Hospicecare, Inc.

“Based on policy review and staff interview, it was determined the agency failed to ensure each patient had an emergency preparedness plan. This failure has the potential to negatively impact all patients receiving care from the agency in the event of an emergency. Findings include:A policy was reviewed titled, “EPP01: Disaster Plan & Emergency Preparedness,” dated 11/06/24. The policy states in part, “...Communication Plan for Disaster/Emergency: …4.As permitted under the HIPAA, the agency shall be prepared to disclose the following information regarding patients enrolled, the condition, needs, location, evacuation requirements…8.Field staff will contact all patients currently on their active census to assess patients’ current needs. Depending on travel restrictions/conditions, visits may be conducted on a limited basis. 9. Staff will report to their Supervisors all patients’ that were un-reachable via phone contact or visit. Staff should make reasonable attempts to contact all their current patients utilizing all phone numbers currently listed if necessary. 10. Supervisors will notify appropriate agencies responsible of the need to evacuate home patients or of patients that the agency is unable to locate. Reporting of the patient’s condition and specialized needs will be provided to the Responding Agency while maintaining HIPPA compliance…”An interview was conducted with staff 1 on 12/18/25 at 11:50 a.m. Staff 1 explained there are no patient risk assessments for the emergency plan status due to an Electronic Medical Record (EMR) system error in not making it as a required charting task on admission. The patients do not have individual emergency plans.”

“Based on record review and staff interview, the facility failed to conduct the required exercises to test the emergency plan at least annually. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 21. Findings include:a) The facility had not conducted an exercise for 2025 as required by the emergency preparedness testing requirements.b) Interview on 12/16/25 at the time of discovery with the Maintenance Supervisor verified this finding. The finding was also acknowledged by facility’s Maintenance Supervisor during the exit interview on 12/16/25 at approximately 4:30 p.m.”

“Based on document reviews, and staff interviews, it was determined the agency failed to ensure hospice aides were competent to perform their assigned duties, by not delineating the care of bed, tub, and shower bath, and bed, tub and shower shampoo, in eighteen (18) out of twenty-one (21) staff reviewed, staff # 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21. This failure had the potential to negatively impact all patients receiving hospice aide care at the agency. Findings include:A review of the initial competency evaluation of staff 4 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 5 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 6 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 7 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 8 dated 09/06/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 9 dated 08/08/24 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 10 dated 06/11/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 11 dated 01/10/24 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 12 dated 11/30/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 13 dated 11/28/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 14 dated 11/27/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 15 dated 08/25/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 16 dated 07/10/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 17 dated 04/21/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 18 dated 04/17/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 19 dated 03/20/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 20 dated 02/27/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 21 dated 02/06/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.An interview was conducted with staff 3 on 12/18/25 at 9:15 a.m. Staff 3 explained the initial competency sheets have bath-shower, bed, or tub and shampoo- bed, shower or tub, and staff 3 did not know they had to be individually listed. The competencies are done in person, and whichever task is performed of each of the three is observed, and the aides describe the process for the other tasks prior to being allowed to work independently.”