Spero Hospice Services, Inc.

“It is required that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. THIS IS A CMS CONDITION LEVEL DEFICIENCY AND A CONTINUING REQUIRED ACTION. This condition of participation was not met as evidenced by document review and interview. The agency did not ensure the hospice provided care and services in compliance with state licensure requirements. Review of the agency’s state licensure revealed the agency was licensed to provide hospice services for one county within the state. A review of active patients on 09/24/2024 noted that the agency had 13 active patients. Ten of the 13 patients resided in a different county than those approved for service by the agency. During an interview on 09/25/2024, the administrator stated, “We have contacted our billing company to let them know they cannot bill for the patients outside of the approved county.” The cumulative effect of this deficient practice has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.116: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency. The agency did not ensure that care was provided in compliance with local, state and federal laws.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed with a certification period expiring since the last site visit on 08/15/2024 revealed that the agency did not ensure that the physician recertification was completed within the required time period. Clinical Record 3: The patient was admitted on 06/19/2024 with a diagnosis of Hypertensive heart disease. The second benefit period was dated 09/17/2024 to 12/15/2024. A clinical record review on 09/24/2024 revealed there was no completed physician recertification for the benefit period dated 09/17/2024 to 12/15/2024. The administrator stated in an interview, “We have been working on making sure the doctor gets them done on time.” She confirmed that the physician certification was not completed within the required time period.”

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of administrative documents related to Emergency Preparedness (EP) and interview with the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services, which revealed that the agency had not developed an Emergency Preparedness Plan that contained the required provisions of a plan, including: Failure to ensure the EP plan included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency [HSEP.2.D/E9]; Failure to ensure the EP plan included strategies for addressing emergency events identified by the all-hazards risk assessment [HSEP.2.D/E6]; Failure to ensure the EP plan addressed the patient population served [HSEP.2.D/E7]; Failure to ensure development of an EP plan based on a documented hospice-based and community-based risk assessment, using an all-hazards approach [HSEP.2.D/E6]; Failure to ensure the EP plan was reviewed and updated at least every two years [HSEP.2.D/E4]; Failure to ensure staff were provided with emergency preparedness training [HSEP.5.D/E37]; and Failure to ensure the EP plan is tested annually [HSEP.6.I/E39]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.113: The hospice must comply with all applicable Federal, State, and local emergency preparedness requirements. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency. In the review of the emergency preparedness (EP) plan on 08/14/2024, the documentation lacked evidence of a written emergency preparedness plan, all hazards risk assessment, and a communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked proof that the hospice had demonstrated compliance with applicable federal, state, and local emergency preparedness requirements. The only document included in the Agency’s EP binder upon initial review was a copy of their policy and procedures.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, review of personnel records, administrative documents, and interviews with the Administrator/Director of Patient Care Services and the Alternate Administrator/Alternate Director of Patient Care Services, which revealed issues with the organization and administration of services in the following areas: Failure to ensure the hospice’s governing body assumed full legal authority and responsibility for the organization’s overall management, operations, and provision of care and services [HSLG.2.I/L651]; Failure to ensure the skills and competencies of individuals providing care were assessed and documented as required by agency policy [HSRM.14.I/L663]; and Failure to ensure initial orientation addressed the employee’s specific job duties [HSRM.15.I/L662]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review and interview. The agency did not ensure the hospice provided care and services in compliance with state licensure requirements. Review of the agency’s state licensure revealed the agency was licensed to provide hospice services for one county within the state. During the site visit 3 home visits were completed, and it was noted that the patients lived in another county appropriately 70 miles from the county licensed by the state. Review of the agency’s active census revealed the agency had 19 active hospice patients, 3 patients resided within the county licensed by the state, 11 patients resided in a county approximately 130 miles from the state licensed county, and 5 patients resided in a county approximately 70 miles from the state licensed county. During an interview, joint record review, and review of findings on 08/15/2024, the Administrator/Director of Patient Care Services and the Alternate Administrator/Alternate Director of Patient Care Services confirmed that the agency had active patients that resided in three separate counties within the state, and the agency’s state license listed only one of these counties. The Administrator/Director of Patient Care Services and the Alternate Administrator/Alternate Director of Patient Care Services stated the agency did not currently have a state license to serve patients outside the one county approved by the state. The cumulative effect of this deficient practice has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.116: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure the EP plan was reviewed and updated at least every two years. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan, all hazards risk assessment, and a communication plan. The agency’s EP binder included a copy of the EP policy and procedure but did not include a documented EP plan for the agency. The governing body meeting minutes for 2021, 2022, 2023, and 2024 did not include documentation or notations that an EP plan had been reviewed and/or updated at least every two years. During an interview and joint document review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “We just started in April 2024, and we haven’t reviewed it (the EP plan) since we have been here.” In the review of the emergency preparedness (EP) plan on 08/14/2024, the documentation lacked evidence of a written emergency preparedness plan, all hazards risk assessment, and a communication plan. The only document included in the Agency’s EP binder upon initial review was a copy of their policy and procedures. The Governing Body meeting minutes did not include notations that the EP plan had been reviewed or updated in 2021, 2022, 2023 or 2024.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. The agency did not ensure development of an EP plan based on a documented hospice-based and community-based risk assessment, using an all-hazards approach. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan and all hazards risk assessment. The agency’s EP binder included a copy of the EP policy and procedure but did not include a documented EP plan and all hazards risk assessment specific to the geography and population served. During an interview and joint document review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “We just started in April 2024, and we haven’t reviewed it (the EP plan) since we have been here.””

