Copper State Hospice Inc.

“It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review and interviews with the Executive Director, which revealed the hospice: Failed to provide occupational therapy services, directly or under arrangement, in a manner consistent with accepted standards of practice [HCDT.1.I/L652/418.100(c)(1)]. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to ensure the provision of quality hospice care for the condition of participation CFR 418.70: Furnishing of non-core services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.”

“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. This standard was not met as evidenced by document review and interview. The document review revealed that the agency did not ensure the volunteers provided day-today 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. A review of the Volunteer Activity Report on 04/17/2025 for the period 01/01/2024-12/31/2024 revealed a cost savings of 0.03%. The report revealed a cost savings of 0.22% for the period 04/16/2024-04/16/2025. The agency did not ensure that that hospice volunteers provided 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. During a joint review of the Volunteer Activity Report and interview on 04/17/2025, the Executive Director agreed that the agency did not meet the minimum five percent cost savings requirement for the periods 01/01/2024-12/31/2024 and 04/16/2024-04/16/2025. Additionally, the Executive Director stated, “We are working on new recruitment efforts to get more volunteers.””

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: Physical therapy, occupational therapy, and speech-language pathology services. This standard was not met as evidenced by document review and interview. A review of documents revealed that the agency did not ensure occupational therapy services were available. Agency Policy, “Rehabilitative Care Services, Policy No. 2-011.1,” stated in part, “The provision of rehabilitation services will be appropriate to the patient’s and family’s end of life goals, care environment, and comfort needs. All services will be provided in accordance with accepted standards of practice by or under the direction of a qualified physical, occupational, or speech therapist.” During an interview on 04/17/2025, the Executive Director agreed that the agency did not have a occupational therapist (OT) or contract for occupational therapy services available to patients. Additionally, the Executive Director stated, “We don’t have one. We are working on getting an OT from an agency.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) personnel records reviewed revealed the hospice did not ensure the competencies of employees and volunteers were assessed. PERSONNEL RECORD 7: The Social Worker was hired on 07/08/2024. There was no documented evidence that hospice assessed the competency of the Social Worker. PERSONNEL RECORD 8: The Spiritual Counselor was hired on 09/04/2024. There was no documented evidence that hospice assessed the competency of the Spiritual Counselor. PERSONNEL RECORD 10: The Volunteer was hired on 11/15/2024. There was no documented evidence that hospice assessed the competency of the Volunteer. During a joint record review and interview on 04/17/2025, the Executive Director stated, “These were missed. We need to establish a plan for ensuring these are done.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which the patient revoked or was discharged for no longer being terminally ill, it was revealed that the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 10: The patient elected the hospice benefit on 06/28/2024. The patient was discharged, seeking aggressive treatment at the hospital, on 12/21/2024. There was no documented evidence the discharge summary was provided to the attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/23/2024. The patient was discharged, no longer terminally ill, on 07/19/2024. There was no documented evidence the discharge summary was provided to the attending physician. During a joint review of the record and interview on 04/17/2025, the Executive Director agreed there was no documented evidence the discharge summary was sent to the attending physician. Additionally, the Executive Director stated, “We need to update our process with a checklist and delegate the task.””