Unicare Hospice Provider, Inc.

“It is required that the hospice Emergency Preparedness (EP) training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) of personnel records reviewed, the organization did not ensure that EP training was provided to all personnel. Personnel Record 9: During a joint personnel record review with the Administrator on 09/06/2024, the Administrator, who also holds the organization’s volunteer coordinator role, confirmed that the organization’s only current active volunteer (date of hire 12/11/2022) never received any training in the organization’s EP policies and procedures at hire or at any time in 2023 or before the date of the survey exit conference (09/06/2024).”

“It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 14 of 14 (100%) of clinical records reviewed, the organization did not ensure that written information about its policies on advance directives, including a description of applicable state law, was distributed to patients as required by state law and regulation. On 09/05/2024, the Administrator participated in a joint review of the documents provided to all patients at the time of admission to hospice services. The Administrator confirmed that the admission documents and patient clinical records reviewed [Clinical Records 1-14] did not include the organization’s policy on advance directives and did not include state-specific information on advance directives as required by state law. The Administrator stated that she was not aware that there was state-specific advance directive information and that it had to be provided to patients. Before the daily wrap-up conference on 09/05/2024, the Administrator stated that she did an internet search and found state-specific advance directive information that will be printed and provided to all hospice patients as required. Clinical Record 1: The patient was admitted to hospice services on 06/27/2024, Benefit Period 3 effective 07/15/2024-09/12/2024. During Home Visit 1 with the Personnel Record 5 Chaplain in an ALF on 09/04/2024, it was observed that the patient’s home folder did not include a written copy of the organization’s policies on advance directives including a description of applicable state law. During a joint personnel record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 2: The patient was admitted to hospice services on 07/01/2024, Benefit Period 4 effective 07/29//2024-09/26/2024. During Home Visit 2 with the Personnel Record 7 Hospice Aide in a Board & Care on 09/05/2024, it was observed that the patient’s home folder did not include a written copy of the organization’s policies on advance directives including a description of applicable state law. During a joint personnel record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 3: The patient was admitted to hospice services on 07/01/2024, Benefit Period 4 effective 08/16/2024-10/14/2024. During Home Visit 3 with the Personnel Record 2 RN in a Board & Care on 09/05/2024, it was observed that the patient’s home folder did not include a written copy of the organization’s policies on advance directives including a description of applicable state law. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 4: The patient was admitted to hospice services on 08/22/2024 in Benefit Period 1. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 5: The patient was admitted to hospice services on 07/26/2024 in Benefit Period 2. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 6: The patient was admitted to hospice services on 07/12/2024 in Benefit Period 1. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 7: The patient was admitted to hospice services on 06/27/2024 in Benefit Period 2. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 8: The patient was admitted to hospice services on 05/11/2024, Benefit Period 2. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 9: The patient was admitted to hospice services on 02/23/2023, Benefit Period 3 effective 08/21/2024-10/19/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 10: The patient was admitted to hospice services on 01/02/2024 Benefit Period 7 effective 08/09/2024-10/07/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 11: The patient was admitted to hospice services on 01/04/2024, Date of Live Discharge/Extended Prognosis in Benefit Period 11 on 08/30/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 12: The patient was admitted to hospice services on 04/21/2024 and was Live Discharged/Transferred to an SNF with another Hospice on 04/25/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 13: The patient was admitted to hospice services on 08/20/2024, Date of Death in an ALF was 08/24/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. Clinical Record 14: The patient was admitted to hospice services on 07/11/2024, Date of Death at home was 07/12/2024. During a joint clinical record review with the Administrator on 09/05/2024, the Administrator confirmed that the patient’s clinical record did not include documentation that the patient had been provided with a written copy of the organization’s policies on advance directives including a description of applicable state law as required by regulations during the patient’s course of hospice care and services. On 09/05/2024, the Administrator participated in a joint review of the documents provided to all patients at the time of admission to hospice services. The Administrator confirmed that the admission documents and patient clinical records reviewed [Clinical Records 1-14] did not include the organization’s policy on advance directives and did not include state-specific information on advance directives as required by state law. The Administrator stated that she was not aware that there was state-specific advance directive information and that it had to be provided to patients. Before the daily wrap-up conference on 09/05/2024, the Administrator stated that she did an internet search and found state-specific advance directive information that will be printed and provided to all hospice patients as required.”

“It is required that the hospice documents and maintains an effective infection control program that includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) of personnel records reviewed, the organization did not ensure that infection control education was provided to all personnel. Personnel Record 9: During a joint personnel record review with the Administrator on 09/06/2024, the Administrator, who also holds the organization’s volunteer coordinator role, confirmed that the organization’s only current active volunteer (date of hire 12/11/2022) never received any infection control education. The Administrator/Volunteer Coordinator confirmed that the volunteer did not receive infection control training at hire or at any time in 2023 or before the date of the survey exit conference (09/06/2024), including when infection control education was provided to all of the organization’s clinical personnel and contracted employees. The Administrator/Volunteer Coordinator acknowledged that the organization’s infection control policy with a revision date of April 2021 indicated that all employees, contracted providers, and volunteers would be trained on the organization’s infection control program at hire and minimum, annually.”

“It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) of aide personnel records reviewed, the organization did not ensure that hospice aides received at least 12 hours of inservice training during each 12 months. Personnel Record 7: The hospice aide was hired on 12/11/2022. During a review of training binders provided by the Administrator on 09/06/2024, the Administrator confirmed that the Training 2023 binder included documented evidence of only one (1) hour of inservice training for the aide in 2023. The Administrator confirmed that there was no other documented training to review for the aide in 2023 before the exit conference.”