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan. The plan includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk, and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. The agency did not ensure development of an EP plan that included strategies for addressing emergency events identified by the risk assessment. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan based on an all-hazards risk assessment, that includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk, and other anticipated emergencies that could affect the hospice’s ability to provide care. The agency’s EP binder included a copy of the EP policy and procedure but did not include a documented EP plan for the agency. During an interview and joint document review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “We just started in April 2024, and we haven’t reviewed it (the EP plan) since we have been here.””

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan. The plan addresses the patient population served, specifically, the care and safety of patients with limited mobility, and those requiring evacuation due to a medical or psychiatric condition, or their home environment. Addresses when emergency preparedness officials are contacted regarding evacuation of patients, defines the type of care and services the hospice can provide in an emergency, and addresses continuity of business functions essential to operations, including identification of staff or positions that can assume key organization roles if current staff and leadership are not available. This standard was not met as evidenced by document review and interview. The agency did not ensure development of an EP plan that addressed the patient population served. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan that addresses the patient population served, specifically: the care and safety of patients with limited mobility, and those requiring evacuation due to a medical or psychiatric condition, or their home environment, addresses when emergency preparedness officials are contacted regarding evacuation of patients, defines the type of care and services the hospice can provide in an emergency, and addresses continuity of business functions essential to operations, including identification of staff or positions that can assume key organization roles if current staff and leadership are not available. The agency’s EP binder included a copy of the EP policy and procedure but did not include a documented EP plan for the agency. During an interview and joint document review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “We just started in April 2024, and we haven’t reviewed it (the EP plan) since we have been here.””

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan. The plan includes a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. This standard was not met as evidenced by document review and interview. The agency did not ensure the EP plan included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. The agency’s EP binder included a copy of the EP policy and procedure but did not include a documented EP plan for the agency. During an interview and joint document review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “We just started in April 2024, and we haven’t reviewed it (the EP plan) since we have been here.””

