s shoes and socks to assess the feet, replaced them, and then wrote down the findings. The RN was observed to returned to the car for a tape measure and a second time for paper to document the visit. At the end of the visit, the RN removed gloves and closed the nursing bag. The RN did not perform hand hygiene after touching the patient’s shoes, socks, and feet; after returning to the car twice; and after glove removal. During an interview on 12/23/2025, the Administrator/Director of Nursing/Volunteer Coordinator agreed the staff member did not follow the agency’s hand hygiene policy.”

“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 3 of 6 (50%) clinical records reviewed with hospice aide services provided, the agency did not ensure the registered nurse provided patient specific care instructions for the hospice aide. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/26/2024. The primary hospice diagnosis was cerebral infarction. The aide care plan dated 10/26/2024 to 01/23/2025 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 01/23/2025.” The aide care plan did not provide clear instructions to the hospice aide regarding the type of bath to provide to the patient. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/07/2025. The primary hospice diagnosis was chronic respiratory failure with hypercapnia. The aide care plan dated 04/07/2025 to 07/05/2025 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 07/05/2025.” The aide care plan did not provide clear instructions to the hospice aide regarding the type of bath to provide to the patient. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/26/2024. The primary hospice diagnosis was Alzheimer’s disease. The aide care plan dated 06/26/2024 to 09/23/2024 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 09/32/2024.” The aide care plan did not provide clear instructions to the hospice aide regarding the type of bath to provide to the patient. During a joint review of the record and an interview on 12/24/2025, the Administrator/Director of Nursing/Volunteer Coordinator agreed the instructions on the hospice aide care plan were not specific for the type of bath to provide.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide completed documentation of care provided and notified the registered nurse of the changes in the patient’s needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/26/2024. The primary hospice diagnosis was cerebral infarction. The aide care plan dated 10/26/2024 to 01/23/2025 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 01/23/2025.” The hospice aide did not document on the aide visit notes dated 12/06/2024, 12/13/2024, 12/24/2024, and 12/26/2024 the type of bath provided to the patient and there was no documented evidence in the clinical record that the aide communicated with the registered nurse for instructions on the type of bath to provide. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/07/2025. The primary hospice diagnosis was chronic respiratory failure with hypercapnia. The aide care plan dated 04/07/2025 to 07/05/2025 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 07/05/2025.” The hospice aide documented on the aide visit notes dated 04/09/2025, 04/22/2025, 04/25/2025, 05/05/2025, and 05/07/2025 that the bath type shower was circled and completed. There was no documented evidence in the clinical record that the aide communicated with the registered nurse for instructions on the type of bath to provide. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/26/2024. The primary hospice diagnosis was Alzheimer’s disease. The aide care plan dated 06/26/2024 to 09/23/2024 assigned the hospice aide the tasks of “Bath: Tub/Bed Bath/Shower (circle one) QV [every visit] ... Care Plan Expires 09/32/2024.” The hospice aide documented on the aide visit note dated 07/05/2025 that a sponge bath was provided. The aide documented in the narrative “Pt (patient) wasn’t cooperative to get into shower safely. Sponge off, lotion, comb hair, brush teeth, redress, pt wash hitting on at me. Reported BP (blood pressure) and pulse to office.” There was no documented evidence in the clinical record that the aide communicated with the registered nurse and reported the changes in the patient’s status. During a joint clinical record review and interview on 12/24/2025, the Administrator/Director of Nursing/Volunteer Coordinator confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in the patient’s status.”

“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 6 (17%) clinical records reviewed with recertification of hospice benefit, the agency did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness no more than fifteen (15) days before the next benefit period begins. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/07/2025. The patient was recertified for the certification period dated 07/06/2025 through 09/04/2025. The Medical Director signed and dated the physician narrative for the Recertification of Terminal Illness on 06/18/2025, 18 days prior to the start of the certification period. The patient was recertified for the certification period dated 01/02/2026 through 03/02/2026. The Medical Director signed and dated the physician narrative for the Recertification of Terminal Illness on 12/17/2025, 17 days prior to the start of the certification period. The physician narratives were completed more than fifteen days before the next certification period began. During a joint review of the record and an interview on 12/24/2025, the Administrator/Director of Nursing/Volunteer Coordinator agreed that the written and signed recertification of the terminal illness was completed more than fifteen days before the next benefit period began.”

