Inspection Details
Inspection #
INSP-0158460
Inspection Date(s)
8/27/2025
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Hospice Service Agency
Certificate Number
HSPC9712
Location Type
—
Initial Comments
The following deficiencies were found during the unannounced on-site State Compliance survey conducted on August 27, 2025 for Survey #1D4E8F-HI.Compliance Officer 08/27/2025
Statement of Deficiency
2 deficiencies found
Deficiency #1
R9-10-610
✓ Plan Provided
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Rule
R9-10-610. Patient Rights A. An administrator shall ensure that: 3. Policies and procedures include: b. Where patient rights are posted as required in subsection (A)(1).
Evidence
Based on observation and staff interviews, the Department determined the hospice agency failed to ensure that facility policies and procedures include where the patient rights are conspicuously posted. This deficient practice prevents patients from making informed decisions regarding their care.
Plan of Correction
Permanent Correction Date
2025-09-30
Deficiency #2
R9-10-612
✓ Plan Provided
▼
Rule
R9-10-612. Hospice Services E. A director of nursing shall ensure that: 6. A registered dietitian or a personnel member under the direction of a registered dietitian plans menus for a patient;
Evidence
Based on observation and staff interviews, the Department determined the hospice agency failed to provide evidence that their facility has a registered dietician on staff or contract, as required by R9-10-612(E)(6). This deficient practice has the potential for negatively impacting a patient’s nutritional needs.
Plan of Correction
Permanent Correction Date
2025-09-30