“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) year, 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 document review, personnel record review, and interview. In 6 of 7 (86%) personnel records reviewed, the agency did not ensure staff were provided with emergency preparedness training. Personnel Record 1: Medical Director date of hire 01/08/2022. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Medical Director. Personnel Record 2: Administrator/Director of Patient Care Services date of hire 04/02/2024. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Administrator/Director of Patient Care Services. Personnel Record 3: Registered Nurse date of hire 04/02/2024. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Registered Nurse. Personnel Record 4: Social Worker date of hire 06/20/2024. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Social Worker. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 06/19/2023. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Spiritual Counselor/Bereavement Coordinator. Personnel Record 7: Volunteer with no documented date of hire. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Volunteer. Personnel Record 8: Volunteer Coordinator date of hire 04/02/2024. The personnel record contained no documented evidence of initial training in EP policies and procedures consistent with the expected role for Volunteer Coordinator. During an interview and joint record review on 08/14/2024, the Administrator/Director of Patient Care Services, Alternate Administrator/Alternate Director of Patient Care Services, and Human Resources Designee “stated they will have everyone do EP training from now on.” Upon reviewing the emergency preparedness (EP) plan on 08/14/2024, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023. The personnel files did not include documentation of emergency preparedness training during initial orientation.”

“It is required the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including: 1. Participation in a full-scale exercise that is community-based every two (2) years. a) When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. b) If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. 2. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to: a) A second full-scale exercise that is community-based or a facility-based functional exercise; or b) A mock disaster drill; or c) A tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure the emergency preparedness (EP) plan was tested annually. Review of the agency’s emergency preparedness (EP) binder on 08/14/2024 revealed no documented evidence of a written emergency preparedness plan, all hazards risk assessment, and a communication plan. The agency’s EP binder included a copy of the EP policy and procedure but did not include documentation that the agency had tested the EP plan, including participation in full-scale exercise that is community-based every two years and conducting an additional exercise every two years – opposite the year that a full-scale exercise. During an interview and joint document review on 08/14/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “the agency had not conducted a tabletop exercise, participated in a mock disaster drill, community-based exercise, or activated the agency’s emergency preparedness plan.” Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure the medication profile contained the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 10/24/2023 and resided at a care facility. During the home visit observation with the Hospice Aide (HA) (Personnel Record 6), a medication review was completed by comparing the hospice medication profile with the facility medication profile. The facility medication profile included the following medications not included on the hospice medication profile, Moxifloxacin HCL dated 10/24/2023, Zofran HCL dated 01/04/2024, Fluoxetine HCL dated 10/24/2023, Ipratropium dated 10/24/2023. The facility medication profile included Carvedilol twice daily dated 10/24/2023 and the hospice medication profile included Carvedilol once daily. The hospice medication profile included the following medications not included on the facility medication profile, Atropine dated 04/19/2024, Bisacodyl dated 04/19/2024, Zinc dated 04/19/2024, Loperamide dated 04/19/2024 and Prednisolone eye drops dated 04/19/2024. During an interview and joint record review on 08/14/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services confirmed the hospice medication was not up to date with the patient’s current medications.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 8 (25%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services included in the plan of care. Home Visit 1/Clinical Record 1: During the home visit observation with the Hospice Aide (HA) (Personnel Record 6), the HA was observed to take the patient’s vital signs during the visit. Review of the hospice aide care plan revealed the HA was not assigned the task of obtaining vital signs. Clinical Record 14: Clinical record review revealed the hospice aide visit notes dated 12/11/2023, 12/14/2023, 12/14/2023, 12/19/2023, 12/22/2023, 12/25/2023, 12/28/2023 and 01/01/2024 included the hospice aide’s signature at the bottom of the visit note but did not include documentation of the tasks performed during the visits. The tasks were not marked off as completed. During an interview and joint record review on 08/14/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services confirmed the hospice aide care plan tasks had not been completed per the plan of care.”

“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 personnel record review and interview. In 1 of 1 (100%) personnel record reviewed for volunteer, the agency did not ensure the volunteer received volunteer orientation and training consistent with hospice industry standards. Personnel Record 7: Personnel record review for a volunteer without a hire date revealed no documented evidence that the volunteer received orientation and training related to individual responsibilities, confidentiality and protection of the patient’s and family’s rights, procedures to following in case of emergency, and orientation to hospice philosophy. During an interview and joint record review on 08/144/2024, the Volunteer Coordinator stated the agency just listed the hours the volunteer “came into the office to make binders in their personnel file.””

