Dayspring Hospice, LLC

“Based on review of the agency Emergency Operations Plan (EOP), agency policy, and staff interviews the agency failed to develop arrangements with other facilities to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to agency patients. This deficient practice had the potential to affect all patients served by the agency. Findings include: Agency Policy: Emergency Preparedness Policy Number: HR 170 Effective Date: 3/1/2020 Purpose: To perform and respond as seamlessly as possible to meet patient and community needs in the event of an emergency. To delay the (and) minimize confusion, errors, and expense by detailing the course of action to follow... Policy: ...7. Suspension or Transfer of Services. a. In the event that an emergency results in the inability of the agency to continue providing services, the agency has a plan for continuity of services... c. The agency has pre-identified organizations that can deliver required services... Review of the agency EOP Plan on 7/16/24 revealed no documentation of an arrangement with another facility to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to agency patients. An interview was conducted on 7/17/24 at 12:42 PM with Employee Identifier (EI) # 4, Executive Director, who confirmed there was no documentation of an arrangements with another facility to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to agency patients.”

“Based on review of the agency Emergency Operations Plan (EOP), agency policy, and staff interviews the agency failed to provide training to agency staff on the EOP plan at orientation and every two years. This deficient practice did affect four of five personnel files reviewed, including Employee Identifier (EI) # 8, EI # 9, EI # 10, and EI # 11, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Emergency Preparedness Policy Number: HR 170 Effective Date: 3/1/2020 Purpose: To perform and respond as seamlessly as possible to meet patient and community needs in the event of an emergency. To delay the (and) minimize confusion, errors, and expense by detailing the course of action to follow... Policy: ...8. Training a. A program for training and testing, including initial training on this policy and procedure will be conducted. i. Current staff will be trained on the new or updated EOP at the time of this publication. ii. All new (staff) will be trained on the EOP during initial orientation. Review of the agency EOP plan on 7/16/24 and personnel files on 7/18/24 revealed no documentation the following staff had been provided training on the agency EOP program: EI # 8, Registered Nurse (RN), date of hire 11/30/2020. EI # 9, RN, date of hire 4/10/23. EI # 10, Chaplain, date of hire 3/3/2020. EI # 11, Social Worker, date of hire 11/28/22. An interview was conducted on 7/18/24 at 12:53 PM with EI # 4, Executive Director, who confirmed there was no documentation the staff had been provided training on the agency EP program.”

“Based on the review of the agency Emergency Operations Plan (EOP), agency policy, and staff interviews it was determined the agency failed to: 1. Document actions taken by the agency during an actual event activation of the EOP. 2. Conduct an additional exercise at least every 2 years. 3. Analyze the agency response drills and emergency events to identify areas for improvement. This deficient practice had the potential to affect all patients and staff served by the agency. Findings include: Agency Policy: Emergency Preparedness Policy Number: HR 170 Effective Date: 3/1/2020 Purpose: To perform and respond as seamlessly as possible to meet patient and community needs in the event of an emergency. To delay the (and) minimize confusion, errors, and expense by detailing the course of action to follow... Policy: ...9. Testing. c. The agency will conduct a second exercise annually. This may be a full-scale exercise or a tabletop exercise. ...e. The agency will analyze the response and identify areas for improvement, and update the EOP if needed... Review of the agency EOP on 7/16/24 revealed: 1. The agency documented a disaster drill for active shooter on 12/30/19. There was no documentation the agency performed an analysis of the agency response to the emergency event. 2. The agency activated the EOP for COVID-19 on 3/3/2020 through 12/4/22. There was no documentation the agency performed an analysis of the agency response to the emergency event. 3. The agency activated the EOP for a hurricane on 9/15/2020. There was no documentation of the actions taken by the agency in response to the activation and no documentation the agency performed an analysis of the agency response to the emergency event. Further review of the agency EOP revealed no documentation of a second full-scale exercise, mock disaster drill, or tabletop exercise since 12/30/19. The agency failed to conduct an additional exercise at least every 2 years. An interview was conducted with Employee Identifier (EI) # 4, Executive Director, who confirmed there was no documentation of a second full-scale exercise, mock disaster drill, or tabletop exercise since 12/30/19, no documentation of the agency actions taken for the activation on 9/15/2020, and no documentation the agency performed an analysis of the agency response to the emergency events and drill.”