“It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes: the volunteer’s duties and responsibilities; the person to whom they report; the person to contact if they need assistance and instruction; Hospice goals, services, and philosophy; Confidentiality and protection of the patient’s and family’s rights; Family dynamics and psychological issues surrounding terminal illness, death, and bereavement; Procedures to be followed in an emergency and/or following the death of a patient; and guidance specific to individual responsibilities. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) of volunteer personnel files reviewed, the organization did not ensure that volunteer-specific orientation and training, which included all topics required by regulation, was provided and documented. Personnel Record 9: During a joint personnel record review with the Administrator on 09/06/2024, the Administrator, who also holds the organization’s volunteer coordinator role, confirmed that the organization’s only current active volunteer (date of hire 12/11/2022) never received a volunteer-focused orientation consistent with hospice industry standards on topic required by the Medicare Conditions of Participation and CHAP Standards of Excellence. The Administrator stated, “I know we reviewed some of our orientation topics with her [the volunteer] when she was hired. I was not aware that there was a topic-specific training that she needed. We did not document any of the training that we did give her. It was just verbal.””

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During an interview with the Administrator on 09/05/2024, the Administrator provided a binder labeled Volunteer Program for review and discussion. The binder contained documents “that we could use for our program” along with a printout of how 5% cost-savings were achieved in 2022 and 2023. The Administrator stated that she was unaware she was required to document recruitment and retention efforts. “Now that I know it is required, I will document what I do going forward.” During an interview with the Administrator on 09/05/2024, the Administrator provided a binder labeled Volunteer Program for review and discussion. The binder contained documents “that we could use for our program” along with a printout of how 5% cost-savings were achieved in 2022 and 2023. The Administrator stated that she was unaware she was required to document recruitment and retention efforts. “Now that I know it is required, I will document what I do going forward.””

“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 maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 10 (30%) of personnel records reviewed, the organization did not ensure that documented skills and competencies of all individuals providing care, including volunteers, were maintained. Document review: The organization’s policies titled Competency Assessment and Performance Evaluations with a revision date of April 2021, indicated that personnel competency was to be assessed at hire and annually. Personnel Record 4: The Nurse Practitioner (NP) was hired on 12/13/2022. During a joint personnel record review with the Administrator on 09/06/2024, the Administrator confirmed that the NP’s personnel file included a competency assessment documented at hire, but did not include a documented competency assessment for 2023 or 2024. Personnel Record 5: The Chaplain was hired on 12/11/2022 for the Chaplain and Bereavement Coordinator roles. During a joint personnel record review with the Administrator on 09/06/2024, the Administrator confirmed that the Chaplain’s personnel file included a documented competency assessment at hire and in 2023 but did not include any documented competency assessments for his role of Bereavement Coordinator. The Administrator stated, “We didn’t think about needing to assess or document the Chaplain’s skills as a Bereavement Coordinator, but it makes sense.” Personnel Record 9: The volunteer was hired on 12/11/2022. During a joint personnel record review with the Administrator on 09/06/2024, the Administrator, who also holds the organization’s volunteer coordinator role, confirmed that there was no documented skill or competency assessment in the volunteer personnel file. The Administrator acknowledged that the volunteer had never been assessed at hire or at any time since hire to ensure that the volunteer had the skills and competency required for the volunteer role.”

“It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) of records reviewed in which the patient was a resident of a contracted skilled nursing facility, the organization did not ensure that individual patient plans of care identified which provider was responsible for performing the functions agreed upon in each patient-specific plan of care. Clinical Record 9: The patient was admitted to hospice services on 02/23/2023, Benefit Period 3 effective 08/21/2024, and resides in a skilled nursing facility. Diagnoses included Alzheimer’s disease, dementia, psychosis, a history of falls, dysphagia, a pressure ulcer of the left buttock, stage 2, pressure-induced deep tissue damage of the left heel, a history of trans ischemic attacks, and insulin-dependent diabetes. During a joint clinical record review with the Administrator and alternate DPCS before the exit conference on 09/06/2024, it was confirmed that the patient’s individualized plan of care effective 08/21/2024 did not include a description of specific care and services to be performed by facility staff. The alternate DPCS stated, “We document conversations and teaching with the facility staff, but I wasn’t aware we need to document specifically which tasks the facility staff will be performing.” Clinical Record 11: The patient was admitted to hospice services on 01/04/2024 and was live discharged for extended prognosis in Benefit Period 11 on 08/30/2024. The patient resided in a skilled nursing facility and had a primary terminal diagnosis of Alzheimer’s Disease. During a joint clinical record review with the Administrator and alternate DPCS before the exit conference on 09/06/2024, it was confirmed that the patient’s individualized plan of care effective in Benefit Period 11 did not include a description of specific care and services to be performed by facility staff.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) of personnel records reviewed, the organization did not ensure that a criminal background check was performed on all personnel having direct patient contact or access to patient records. Personnel Record 9: During a joint personnel record review with the Administrator on 09/06/2024, the Administrator, who also holds the organization’s volunteer coordinator role, confirmed that the organization’s only current active volunteer (date of hire 12/11/2022) never had a criminal background check performed. The Administrator stated, “She [the volunteer] does work in our office and maintains patient records. We didn’t think about checking her criminal background.””