“It is required that the hospice’s governing body assumes full legal authority and responsibility for the organization’s overall management and operation and provision of care and services. This standard was not met as evidenced by document review and interview. The agency did not ensure the hospice’s governing body assumed full legal authority and responsibility for the organization’s overall management, operations, and provision of care and services. Review of the agency’s state licensure revealed the agency was licensed to provide hospice services for one county within the state. During the site visit 3 home visits were completed, and it was noted that the patients lived in another county appropriately 70 miles from the county licensed by the state. Review of the agency’s active census revealed the agency had 19 active hospice patients, 3 patients resided within the county licensed by the state, 11 patients resided in a county approximately 130 miles from the state licensed county, and 5 patients resided in a county approximately 70 miles from the state licensed county. For the 16 patients that resided outside the state licensed county, the hospice did not ensure general inpatient (GIP) and respite contracts were in place to provide an increased level of care if needed. For the 11 patients that lived approximately 130 miles from the state licensed county, the agency was unable to provide an on-call schedule or call log. During an interview and joint record review on 08/15/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services (ADPCS) stated the on-call schedule was “verbal.” The ADPCS also stated “the calls were answered by a non-clinical office person” who tried to triage the call and then would try to call and get one of the nurses in the area to respond.” The June 2024 on-call schedule was requested by the site visitor, and the ADPCS was overheard asking one of the office personnel to “type something up to give to her.” When the site visitor walked into the room, the site visitor observed the office personnel typing the June calendar on the computer. The ADPCS then stated the call schedule was “verbal.” During an interview, joint record review, and review of findings on 08/15/2024, the owner via telephone, the Administrator/Director of Patient Care Services and the Alternate Administrator/Alternate Director of Patient Care Services confirmed that the agency had active patients that resided in three separate counties within the state, and the agency’s state license list one of these counties. The Administrator/Director of Patient Care Services and the Alternate Administrator/Alternate Director of Patient Care Services stated the agency did not currently have a state license to serve patients outside the one county approved by the state. On 08/14/2024, the Site Visitor conducted three (3) home visits (Clinical Records 1. 2 and 3) and noted these patients to live in Ventura County. Upon arrival back at the Agency, the Site Visitor noted that the Agency had active patients in San Diego County, which is approximately 150 to 175 miles away. It was revealed that the Agency had an active census of 19 patients and 11 of those were in San Diego County, 5 in Ventura County and 3 in LA County. Licensure paperwork from 2021 had the agency licensed to serve LA County. The governing body was providing care to patients in counties they were not licensed to operate. It was also revealed the Agency did not ensure they had GIP/respite contracts in San Diego or Ventura Counties. They also did not have a hospice aide that lived in San Diego County and currently none of the San Diego County patients had a hospice aide. The Agency was also unable to produce an on-call schedule or call log for the San Diego County area.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by personnel record review and interview. In 6 of 8 (75%) personnel records reviewed, the agency did not ensure the initial orientation addressed the employee’s specific job duties. Personnel Record 1: Medical Director date of hire 01/08/2022. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. Personnel Record 2: Administrator/Director of Patient Care Services 04/02/2024. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. Personnel Record 3: Registered Nurse date of hire 04/02/2024. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. Personnel Record 4: Social Worker date of hire 06/20/2024. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 06/19/2023. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. Personnel Record 8: Volunteer Coordinator date of hire 04/02/2024. Personnel record review revealed no documented evidence that the employee had been instructed on the job specific duties and there was no evidence of a signed job description in the personnel record. During an interview and joint record review on 08/14/2024, the Administrator/Director of Patient Care Services, Alternate Administrator/Alternate Director of Nursing, and Human Resources Designee confirmed the personnel files did not contain signed job descriptions.”