“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 1 (100%) personnel record reviewed for hospice aide, the agency did not ensure the hospice aide was certified to work as a hospice aide in the state of employment. PERSONNEL RECORD 9: Hospice aide date of employment 09/12/2025. Personnel record review revealed no documented evidence of verification of state certification for hospice aide, as of the date of record review on 12/22/2025. The record contained a certificate from the National Home Caring Council Division, The Foundation for Hospice and Homecare, awarded on 06/28/1991 with a certificate number. A search of the state licensing and certification information portal on 12/23/2025 revealed the aide was not listed in the state registry of Certified Nurse Aides. The search included the first and last names and the last four digits of the social security number. The result was “No Records Found.” During a joint personnel record review and interview on 12/22/2025, the Administrator/Director of Nursing/Volunteer Coordinator confirmed that the personnel record lacked evidence that the hospice aide had maintained a current state certification. The Administrator/Director of Nursing/Volunteer Coordinator stated that the hospice aide told the agency that they were grandfathered from having to renew the certification since the original certification was obtained in 1991. All investigations into whether an aide could be grandfathered were unsuccessful. On 12/23/2025, the Administrator/Director of Nursing/Volunteer Coordinator reported that a search for the employee in the state licensure and certification information portal resulted in “No Records Found.” On 12/23/2025, the Administrator/Director of Nursing/Volunteer Coordinator reported the employee had been terminated, and all visits had been moved to a registered nurse or licensed vocational nurse. There was also a posting started for a certified nurse aide with an interview scheduled for 12/29/2025.”

“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. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. 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 document review and interview. In 4 of 8 (50%) hospice contracts reviewed, the agency did not ensure hospice contracts required that contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. CONTRACT 4: Review of the hospice contract for the Hospice Service Agreement, for physical therapy, occupational therapy, and speech therapy, dated 01/24/2025, revealed the contract did not include the language that required all contracted employees who have direct patient contact or access to patient records to obtain criminal background checks. CONTRACT 6: Review of the hospice Contract for Pharmacy Services, dated 02/26/2024, revealed the contract did not include the language that required all contracted employees who have direct patient contact or access to patient records to obtain criminal background checks. CONTRACT 7: Review of the hospice contract for the Medical Director Services Agreement, dated 04/03/2023, revealed the contract did not include the language that required all contracted employees who have direct patient contact or access to patient records to obtain criminal background checks. CONTRACT 8: Review of the hospice contract for the Alternate Medical Director Services Agreement, dated 02/23/2023, revealed the contract did not include the language that required all contracted employees who have direct patient contact or access to patient records to obtain criminal background checks. During a joint contract review and interview on 12/22/2025, the Administrator/Director of Nursing/Volunteer Coordinator confirmed that the hospice contracts did not include the language requiring all contracted employees who have direct patient contact or access to patient records to obtain criminal background checks.”

“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. 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 3 of 10 (30%) personnel records reviewed, the agency did not ensure criminal background checks were obtained within three months of the date of employment. PERSONNEL RECORD 3: Medical Director date of hire 04/03/2023. Personnel record review revealed no documented evidence of a criminal background check within three months of the date of employment. PERSONNEL RECORD 4: Alternate Medical Director date of hire 02/23/2023. Personnel record review revealed no documented evidence of a criminal background check within three months of the date of employment. PERSONNEL RECORD 10: Volunteer date of hire 08/29/2023. Personnel record review revealed no documented evidence of a criminal background check within three months of the date of employment. During a joint personnel record review and interview on 12/23/2025, the Administrator/Director of Nursing/Volunteer Coordinator confirmed that the records did not include documentation of a criminal background check within three months of the date of employment.”