The Medical Team

“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, interview, and observation. In 2 of 4 (50%) home visit observations, the agency did not ensure that clinical staff followed the agency’s “Hand Hygiene Policy and Compliance Program” policy. POLICY: The agency’s “Hand Hygiene and Compliance Program” policy (Policy IC.07, Undated) stated in part, “Indications for hand hygiene are: I. Before re-entering the nursing bag or patient’s clean supplies” and “Bacteriostatic foam/gel/liquid is the preferable hand hygiene method. When using bacteriostatic foam/gel/liquid, the procedure is as follows: A. Place adequate amount of foam/gel/liquid on hands. Follow manufacturer’s recommendations regarding the volume of the product to use. B. Using friction, clean between fingers, around and under nails, palms and backs of hands until hands are completely dry.” HOME VISIT 1: During the home visit observation visit with the Registered Nurse (RN) (Personnel Record 4) on 08/11/202, the RN was observed in several instances entering the clinical bag without performing hand hygiene per the agency’s policy. HOME VISIT 2: During the home visit observation with the Registered Nurse (RN) (Personnel Record 4) on 08/11/2025, the RN was observed in several instances entering the clinical bag wearing gloves without performing hand hygiene per the agency’s policy. The Alternate Administrator (Personnel Record 2) was interviewed on 08/11/2025 and stated, “The nurse should perform hand hygiene each time she enters the bag.””

“It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that medical social services were provided as ordered in the interdisciplinary plan of care. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 06/30/2025. The initial Plan of Care (POC) dated 06/30/2025 included an order for Social Work (SW) for a one-visit evaluation. There was a documented SW evaluation visit on 07/01/2025. A subsequent order dated 07/11/2025 for SW was present in the record that contained a visit frequency for SW of “1 visit(s) 1 Times”. There were no further documented SW visits in the clinical record, nor any documented missed visits or documentation that the patient declined SW services. Additionally, there was no documentation in the clinical record that the physician was notified of the missed visit. CLINICAL RECORD 13: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 02/27/2025. The initial Plan of Care (POC) dated 02/27/2025 included an order for Social Work (SW) for a one-visit evaluation. There was a documented SW evaluation visit on 03/04/2025, and the SW clinical note indicated that no additional SW visits were required. The updated POC dated 04/07/2025 included an order “1 visit(s) 1 Times”. There were no further documented SW visits in the clinical record, nor any documented missed visits or documentation that the patient declined SW services. Additionally, there was no documentation in the clinical record that the physician was notified of the missed visit. The Alternate Clinical Manager (Personnel Record 3) was interviewed on 08/14/2025 and stated, “The EMR ‘clones’ the previous frequency in the scheduling module if it is not discontinued and moves the visit frequency forward to the next IDG. The clinicians should discontinue the discipline frequency if it is no longer needed so it’s not pulled forward.””

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. Volunteers are supervised by a designated hospice employee. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 1(100%) personnel records for the hospice volunteer reviewed revealed the agency did not ensure the hospice volunteer had orientation and training that is consistent with hospice industry standards. POLICY: The agency’s policy, “Employee Orientation” (Policy 4.27.1, Undated) stated in part, “Each employee and contracted staff who has patient and family contact will receive and orientation about the Hospice philosophy.” and “Orientation for each employee will minimally include: Review of the individual’s job description and duties performed and their role in the organization; Organization chart; Mission statement; Hospice philosophy; Record keeping and reporting; Confidentiality and privacy of Protected Health Information; Patient’s rights; Advance Directives; Conflict of interest; Written policies and procedures; Emergency Plan; Training specific to job requirements; Additional training for special populations, if applicable (e.g., pediatrics); Cultural diversity; Communication barriers; Ethical issues; Professional boundaries; Quality Assessment/Performance Improvement Plan; Corporate Compliance Program; conveying of charges for care/services; OSHA requirements, safety and infection control; Orientation to equipment, if applicable as outlined in job description; Incident/variance reporting; Handling of patient complaints/grievances; Concepts of death and dying and bereavement; Emotional support, psychosocial and spiritual issues; Pain and symptom management; Diseases and medical conditions common to Hospice; Stress management.” PERSONNEL RECORD 10: A review of the Volunteer personnel record (date of hire 10/28/2024) revealed that there was no documented orientation checklist present in the record per the agency’s policy. The Alternate Administrator was interviewed on 08/14/2025 and stated, “I remember the volunteer coming into the office for orientation, but the documentation is not in the file.””

“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 revealed the agency did not ensure recruitment and retention of volunteers was documented. The volunteer program was reviewed and revealed that there was a comprehensive training program for new volunteers as well as policies and procedures for recruitment, retention, and onboarding. However, there was no documentation present in the binder of efforts for the recruitment and retention of volunteers in the last three years. The Alternate Administrator (Personnel Record 2) was interviewed on 08/14/2025 and stated that hospice volunteer utilization has been low for the last three years, less than 5%, and a project will be developed to increase the number of available volunteers to increase utilization, including recruitment and retention. The agency did not ensure that ongoing efforts to recruit and retain volunteers were in place and documented.”

“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. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview revealed the agency did not ensure 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. DOCUMENT: A review of the agency’s documented utilization of volunteer services revealed that services in 2024 equaled 3.4% and year-to-date in 2025 equaled 2.4%. Data was not available for 2023. Volunteer services did not equal, at a minimum, five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Alternate Administrator (Personnel Record 2) was interviewed on 08/14/2025 and stated that hospice volunteer utilization has been low for the last three years, less than 5%, and a project will be developed to increase the number of available volunteers to increase utilization. The agency did not ensure 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.”