“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 document review, personnel record review, and interview. In 6 of 8 (75%) personnel files reviewed, the agency did not ensure the skills and competencies of individuals providing care were assessed and documented as required by agency policy. Agency policy No. 4.28.1 Staff Competency Program, without a date, required in part, “Hospice will provide initial and ongoing competencies for all patient care staff by qualified individuals. Competencies will be assessed at defined intervals. For each new employee, including contract staff during orientation. At least every three years for all patient care staff. Hospice aides will be assessed annually by an RN [Registered Nurse].” Personnel Record 1: Medical Director date of hire 01/08/2022. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. Personnel Record 2: Administrator/Director of Patient Care Services date of hire 04/02/2024. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. Personnel Record 3: Registered Nurse date of hire 04/02/2024. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. Personnel Record 4: Social Worker date of hire 06/20/2024. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 06/19/2023. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. Personnel Record 8: Volunteer Coordinator date of hire 04/02/2024. Review of the personnel record revealed no documented evidence that an initial competency evaluation was completed. During an interview and joint record review on 08/14/2024, the Administrator/Director of Patient Care Services, Alternate Administrator/Alternate Director of Patient Care Services, and Human Resources Designee confirmed the initial competencies were not present in the personnel files and the policy had not been followed.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 4 of 6 (67%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 1: The patient elected the hospice benefit on 10/24/2023. Clinical record review revealed the fourth benefit period started on 06/20/2024. The recertification of terminal illness was signed by the hospice medical director on 08/13/2024, 54 days after the start of the benefit period and 52 days outstanding. Clinical Record 6: The patient elected the hospice benefit on 07/06/2023. Clinical record review revealed the sixth benefit period started on 06/30/2024. The recertification of terminal illness was signed by the hospice medical director on 08/13/2024, 44 days after the start of the benefit period and 42 days outstanding. Clinical Record 11: The patient elected the hospice benefit on 08/14/2023. Clinical record review revealed the fifth benefit period started on 06/09/2024. The recertification of terminal illness was signed by the hospice medical director on 08/13/2024, 65 days after the start of the benefit period and 63 days outstanding. Clinical Record 12: The patient elected the hospice benefit on 02/14/2024. Clinical record review revealed the third benefit period started on 05/14/2024. The recertification of terminal illness was signed by the hospice medical director on 08/13/2024, 100 days after the start of the benefit period and 98 days outstanding. During an interview and joint record review on 08/13/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services confirmed the recertifications of terminal illness had not been signed in the required timeframes.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by document review, clinical record review, and interview. In 6 of 6 (100%) clinical records reviewed for patients admitted since April 2024, the agency did not ensure the patient was provided with a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications. Review of the agency’s admission packet/binder revealed no documented evidence that the agency’s policy for disposal or management of controlled substances was included in the packet. Clinical Record 2: The patient was admitted to home health services on 04/29/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. Clinical Record 4: The patient was admitted to home health services on 07/25/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. Clinical Record 5: The patient was admitted to home health services on 07/15/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. Clinical Record 7: The patient was admitted to home health services on 07/05/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. Clinical Record 8: The patient was admitted to home health services on 06/19/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. Clinical Record 9: The patient was admitted to home health services on 05/23/2024. Clinical record review revealed no documented evidence that the patient was provided with the agency’s policy and procedure for management and disposal of controlled substances and the patient’s informed consent did not include a statement that acknowledged receipt of the agency’s policy for management and disposal of controlled substances. During an interview and joint record review on 08/13/2024, the Administrator/Director of Patient Care Services and Alternate Administrator/Alternate Director of Patient Care Services stated, “when we started in April 2024 the old staff took everything and we had to create everything from scratch.” They stated that they created a new home binder and “must have forgotten to include that policy/procedure for management and disposal of controlled substance in the new home binder.” During a review of the informed consent of patients admitted since April 2024, clinical records and interviews revealed the Agency’s controlled substance disposal policies were not provided to the patients/families or legal representatives upon admission and there was not evidence of a discussion upon ordering a controlled substance. A review of the home binder did not include the Agency Policy/Procedure for “Disposal or Management of Controlled Substances” and the Informed Consent did not include a statement that acknowledged receipt of this Agency Policy/Procedure.”