“Based on review of Medical Records (MR), agency policies and procedures, and interviews, it was determined the agency failed to ensure an initial Bereavement Assessment was conducted on each patient as part of the comprehensive assessment. This deficient practice affected 4 of 19 MRs reviewed including MR # 15, MR # 1, Home Visit (HV) # 4, MR # 2, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Bereavement Services Policy Number: SS-040 Revised: 5/1/19 Purpose: To provide DaySpring Hospice, LLC staff with guidelines regarding bereavement services. ...Procedure: As part of the initial psychosocial assessment ..., the Social Worker will complete a bereavement risk assessment. The Social Worker will notify the bereavement coordinator of any critical risk factors... 4. MR # 15 was admitted on 1/9/24 with a terminal diagnosis of Senile Degeneration of the Brain. Review of the Hospice Plan of Care dated 1/9/24 revealed no documentation bereavement risks were included in the Plan of Care. Review of the MSW Comprehensive Assessment - Psychosocial note dated 1/10/24 revealed the Social Worker documented in the Assessment Summary, “no bereavement issues or concerns at this time.” There was no documentation a bereavement risk assessment was completed. Review of the Spiritual Assessment dated 1/10/24 revealed no documentation of a bereavement assessment. An interview was conducted on 7/18/24 at 2:05 PM with EI # 1, Clinical Manager, Dothan, who confirmed there was no documentation a bereavement assessment was performed at the start of care. 3. HV # 2 was admitted on 7/8/24 with a terminal diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominate Side, Personal History of Transient Ischemic Attack, and Hypertension. Review of the Hospice Plan of Care dated 7/8/24 revealed no documentation bereavement risks were included in the Plan of Care. Review of the Medical Social Worker (MSW) Comprehensive Assessment - Psychosocial note dated 7/9/24 revealed the Social Worker documented in the Assessment Summary, “no bereavement issues or concerns at this time.” There was no documentation bereavement risk assessment was completed. An interview was conducted on 7/18/24 at 1:24 PM with Employee Identifier (EI) # 3, Clinical Manager, Enterprise, who confirmed there was no documentation a bereavement assessment was performed at the start of care. 1. MR # 1 was admitted to the agency on 11/1/23 with diagnoses including Parkinson’s Disease without Dyskinesia, without Mention of Fluctuations and Muscle Weakness. Review of the MR revealed no documentation an initial bereavement assessment was conducted. An interview was conducted on 7/18/24 at 1:54 PM with EI # 2, Clinical Manager, Andalusia, who confirmed there was no documentation an initial bereavement assessment was conducted. 2. HV # 4 was admitted to the agency on 1/8/24 with diagnoses including Malignant Neoplasm of Pancreas, Unspecified and Other Specified Diseases of Pancreas. Review of the MR revealed no documentation an initial bereavement assessment was conducted. An interview was conducted on 7/18/24 at 2:07 PM with EI # 2 who confirmed there was no documentation an initial bereavement assessment was conducted.”

