Heart and Soul Hospice

“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. Upon reviewing the EP plan, the documentation lacked evidence of the EP being reviewed for 2025. The most recent EP review was for 2023. During a document review and an interview on 09/11/2026, the Executive Director confirmed that the EP plan was not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2025. The most recent emergency plan was for 2023.”

“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. Upon reviewing the 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 year 2025. The most recent EP review with an all hazards approach risk assessment was for 2023. During an interview on 09/11/2026, the Executive Director confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. 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 year 2025”

“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. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the EP communication plan, including all contact information, was reviewed and updated at least every two (2) years. The most recent EP communication plan review was for 2023. There was no documented review of the EP communication plan for 2025. During an interview on 09/11/2026, the Executive Director confirmed that the communication plan, including all contact information, was not reviewed and updated at least every two (2) years 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 follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. 1 of 4 (25%) home visit observations revealed the agency did not ensure the staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases Agency Policy: “Hand Hygiene” IC.15, last revised 09/01/2024, stated in part, “Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situation described below: after removing gloves.” HOME VISIT 1: During the observed home visit on 09/09/2026 with the Hospice Aide (HA - Personnel Record 9), the HA was observed changing her gloves twice without disinfecting her hands. During a joint document review and an interview on 09/09/2026, the Executive Director agreed the HA did not follow the agency’s hand hygiene policy.”

“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. 3 of 19 (16%) clinical records that had hospice aide services reviewed revealed that the agency did not ensure that the registered nurse(s) made an on-site supervisory visit to the patients’ homes no less frequently than every 14 days. CLINICAL RECORD 1: The patient’s date of election was 03/17/2025. Hospice Aide services started on 03/20/2025. Registered nurse on-site supervisory visit notes were dated 07/13/2026, 08/03/2026, and 08/28/2026. More than 14 days elapsed between 07/13/2026 and 08/03/2026 (21 days), and between 08/03/2026 and 08/28/2026 (25 days). CLINICAL RECORD 5: The patient’s date of election was 11/25/2024. Hospice Aide services started on 11/28/2024. Registered nurse on-site supervisory visit notes were dated 07/13/2026 and 08/03/2026 (21 days). More than 14 days passed between 07/13/2026 and 08/03/2026. CLINICAL RECORD 7: The patient’s date of election was 04/27/2026. Hospice Aide services started on 04/29/2026. Registered nurse on-site supervisory visit notes were dated 08/04/2026 and 08/27/2026 (23 days). More than 14 days passed between 08/04/2026 and 08/27/2026. A Registered Nurse Hospice Comprehensive visit was completed on 08/22/2026, but the supervisory portion was documented as “not applicable” for the visit. During a joint clinical record review and interview on 09/11/2026, the Executive Director confirmed that the registered nurse(s) did not make on-site supervisory visits no less frequently than every 14 days as required.”