“Based on review of medical records (MR), agency policies and procedures, and interviews it was determined the agency failed to ensure the visit frequency was followed for all disciplines and the physician was notified of missed visits. This affected 3 of 19 MR’s reviewed, including MR # 7, MR # 2, and MR # 3, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Plan of Care Policy Number: MP 550 Revised: 7/1/18 Purpose: To establish the care to be provided for the patient and family to coordinate all disciplines... Procedure: The plan of care will be established by the attending physician and/or the Hospice Physician and the Interdisciplinary Team prior to providing care and will include the following: ...6. Frequency of care... Agency Policy: Missed Visits Policy Number: ADM/HR 435 Policy: A missed visit is an alteration in the plan of care; therefore, the physician must be notified... Procedure: ...3. A missed visit which cannot be rescheduled shall be documented and communicated to the physician... 3. MR # 3 was admitted on 3/5/24 and recertified on 6/3/24 to 8/31/24 with diagnoses including Nonrheumatic Aortic (Valve) Stenosis, Pulmonary Hypertension, Unspecified, and Atherosclerotic Hear Disease of Native Coronary Artery without Angina Pectoris. Review of the Hospice Plan of Care dated 6/3/24 revealed physician’s orders for SN two visits per week for 13 weeks beginning 6/3/24. Review of the SN Visit Notes the week of 6/9/24, revealed only one SN visit was completed. Review of the Missed Visit Note dated 6/14/24 revealed the SN documented the physician was not notified of the missed visit. Review of the IDT Meetings note dated 6/19/24 revealed no documentation the physician and IDT was notified of the missed visit. An interview was conducted on 7/18/24 at 2:00 PM with EI # 1, Clinical Director of Dothan, who confirmed the physician was not notified of the missed visit and the missed visit was not discussed in the IDT meeting. 2. MR # 2 was admitted on 3/6/24 and recertified on 6/4/24 to 9/1/24 with diagnoses including Parkinson’s Disease without Dyskinesia, Essential Tremor, and Essential hypertension. Review of the Hospice Plan of Care dated 6/4/24 revealed physician’s orders for SN two visits per week for 13 weeks beginning 6/4/24. Review of the SN Visit Notes during the week of 6/30/24 revealed no SN visits were performed, and no missed visit were completed. Review of the IDT Meetings note dated 7/9/24 revealed no documentation the physician and IDT were notified of the missed visit. An interview was conducted on 7/18/24 at 1:15 PM with Employee Identifier (EI) # 1, who confirmed the physician was not notified of the missed visit and the missed visit was not discussed in the IDT meeting. 1. MR # 7 was admitted to the agency on 12/28/21 with diagnoses including Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung and Secondary Malignant Neoplasm of Brain. Review of the Hospice Plan of Care dated 6/15/24 revealed physician’s orders for SN (Skilled Nurse) two visits per week for eight weeks beginning 6/16/24. Review of the Missed Visit Note dated 7/5/24, week three, revealed there was a missed SN visit. There was no documentation the physician was notified of the SN missed visit. Review of the IDT (Interdisciplinary Team) Meetings note dated 7/10/24 revealed no documentation the physician and IDT was notified of the missed visit. An interview was conducted on 7/18/24 at 1:56 PM with EI # 2, Clinical Manager of Andalusia, who confirmed the physician was not notified of the missed visit and the missed visit was not discussed in the IDT meeting.”

“Based on review of employee’s Relias transcript, agency policy and procedure, and interviews, it was determined the agency failed to ensure the Home Health Aide earned 12 in-service hours yearly. This deficient practice affected one of 11 Home Health Aide files reviewed and had the potential to negatively affect all patients served by this hospice Findings include: Agency Policy: Home Health Aide Program Policy Number: MP-340 Revised: None listed Purpose: To establish a program for the evaluation and to monitor competencies of the Home Health Aide. Policy: It is the policy of DaySpring Hospice, LLC to have Home Health Aides that provide personal care and light housekeeping for DaySpring Hospice have met the Alabama Certified Nursing Assistant requirements. Procedure: ...5. The Home Health Aide will receive 12 hours of in-service yearly to maintain and increase their knowledge... A review of Employee Identifier (EI) # 5, Relias training for 2023, revealed the Home Health aide (HHA) did not meet the required 12 hours in-service training for the year. An interview was conducted on 7/18/24 at 12:57 PM, with EI # 4, Executive Director, who confirmed the HHA did not meet the required in-service training hours for the year of 2023.”

“Based on review of Hospice Volunteer files, agency volunteer training insert, and interviews, it was determined the agency failed to ensure the direct patient care volunteer received the Hepatitis B vaccination or signed a declination upon orientation. This deficient practice affected 1 of 5 Hospice Volunteers files reviewed, and had the potential to negatively affect all Volunteers recruited by this hospice. Findings include: A review of Employee Identifier (EI) # 6, personnel file revealed the direct patient care volunteer did not have a Hepatitis B (Hep B) vaccination form or a signed declination on file. An interview was conducted on 7/18/24 at 2:00 PM with EI # 7, Volunteer Coordinator, who confirmed EI # 6, Volunteer, did not have a Hep B vaccination form or a signed declination on file.”